Effectiveness of a Positive Deviance Approach to Improve Mother's Nutritional Knowledge, Attitude, Self-efficacy, and Child's Nutritional Status in Maji District, West Omo Zone, South West Region, Ethiopia: A Cluster Randomized Control Trial

"This intervention study...contributes to...nutrition programs by inspiring the public health practitioner toward community-based participatory approaches to resolving nutrition-related issues in the study area and beyond."

The positive deviance approach (PDA) in the field of health refers to the phenomenon where certain individuals achieve positive outcomes despite challenging circumstances. The PDA focuses on the strengths of a community, uses a problem-solving methodology, and empowers the community to lead the change. This study aimed to assess the effectiveness of a community-based intervention using the PDA in enhancing mothers' nutritional knowledge, attitudes, and self-efficacy and improving their children's nutrition outcomes in rural Ethiopia.

A parallel-group, single-blinded, cluster-randomised, two-arm trial was conducted in Maji Woreda, a rural setting, from April 15 to October 19 2022. Five hundred and sixteen mothers were randomly assigned to either an intervention or control group after collecting baseline data. The trial participants in the intervention cluster received a PD intervention for 6 months, whereas those in the control group received only the usual care. The intervention involved:

• Part 1: training of selected positive-deviant mothers (PDMs) - Village leaders, women's representatives, and health development army leaders (HDALs) suggested PDMs. Twenty-two PDMs took part in a 2-week training to enrich the tacit knowledge they have about the recommended infant and young child feeding practices (IYCFP). The instructional strategies delivered included direct, interactive, participatory, and experience-sharing activities. After the training, all PDMs received a copy of the information, education, and communication (IEC) material prepared for the sessions. Equipped with practical knowledge, positive attitudes, and a strong sense of self-efficacy, these mothers effectively provide guidance, lead support groups, and engage in productive discussions with other mothers to encourage the adoption of the recommended IYCFP.
• Part 2: group training of mothers with PDMs - Nutrition education sessions, including demonstrations, were provided to selected mothers in the intervention group for 12 consecutive days in groups in their community setting for 90-120 minutes each day. The intervention consists of these elements: (a) providing education on breastfeeding (BF) to increase knowledge, attitude, and self-efficacy in BF; (b) offering support for complementary feeding (CF); (c) counseling on methods to enhance consistency, quantity, and frequency of food intake using locally accessible food options; (d) conducting practical demonstrations on cooking locally available food items; (e) providing hygiene support; and (f) guiding parents on how to feed their child during and after an illness.
• Part 3: home visits - Each PDM conducted 12 home visits (twice a month) for the intervention group, sharing experiences of how they overcome their problems and offering support for the mother to reinforce the adoption of feeding practices toward optimum IYCFP. Mothers were encouraged to ask questions of the PDMs. In addition, each mother was provided with a culturally suitable poster containing key messages to reinforcing the desired behaviours. The poster also included images showcasing the advantages of adhering to the recommended IYCFP, presenting babies who were properly nourished versus those who were not.

This entire process was participatory, with the researchers, village leaders, women representatives, HDALs, and health extension workers (HEWs) collaborating on design artifacts, workflows, and work environments. Through repeated discussions, they were able to deepen and refine their understanding of the implicit and tacit knowledge that mothers possess. The team used positive deviant queries to identify and examine the exemplary practices in specific settings that were incorporated into the above activities.

A pretested, structured, interviewer-administered questionnaire was used for data collection. Generalised estimating equation regression analysis adjusted for baseline covariates and clustering was used to test the intervention effect.

The results showed that PDA improved breastfeeding outcomes in the intervention groups compared to their counterparts. A mean difference (MD) of BF knowledge (MD = 6.47; 95% confidence interval (CI): 6.45-6.49), BF attitude (MD = 12.68; 95% CI: 11.96-13.40), and BF self-efficacy (MD = 3.13; 95% CI: 3.05-3.21) was observed, favouring the intervention. The intervention group showed better improvement in CF knowledge, attitude, and self-efficacy among mothers compared to the control group. A mean difference in CF knowledge (MD = 4.53, 95% CI: 4.31-4.75), CF attitude (MD = 9.14, 95% CI: 8.52-9.75), and CF self-efficacy (MD = 11.64, 95% CI: 11.16-12.12) was observed, favouring the intervention. At the end of the 6-month follow-up, children in the intervention group showed a lower prevalence of underweight (18.23%) (95% CI: 4.55, 22.54%; p = 0.004) compared with the control group.

Thus, the use of PDA resulted in increased knowledge, improved attitudes, and greater self-efficacy toward BF and CF. Moreover, the study indicated notable improvements in weight-for-age z-scores (WAZ) and a reduction in cases of underweight among the children. These findings highlight the potential of implementing PDA as a strategy to address malnutrition and improve the overall health and well-being of rural communities.

In conclusion: "It is important to address the mother's nutritional knowledge, attitude, and self-efficacy in promoting actual behavior. Therefore, these findings can inspire community-based participatory approaches to nutritional interventions. Additionally, there is a need to conduct further research to comprehensively understand the mechanisms by which PDA affects feeding practices."