Effectiveness of Positive Deviance Approach to Promote Exclusive Breastfeeding Practice: A Cluster Randomized Controlled Trial

"To achieve optimal BF practices, giving equal or prior attention to social factors of women about BF is needed as of addressing systemic and health factors."

It is estimated that suboptimal breastfeeding (BF) contributes to 24% of the annual infant death rate in Ethiopia. Poor social support, negative subjective norms about exclusive breastfeeding (EBF), and job-related challenges to practice EBF are among the barriers women face. To attempt to prevent high rates of acute malnutrition by promoting EBF in Jimma town, Oromia, Ethiopia, a community-based trial was undertaken that integrated the positive deviance approach (PDA). This approach is based on the idea that solutions to problems already exist within the community, often practiced by "positive deviants" who engage effectively in healthy, although uncommon, behaviours. Once identified, these practices are shared with community members in different ways. This cluster randomised controlled trial (RCT) evaluated whether a PDA intervention was successful in increasing the proportion of EBF in Jimma.

The PDA was used to guide the intervention through participatory design. In the study area, there are mothers whose uncommon but successful behaviours enable them to find better solutions while feeding breast milk only for the first 6 months. The project team, health extension professionals, and invited volunteer women identified PDs using a series of 6 steps: defining the problem of EBF, exploring the presence of PD individuals (selected using 5 criteria), discovering uncommon practices/behaviours, designing the programme, planning for monitoring and evaluation, and planning for scale-up. The researchers and PDs cooperatively and iteratively designed the intervention, drawing on mothers' tacit and implicit knowledge and lived experiences. This participatory design process helped the researchers to find a common "language" with implementers and to capture diverse information on how to implement the intervention.

The selected PDs were trained with different modalities including: classroom sessions on theoretical aspects of breastfeeding, counseling, and communication; practical sessions on counseling skills (listening and learning skills, confidence and support skills), demonstrations/simulation, and work in smaller groups with discussion and role-plays. Then, the content of modules for the intervention was developed (co-created) in consultation with the PDs to be used in the visits with women.

A cluster-randomised controlled trial (RCT) was carried out from February 1 to September 30 2018. Six randomly selected clusters (kebeles) were randomised into two arms. Then, 260 pregnant women in their third trimester (36 weeks of gestational age) were enrolled in either the intervention or control arm depending on where they lived. Women in the in the control group received the usual community-based services from urban health extension professionals. Each woman in the intervention group received 6 comprehensive and personalised informational and psychosocial counseling sessions at her home by a trained PD who promoted and supported EBF practice using her preferred local language (Afan Oromo or Amharic). The 13 PDs were assigned to visit 10 mothers each.

During the visits, the PDs brought skills and knowledge of EBF issues, and the family brought their own experience and resources to engage in discussion and reach a consensus. The PDs used guided discovery, which is a style of engagement to both gently probe for the individual's and family's BF beliefs and to stimulate alternative ideas (e.g., by asking, What are the prevaling EBF subjective norms at the individual and community level?) PDs worked to develop an empathic, trusting, safe, alliance with the mother and other family members, in part by using culturally appropriate illustrations to facilitate communication. Putting knowledge into practice and behavioural activation means the mother tried things out in between counseling sessions, putting what had been learned into practice. PDs worked with key family members to motivate and encourage mothers to take small steps and then to build on these. They tried to solve problems and barriers by putting new knowledge and skills into practice.

Baseline data were collected at 37 weeks of gestation before the intervention. Then, the first, second, third, fourth, fifth, and sixth visit were conducted at 38-40 weeks of gestation, first day of delivery, first, second, third, and fourth month of postpartum, respectively. The midline and endline data were collected at third and sixth month of postpartum, respectively. For all statistical tests, 95% confidence interval (CI) with a P-value of 0.05 was used.

A higher proportion of mothers in the intervention group reported EBF compared to the control group at mid and end-line. The rate of EBF increased by 18.5% (P=0.01) in the intervention group, as compared to 0.2% in the control group, with a net effect of +18.2%. The probability of practicing EBF was significantly higher for the intervention group compared to the control group. At baseline, the relative risk (RR) of avoiding EBF (RR:1.112) was similar among the two groups. However, at follow-up, mothers in the intervention group were 2 times more likely to practice EBF (RR: 2.294) compared to those in the control group. They were also 2 times more likely to initiate timely complementary feeding practice (RR: 2.124) and 3 times more likely to avoid bottle feeding (RR: 3.245) compared to those in the control groups.

At baseline, there were no significant differences between the groups on ideation factors of BF such as knowledge, attitude, and self-efficacy. The percentage of mothers in the intervention group who had good knowledge significantly increased by 16 points from baseline to midline and then increased by 20 points to endline, while the increase was only 7 points in the control group from baseline to endline. The percentage of mothers who reported favourable attitudes toward EBF significantly increased by 22 points in the intervention group from baseline to endline, while the level remained almost the same in the counterparts. The percentage of mothers in the intervention group who had good self-efficacy significantly increased by 28 points from baseline to midline and then increased by 33 points to endline, while this level increased by only 5 points in the control group from baseline to endline.

In short, the findings indicate that the PDA had the intended desirable effect on improving EBF practices. Mothers in the intervention group had a better practice of EBF, duration of feeding, frequency of feeding, and timely initiation of complementary feeding compared to the control group. There were positive changes in all standard indicators of BF practice for the intervention group. This finding remained significant even after controlling for relevant baseline characteristics of the mothers. According to the researchers, the acceptance and support for the PDA by the implementers, community members, mothers, spouses, and relevant others may have contributed for the effectiveness of this approach. They also point to the study's participatory design, arguing that an effective community-based intervention demands consideration of the context into which the PDA must fit.

The researchers conclude that "the PD approach has important implications for researchers and practitioners who are trying to address global nutrition challenges through local community-based solutions....Improved knowledge, attitude and transferable skill from PDs to mothers, the spill-over effect of remained information in the community, and solving the community's problem by, from, and to the community are some of the practical implications and strengths....Hence, the health system should explore the adoption of the PD approach as a way of promoting optimal BF. In line with this, adopters should consider interventions focusing on improving maternal ideation factors, which in turn might improve BF practices..."