Positive Deviance: Frequent Blood Pressure Monitoring Among Non-hypertensive Middle-aged Women in Rural Indonesia

Mayumi Mizutani, Heri Sugiarto, Harumi Bando, Izumi Kondo, Jeremiah Mock


Background: In Indonesia, as in many low and middle-income countries, hypertension is a significant health issue. Community health nurses need to identify those with early onset of hypertension by promoting frequent blood pressure (BP) checks, even among those with normal BP. Positive deviance approaches focus on identifying people who undertake uncommon preventive actions. Among middle-aged women in rural West Java, Indonesia, we aimed to identify covariates of the positive deviant practice of having one’s BP checked at least once every three months even when having normal BP.  Methods: We conducted a cross-sectional survey recruiting participants at health centers. Our structured questionnaire measured socio-demographic characteristics, frequency of BP checks, BMI, beliefs and practices. We used binomial logistic regression to identify covariates. Results: Among 520 participants, 265 had normal BP, and of those 156 had obtained frequent BP checks, making them positive deviants. For women with normal BP, significant covariates of obtaining frequent BP checks were: 1) having BMI ≥25.0 (adjusted odds ratio (AOR)  =2.57, 95% confidence interval (CI)=1.39–4.78), 2) greater tendency to seek health information (AOR=1.13, 95% CI=1.03–1.24), 3) receiving less support from family members (AOR=0.87, 95% CI=0.77–0.97), and 4) receiving greater support from health volunteers (AOR=1.12, 95% CI=1.01–1.23). Conclusion: Positive deviants were more likely to be proactive because of the convergence of their own individual-level tendencies to learn about  their health, family-level conditions that allowed for greater autonomy, and community-level capacity of health volunteers to provide them with support. Community health nurses should focus simultaneously on activating individual-level, family-level, and community-level capacity to prevent hypertension.


Blood pressure screening; middle-aged; women; rural; positive deviance


Hussain MA, Mamun AA, Reid C, et al. Prevalence, awareness, treatment and control of hypertension in Indonesian adults aged ≥40 years: findings from the Indonesia Family Life Survey (IFLS). Plos One. 2016;11(8):e0160922-e.

Glynn LG, Murphy AW, Smith SM, et al. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010(3):CD005182.

Crabtree MM, Stuart-Shor E, McAllister M. Home blood pressure monitoring: an integrated review of the literature. J Nurse Practitioners. 2013;9(6):356-61.

Fuchs SC, Mello RGBd, Fuchs FC. Home blood pressure monitoring is better predictor of cardiovascular disease and target organ damage than office blood pressure: a systematic review and meta-analysis. Curr Cardiol Rep. 2013;15(11):413.

Sheikh S, Sinha AD, Agarwal R. Home blood pressure monitoring: how good a predictor of long-term risk? Curr Hypertens Rep. 2011;13(3):192-9.

George J, MacDonald T. Home blood pressure monitoring. European Cardiology. 2015;10(2):95-101.

Guenter D, Angeles R, Kaczorowski J, et al. Choosing the optimal method of blood pressure measurement for limited-resource rural communities in the “Community Health Assessment Program-Philippines”. J Clin Hypertens. 2017;19(9):899-903.

Park S, Buranakitjaroen P, Chen C-H, et al. Expert panel consensus recommendations for home blood pressure monitoring in Asia: the Hope Asia Network. J Hum Hypertens. 2018;32(4):249-58.

World Health Organization. A global brief on hypertension 2013. Accessed September 2, 2021 http://apps.who.int/iris/bitstream/10665/79059/1/WHO_DCO_WHD_2013.2_eng.pdf?ua=1.

Wang Y, Wang Y, Gu H, et al. Use of home blood pressure monitoring among hypertensive adults in primary care: Minhang community survey. Blood Pressure Monitoring. 2014;19(3):140-4.

Ostchega Y, Berman L, Hughes JP, et al. Home blood pressure monitoring and hypertension status among US adults: the National Health and Nutrition Examination Survey (NHANES), 2009-2010. Am J Hypertens. 2013;26(9):1086-92.

Wang Q, Xu L, Sun L, et al. Rural-urban difference in blood pressure measurement frequency among elderly with hypertension: a cross-sectional study in Shandong, China. J Health Popul Nutr. 2018;37(1):25-.

Ostchega Y, Zhang G, Kit BK, et al. Factors associated with home blood pressure monitoring among US adults: National Health and Nutrition Examination Survey, 2011-2014. Am J Hypertens. 2017;30(11):1126-32.

Kementerian Kesehatan Republik Indonesia [Indonesian Ministry of Health]. Petunjuk teknis pos pembinaan terpadu penyakit tidak menular (POSBINDU PTM) [Technical instructions for integrated health post of noncommunicable diseases]. 2012. Accessed August 28, 2018. http://www.p2ptm.kemkes.go.id/dokumen-p2ptm/petunjuk-teknis-pos-pembinaan-terpadu-penyakit-tidak-menular-posbindu-ptm.

Pascale R, Sternin J, Sternin M. The power of positive deviance: how unlikely innovators solve the world’s toughest problems. Boston, MA: Harvard Business School Publishing. 2010.

Banerjee ES, Herring SJ, Hurley KE, et al. Overcoming obesity: a mixed methods study of the impact of primary care physician counseling on low-income African American women who successfully lost weight. Am J Health Promot. 2018;32(2):374-80.

Positive Deviance Collaborative. What is positive deviance? n.d. Accessed May 4, 2019. https://positivedeviance.org/.

Staessen JA, van der Heijden-Spek JJ, Safar ME, et al. Menopause and the characteristics of the large arteries in a population study. J Hum Hypertens. 2001;15(8):511-8.

Coylewright M, Reckelhoff JF, Ouyang P. Menopause and hypertension: an age-old debate. Hypertension. 2008;51(4):952-9.

Direktorat Jenderal Pengendalian Penyakit dan Penyehatan Lingkungan Kementerian Kesehatan Republik Indonesia [Directorate General of Disease Control and Environmental Health Indonesian Ministry of Health]. Profil pengendalian penyakit dan penyehatan lingkungan tahun 2011 [Profile of disease control and environmental health 2011]. 2012. Accessed May 2, 2014. http://pppl.depkes.go.id/upt?id=85.

Mizutani M, Tashiro J, Maftuhah, et al. Model development of healthy-lifestyle behaviors for rural Muslim Indonesians with hypertension: a qualitative study. Nurs Health Sci. 2016;18(1):15-22.

Perhimpunan Dokter Spesialis Kardiovaskular Indonesia [Indonesian Heart Association]. Pedoman tatalaksana hipertensi pada penyakit kardiovaskular [Guidelines for management of hypertension in cardiovascular disease]. 2015. Accessed September 2, 2021 https://inaheart.org/guideline/

Hair JF, Black WC, Babin BJ, et al. Multivariate data analysis: a global perspective. 7th ed. Upper Saddle River NJ: Pearson Education; 2010.

Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373-9.

Long JS. Regression models for categorical and limited dependent variables. Thousand Oaks, CA: Sage Publications 1997.

Ma P, Magnus JH. Exploring the concept of positive deviance related to breastfeeding initiation in black and white WIC enrolled first time mothers. Matern Child Health J. 2012;16(8):1583-93.

Wallace ME, Harville EW. Predictors of healthy birth outcome in adolescents: a positive deviance approach. J Pediatr Adolesc Gynecol. 2012;25(5):314-21.

Marty L, Dubois C, Gaubard MS, et al. Higher nutritional quality at no additional cost among low-income households: insights from food purchases of “positive deviants”. Am J Clin Nutr. 2015;102(1):190-8.

Peters RM, Templin TN. Measuring blood pressure knowledge and self-care behaviors of African Americans. Res Nurs Health. 2008;31(6):543-52.

Diederichs C, Neuhauser H. The frequency and determinants of blood pressure measurement by a health professional in Germany: a cross-sectional study. Medicine (Baltimore). 2019;98(16):e15093.

Kementerian Kesehatan Republik Indonesia [Indonesian Ministry of Health]. Peraturan Menteri Kesehatan Republik Indonesia nomor 8 tahun 2019 tentang pemberdayaan masyarakat bidang kesehatan [Regulation of the Minister of Health of the Republic of Indonesia number 8 of 2019 concerning community empowerment in the field of health] 2019. Accessed December 19, 2019. http://promkes.kemkes.go.id/permenkes-no8-th-2019-tentang-pemberdayaan-masyarakat-bidang-kesehatan.

Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010(3):Cd004015.

Neupane D, McLachlan CS, Mishra SR, et al. Effectiveness of a lifestyle intervention led by female community health volunteers versus usual care in blood pressure reduction (COBIN): an open-label, cluster-randomised trial. Lancet Glob Health. 2018;6(1):e66-e73.

Kristanti MS, Effendy C, Utarini A, et al. The experience of family caregivers of patients with cancer in an Asian country: a grounded theory approach. Palliat Med. 2019;33(6):676-84.

Effendy C, Vissers K, Tejawinata S, et al. Dealing with symptoms and issues of hospitalized patients with cancer in Indonesia: the role of families, nurses, and physicians. Pain Pract. 2015;15(5):441-6.

Lukman NA, Leibing A, Merry L. Self-care experiences of adults with chronic disease in Indonesia: an integrative review. Int J Chronic Dis. 2020;2020:1379547.

Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global health. 2018;6(11):e1196-e252.

Perrier MJ, Martin Ginis KA. Changing health-promoting behaviours through narrative interventions: a systematic review. J Health Psychol. 2018;23(11):1499-517.

Full Text: PDF


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.