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Factors influencing deviance in growth of children in rural West Bengal

Summary of MSc Thesis1

By Chandrashekhar Pandey and Rosalyn O'Loughlin

This study may have some relevance to emergency situations where there is variation in the growth performance of children enrolled in emergency selective feeding programmes (Ed).

The term positive deviance has been used to identify children who '...grow and develop well in impoverished environments where most children are victims of malnutrition and chronic illness'2. Negative deviants grow at the lower end of the growth spectrum and median growers grow at or around the median of the growth spectrum2. The aim of a recent study was to identify the child-care, feeding behaviours and other factors associated with positive deviance in a deprived rural Indian community in order to improve the maternal and child health and nutrition programme run by the Child In Need Institute (CINI).


A comparative study method was used. Growth velocities were calculated for a sample (n=737) of children, who had been enrolled at birth in the CINI programme in 1998 or 1999 (n=1500) using monthly weight recordings from 6 to 24 months. Children were classified based on growth velocity as either positive deviants >0.6 Z scores, median growers <0.3 to >-0.3 Z scores or negative deviants <-0.6 Z scores1. The final sample drawn from these groups was 233. Interviewer administered questionnaires were conducted with primary carers of this sample in April 2002 and additional information was obtained from child health cards. Analysis was carried out using Pearson's chisquare and trend tests.


The response rate was 97.4% (n=227). Morbidity data was recorded for 90.6% (n=211) of children over the 19 month period. Two thirds (67.8%) of these had at least one episodes of illness. Negative deviants were significantly more likely to have been ill, and to have been ill more frequently than positive deviants or median growers. There was an increasing trend from positive deviants to negative deviants in the number of episodes of fever, chest infection and diarrhoea (table 1).

A significantly higher proportion of negative deviants who were ill in the two weeks preceding the study attended an unqualified doctor during illness compared to median growers who were more likely to attend a qualified practitioner (?2 = 9.4, df 1, p = 0.002). No significant differences were found between the three groups in knowledge, attitude and practice of the primary carers or socio-economic backgrounds.


Table 1: Child morbidity history over 19 months by the three nutritional groups.
  Positive No. (%) (n=72) Median No. (%) (n=65) Negative No. (%) (n=74) Total No. (%) Chi squared test, p value
Episodes of illness (n=211)         ?2= 35.4, df 4 p < 0.0001
No sickness 33 (45.8) 24 (36.9) 11 (14.9) 68 (32.2)
1-2 episodes 34 (47.2) 36 (55.4) 36 (48.7) 106 (50.2)
>2 episodes 5 (6.9) 5 (7.7) 27 (36.5) 37 (17.6)
Episodes of fever (n=210)     (n=73)   ?2 tr = 6.0, p < 0.01
None 49 (68.1) 37 (56.9) 35 (47.9) 121 (57.6)
One or more 23 (31.9) 28 (43.1) 38 (52.1) 89 (42.4)
Episodes of chest infection (n=210)       ?2 tr = 15.8, p < 0.0001
None 52 (72.2) 41 (63.1) 29 (39.7) 122 (58.1)
One or more 20 (27.8) 24 (36.9) 44 (60.3) 88 (41.9)
Episodes of diarrhoea (n=210)       ?2 tr = 15.5, p <0.0001
None 56 (77.8) 46 (70.8) 34 (46.6) 136 (64.8)
One or more 16 (22.2) 19 (29.2) 39 (53.4) 74 (35.2)


Policy implications and further research

The principal finding, that negative deviants were more likely to have recurrent illnesses, have important implications for planning intervention programmes to combat the problem of poor growth. CINI uses a system of community health workers to provide health education and follow-up for sick children. The Integrated Management of Childhood illness, a WHO / UNICEF initiative, emphasises training of community health workers.3,4 This is recommended as an appropriate tool to introduce into the CINI programme. Training should concentrate on early detection of illness, giving appropriate nutritional advice and understanding growth charts. Further research is needed in order to understand whether negative deviance is a cause of, or an effect of, illness and why the primary carers of negative deviants are less likely to take their ill child to qualified health personnel.


This study was done as part of an M.Sc. in community health in the Department of Community Health and General Practice, TCD whose assistance is acknowledged. Thanks also to the Child in Need Institute, West Bengal where the research was carried out and to the Irish Council for Overseas Students who funded this research.

Show footnotes

1'Factors influencing positive and negative deviance in growth of children in rural West Bengal' Pandey C, O'Loughlin R. Dept of Community Health & General Practice, Trinity College Centre for Health Sciences Tallaght Hospital, Dublin 24, Ireland

2Shekhar M, Habicht JP, Latham MC. Use of positive-negative deviant analyses to improve programme targeting and services: Example from the Tamilnadu integrated nutrition project. International Journal of Epidemiology 1992;21(4):707-713.

3Gove S. Integrated management of childhood illness. Bulletin of the World Health Organisation 1997;75(Suppl 1):7-24.

4WHO. Integrated management of the sick child. Bulletin of the World Health Organisation 1995;73(6):735-740

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Chandrashekhar Pandey and Rosalyn O'Loughlin (). Factors influencing deviance in growth of children in rural West Bengal. Field Exchange 18, March 2003. p6.



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