Thomas K. Houston, MD, MPH; Jeroan J. Allison, MD, MSc; Marc Sussman, MHA; Wendy Horn, PhD; Cheryl L. Holt, PhD; John Trobaugh, MFA; Maribel Salas, MD, PhD; Maria Pisu, PhD; Yendelela L. Cuffee, MPH; Damien Larkin, MA; Sharina D. Person, PhD; Bruce Barton, PhD; Catarina I. Kiefe, PhD, MD; Sandral Hullett, MD, MPH
Grant Support: By Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation (RWJF Finding Answers grant 59741), with direction and technical assistance provided by The University of Chicago; a Veterans Affairs Hypertension Stories grant (I01 HX000492-01; Dr. Houston); and the Agency for Healthcare Research and Quality Storyguides project (1R18HS019353-01; Dr. Allison).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1487.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Houston (e-mail, Thomas.Houston@umassmed.edu). Data set: Not available.
Requests for Single Reprints: Thomas K. Houston, MD, MPH, University of Massachusetts Medical School, Quantitative Health Sciences, 55 North Lake Avenue, Worcester, MA 01605; e-mail, Thomas.Houston@umassmed.edu.
Current Author Addresses: Drs. Houston, Allison, Barton, and Kiefe; Mr. Trobaugh; and Ms. Cuffee: University of Massachusetts Medical School, Quantitative Health Sciences, 55 North Lake Avenue, Worcester MA 01655.
Mr. Sussman, Drs. Horn and Hullett, and Mr. Larkin: 1515 6th Avenue South, Birmingham, AL 35233.
Dr. Holt: University of Maryland, SPH Building, Valley Drive, College Park, MD 20742-2611.
Dr. Salas: 1800 Concord Pike, Box 15437, Wilmington, DE 19850-5437.
Drs. Pisu and Person: Medical Towers 612, 1717 11th Avenue South, Birmingham, AL 35205.
Author Contributions: Conception and design: T.K. Houston, J.J. Allison, C.L. Holt, J. Trobaugh, M. Salas, M. Pisu, S.D. Person.
Analysis and interpretation of the data: T.K. Houston, J.J. Allison, C.L. Holt, M. Salas, S.D. Person, B. Barton, S. Hullett.
Drafting of the article: T.K. Houston, J.J. Allison, J. Trobaugh, Y.L. Cuffee, D. Larkin.
Critical revision of the article for important intellectual content: T.K. Houston, J.J. Allison, W. Horn, C.L. Holt, J. Trobaugh, M. Salas, M. Pisu, S.D. Person, B. Barton.
Final approval of the article: T.K. Houston, J.J. Allison, J. Trobaugh, M. Salas, M. Pisu, Y.L. Cuffee, S.D. Person, S. Hullett.
Statistical expertise: J.J. Allison, S.D. Person, B. Barton.
Obtaining of funding: T.K. Houston, J.J. Allison, M. Salas.
Administrative, technical, or logistic support: M. Sussman, W. Horn, D. Larkin, S. Hullett.
Collection and assembly of data: J.J. Allison, W. Horn, M. Salas, S. Hullett.
Houston TK, Allison JJ, Sussman M, Horn W, Holt CL, Trobaugh J, et al. Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized Trial. Ann Intern Med. 2011;154:77-84. doi: 10.7326/0003-4819-154-2-201101180-00004
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Published: Ann Intern Med. 2011;154(2):77-84.
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Albert Einstein Healthcare Network, Philadelphia, PA
January 21, 2011
Role of the principle of positive deviance.
To the Editor: I found the article by Houston et al. (1) to be quite interesting. I feel certain that the use of storytellers from the patient population was critical to the success of this intervention. What was missing from the article, and what I think the success of the intervention can be attributed to, was the role of the principle of positive deviance.
The concept of positive deviance has been defined as follows: "In every community there are certain individuals or groups (the positive deviants) whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers. These individuals or groups have access to exactly the same resources and face the same challenges and obstacles as their peers (2)." In other words, we don't need to discover new approaches to help patients deal with their chronic diseases. Somewhere out there are already are people who have somehow figured things out for themselves and are achieving better results. It is up to us as a healthcare community to help our patients discover these practices and facilitate their application to their own circumstances. The positive deviance approach has been successfully applied to childhood malnutrition (3), hand hygiene (4), and, in my institution, MRSA transmission (5).
I believe the storytellers represented positive deviants in the community. Whether it be through videos, dialogues, social networking, or any other means, the more we help to connect the positive deviants with the broader patient population, the more self-discovery of the positive deviant can occur by the very people whose behaviors need to change.
1. Houston TK, Allison JJ, Sussman M, Horn W, et al. Culturally appropriate storytelling to improve blood pressure. Ann Intern Med 2011;154:77-84.
3. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329:1177-1179.
4. Marra AR, Guastelli LR, de Ara?jo CMP, et al. Positive deviance: a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:12-20.
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