NEW approaches to health behavior change are needed. On the whole, there has been limited effectiveness of interventions in producing lasting health behavior change.1,2 At best, health professionals have had only minimal success at assisting individuals to adopt and sustain healthy lifestyles.3-5 Current health behavior change models are built predominately on philosophies that suggest that not using a particular behavior is a deficit or a problem to be solved.6-9 This article describes a new philosophical approach to promote health behavior change based on appreciative inquiry (AI), an affirmation process of organizational change that focuses on the positive and creative as a force for a more positive future.10 We also explore how it might be adapted from organizational change to individual change in healthcare. An example of its application is illustrated in a hypothetical therapeutic conversation with an African American woman of low-socioeconomic resources who is attempting to increase lifestyle exercise following a cardiac event. The challenges and issues associated with the development of AI as a health behavior change intervention approach are discussed.
WHAT IS AI?
AI is the study and exploration of what gives life to human systems when they function at their best. Developed by David Cooperrider in the mid-1980s11 in the School of Management at Case Western Reserve University, AI is a method of organizational development in which the "best of what is" is made better. Instead of solving the individual problems of an organization, organizations are viewed from the artistic perspective of the "appreciative eye," the notion that in every piece of art there is beauty. It is a process in which positive change is facilitated through energized and creative images of possibility based on strengths. At an organizational level, AI has been successfully used for strategic planning,12,13 team building,14,15 enlivening core values to drive large system cultural change,16-19 global summits,20,21 performance appraisals,22 and coaching.23,24 Since AI's introduction, it has been used in business,25-27 government,28-32 and religious20,33-35 institutions all over the world. AI has been used at all levels of organizations, from the whole organization to the department level, as well as in whole communities30,36,37 and individual community centers.10 AI is being introduced into the healthcare arena, but to date it has been applied only to healthcare organization development.
Although AI has not been used to improve the health of individual clients, it holds promise as a way to guide therapeutic interactions between clinicians and patients to bring about better health. AI achieves its positive outcomes on a simple principle: things that are affirming engender a force toward them.10 Thus, behavior is aligned with the positive images that are imagined and supported through the AI process. AI may be a particularly useful approach to health promotion in underserved women because the AI process permits women's personal situations, views, and desires to be shared and considered as of highest priority in the client-clinician relationship. Underserved women (eg, individuals who experience disadvantages as a result of low-socioeconomic status, educational attainment, or racial and ethnic group membership) are those who experience obstacles in the delivery and access to healthcare, which often result in disparities in the burden of illness. It is possible that the AI process can be used to give voice to underserved women's hopes and dreams regarding their health and to assist them in finding the energy to move toward healthier behaviors.
AI principles, philosophy, and process
In its organizational applications, AI is a generative process. (Although the following description of AI comes from organizational applications, we will eventually describe its adaptation to clinical interactions.) The first step in the AI process begins with interviewing and storytelling among all persons involved in the organizational use of AI (employees, supervisors, boards of directors) about the organization at its very best so that the best of the past can be used to visualize effectively what could be. From there, participants create a series of statements that describe where the organization wants to be based on the best of where it has been. This is done through asking positive questions, with all members of the organization inquiring into the possibilities for the future. In AI, the art of the question is of primary importance. Asking questions is a fateful act. People move in the direction of what we most frequently and systematically ask questions about.
AI is based on 8 general principles: (1) in every society, organization, or group, something works; (2) what is focused on becomes the reality of the organization; (3) the language used creates the reality; (4) the reality is created in the moment, and there are multiple realities; (5) the act of asking questions of an organization or group influences the group in some way; (6) people have more confidence and comfort to journey to the future when they carry forward parts of the past; (7) if we carry parts of the past forward, they should be what is best about the past; and (8) it is important to value differences.10,38Figure 1 shows the basic framework of AI, the 4D cycle. The 4D cycle consists of 4 phases of discover, dream, design, and deliver around a positive core.
The first phase, discovery, focuses on "What gives life to the organization?" and "What creates the best of what is?" within the organization. Examples of questions asked in the discovery phase include "Describe a time when you feel the team performed really well. What were the circumstances during that time?" or "What do you value most about being a member of this team? Why?" In this early phase, pairs of participants interview each other using these questions. One person asks the questions, the other answers, and then roles are switched. The questioner jots down notes and finds additional questions to ask; within the context of AI, conversations are permitted, and neither party needs to remain a neutral interviewer.
The second phase, dream, focuses on envisioning results in the organization and asking "What might be?" and "What is the organization calling for?" People work to collectively explore hopes and dreams for their work, their working relationships, their organization, and the world. Possibilities that are big, bold, and beyond the boundaries of what has been in the past are envisioned.
The third phase is design. Participants take what they have learned in the discovery and dream phases and explore what should be. In this stage, what are called "Provocative Propositions" are developed, which describe the ideal organization. These propositions are stated in the affirmative to remind everyone what is best about the organization and how everyone can participate in creating more of the best. These propositions are also set to stretch, challenge, and energize participants; they remind participants of how things will be when the organization's positive core is boldly alive in all of the strategies, processes, and systems.
The final phase of AI is deliver. In the deliver phase, organizational change is sustained and adjusted if necessary. This stage focuses on the sustaining of personal as well as organizational commitments for change. A question that can be asked at this stage is "How should the organization empower, learn, adjust, and/or improvise?"
Contrasting AI with the problem-solving approach
Traditionally, it is assumed that organizational systems embody or contain problems to be solved, which entails the notion that improving the system is a process of removing deficits and obstacles. The problem-solving approach involves identifying these deficits, analyzing the causes, considering solutions, and developing the treatment of the problem. The problem-solving process is then repeated for each problem that the organization encounters. This approach assumes that there are always problems to be fixed. Alternatively, AI assumes that the organization is not a problem to be solved. Rather, it is a mystery to be embraced. The deficit thinking of problem solving is replaced with the possibility thinking of AI. This possibility thinking is accomplished through systematic inquiry using a set of questions to appreciate and value the best of what is, envision a future of what might be, and dialogue about and create what will be.
CURRENT MODELS OF HEALTH BEHAVIOR CHANGE
Over the last 30 years, a considerable body of knowledge has developed about facilitation of health behavior change. Social learning theory6,39 has greatly contributed to our understanding of how motivation affects behavior change. Interventions that use a cognitive-behavioral approach, such as self-efficacy enhancement40,41 and relapse prevention strategies,7 have been shown to promote health behavior change in healthy adults. More recently, interventions based on the stage of change (transtheoretical model) theory8 and environmental models42 have shown some success in enhancing lifestyle changes. Interventions based on these models, however, have had limited effectiveness in producing lasting behavior change.1-5 Given the overall dismal levels of success in changing lifestyle health behavior, other models of social change must be considered.
Although many current health behavior change models are built predominately on philosophies that suggest that not performing a particular behavior is a deficit or problem to be solved,6,7,9 there are some health behavior change strategies that have components based on more affirmative philosophies. These include motivational interviewing,43 learned resourcefulness,44 imagery,45 and asset assessment.46 Motivational interviewing is an approach to overcoming the ambivalence that keeps many people from making desired changes in their lives, even after they seek medical and/or psychological care. Motivational interviewing consists of a series of interviews with a client in which the interviews create a shift from negative questions "Why isn't this person motivated?" to the more positive "For what is this person motivated?"43 AI differs from motivational interviewing, however, in that AI emphasizes the dialogue between 2 people-the AI process is not scripted (as in motivational interviewing) and evolves as stories are elucidated.
Another affirmative strategy is learned resourcefulness, a cognitive-behavioral repertoire of skills that an individual uses to control the effects of disturbing thoughts, feelings, and sensations on daily task performance.44 These skills include self-instructions such as positive self-talk, priority setting, postponement of need gratification, and belief in coping effectiveness and reinforcement of effective coping behaviors. In contrast to AI, problem solving is an important component of learned resourcefulness.
Numerous types of imagery have been used to promote health behavior change.45,47,48Imagery is defined as a mind-body intervention that uses an individual's imagination to change physical, emotional, or spiritual characteristics by forming a mental representation of an object, place, or situation. Several characteristics make imagery similar to AI. Imagery must be individualized to the situation and be congruent with the values of the person using it, and it works best in a permissive, unforced atmosphere. Imagery is consistent with some of the techniques used in the dream and discover phases of AI.
Asset assessment,46 also known as resiliency or the asset model of assessment, is another affirming health promotion approach that is typically used in social work. Resiliency factors, conceived as the flip side of risk factors, include intrapersonal, interpersonal, and community components. This model presupposes that when the environment is viewed as a source of opportunities rather than obstacles, the number of perceived resources expands. Thus, an asset assessment's goals are to identify factors that facilitate collaboration with natural support systems, then develop asset inventories within a geographical area. Asset assessment has been critiqued for the difficulty of employing data from the assessment to design interventions for the community.
Because of its demonstrated success in effecting change in organizations, AI offers promise as an approach to health promotion in individuals. Individuals and their environments comprise systems. Health professionals desire to influence these person-environment systems to promote healthier lifestyles. It may be reasonable to move beyond the prevailing models of health behavior change, which are predominately based on a deficit model of care, to models based on an affirmation philosophy. As a philosophical framework, deficit thinking can create fragmentation, few images of possibility, negative frames of self that are self-fulfilling, fatigue caused from a visionless voice, defensiveness, and slow change. Alternatively, the use of AI offers a way to shift from deficit thinking to affirmation thinking. AI is based on the positive psychology49 of supporting positive change, building on strengths, generating energy, and encouraging creativity.
AI AS A HEALTH BEHAVIOR CHANGE INTERVENTION
Although applying AI to the promotion of health behavior change requires some modifications to the AI process as it has been used, the principles remain similar. That is, the clinician and client engage in a cooperative search for strengths, passions, and life-giving forces. The clinician's goal is to engage in a dialogue that draws out, builds on, and reinforces stories of what the client feels works or has worked in his or her life, affirming clients' abilities to make decisions. To maintain the fundamentally affirming focus of an AI dialogue, the key is to listen carefully to responses and ask only positive questions. AI also provides an opportunity for enhancing the voices of individuals who are in less advantageous positions, because no question should require or even suggest the need for literacy. Overall, the expected outcome is that the newly created open and inclusive clinician-client relationship will promote information sharing and openness to new possibilities.
Sample questions of an AI dialogue to support health behavior change
A series of sample questions are provided below that can be used by a clinician to guide a dialogue with a client about health behavior change using the AI approach. The questions are organized consistent with the 4D cycle of AI and provide examples from which the clinician might choose. The discover phase consists of the clinician discussing the core life-giving forces of healthy living for this individual. The questions asked in this phase are formulated to determine what aspects of their health clients most value and want to carry into the future. Possible questions for clinician-client interaction in the discover phase are as follows:
1. Describe a time when you had an exceptionally healthy lifestyle.
What did you appreciate about the experience?
What was it about you that made this happen?
What was it about others that made this happen?
What other situational factors supported this positive experience?
2. Take a moment to think about what health means to you.
Tell me what health means to you.
Tell me a story of when you felt particularly healthy and alive. Why was it powerful?
What are the good things about you that helped make this a special time?
Did you learn anything new about yourself?
Who else was involved and how did they help?
Was there anything else that helped make this time special?
3. From time to time, we all need help. Can you tell me an experience when you felt cared for? It might have been through an interaction with a doctor, nurse, or aide; in a hospital, in a home, or in a place having nothing to do with health or care. What made it so special?
How did others help?
Was there anything else that helped make a difference?
The dream phase is a process of challenging the status quo by envisioning more valued and vital futures. Questions are designed to invite the client to think "great" thoughts and create great possibilities for the future. What might be? Sample questions to stretch the imagination are as follows:
1. Imagine a world where everyone could be in charge of his or her own health and care.What are the most important things you would need to take care of your own health and care?
2. Your health and the health of your family is affected by what happens in your community. Imagine that you live in a truly healthy community. What would be different from the way things are now?
What role do you see for yourself?
What steps could your community take to ensure a healthy future?
3. If I were to give you 3 wishes that could be used to improve your exercise, what would those 3 wishes be?
What things would need to be in place for those wishes to come true?
What would you do?
What would others in your life need to do?
What would I need to do?
4. Imagine that you are so physically active that you feel very fit and healthy. What would you feel like on a daily basis? What would you be doing? How do you think you would look? How do you think it would help your heart? Health overall? What would you see yourself doing for exercise that would make you feel good while doing it?
What could you do that would be different from the way things are now?
What steps would those around you need to do to help you?
What steps would I need to do to help you?
The design phase is a collaborative construction of positive images of the person's future. It is the creation of the new social architecture by the generation of provocative propositions. What should be? Questions for the construction of the positive images are as follows:
1. What could you do now to be more in charge of your own health and care?
Who would you go to for help? Is there anything the people you go to now for help could do differently so you could take more charge of your own health and care?
The goal is to create bold statements of ideal possibilities (provocative propositions) and find principles to preserve (features to build into one's life). Examples of bold statements by clients are "I devote time to myself everyday to keep my heart healthy." or "I would miss exercise if I did not have it in my life every day."
The deliver phase is where people are invited to align their interactions in the co-creation of the future. There is a redesign of processes and systems to incorporate the new affirmed vision. The clinician and the client co-create "what should be." In this phase, a consensus is reached regarding principles and priorities. Strategies are designed to accomplish short- and long-term goals and to discuss what is needed to make the dreams come true. The positive future is turned into an action plan to realize it. The clinician and the client determine the who, what, when, where, why, and how of the first steps in the action plan. The client makes personal commitments on the tasks to realize that future, and the clinician can make his or her own commitments toward that future as well. As actions are taken, sharing, learning, and adjusting are done to move closer to the desired positive future. A possible question to be asked is: "What are we going to do to start this process?" One or more simple tasks are chosen for immediate action.
Feasibility of the use of the AI process
The length of time of the AI dialogue can vary. We found that in an 8-minute dialogue individuals can provide their stories about their best of what is? (discover phase). In another 8 minutes, they can describe a positive future they desire (dream phase). If 30 minutes are available, we suggest that all the steps be initiated, including developing a set of provocative propositions and designing action steps (design and deliver phases). It is not necessary for all the steps to be done at one session, although the discover and dream phases are likely most efficiently done together. The process is not necessarily as linear as we have suggested; it may take several sessions and revisiting the dreams, designs, and steps taken toward delivery to make lasting change.
An important issue to address is how the AI interview is documented in the client's health record. Some general guidelines are that documentation should be written in the affirmative and in the active voice. Quotes should be freely used. The clinician documenting the interview should screen for negative phrases and cliches. Figure 2 provides a sample of the documentation of a 30-minute AI session associated with the case study described below.
It is important that the distinctive features of AI be preserved as health professionals design health promotion interventions using this theory. Some of the distinctive features are the following: (1) AI is fully affirmative; (2) AI is inquiry based (art of the question), the ability to craft unconditionally positive questions; (3) AI is improvisational (an experiment to bring out the best); and (4) AI helps participants move from deficit-based change to positive change.
Illustration of use of AI to increase exercise by underserved women
There are several reasons AI may be a promising approach to health promotion in underserved women. First, AI methods equalize power by giving voice to a woman's most personal situation, needs, and desires. It also reduces defensiveness and opens discussions, creating a positive framework that provides ideas and energy to address an immediate situation. One strength is that it does not depend on the client's literacy or advanced problem-solving abilities. AI also builds on spiritual and hopeful thinking, often a characteristic coping style among ethnic minorities. A hypothetical case study is provided next in which sample questions to support the AI process are used to assist an African American woman of low-socioeconomic resources to increase her physical exercise.
Mrs S is a 55-year-old African American woman who had a myocardial infarction 11 weeks ago. She is married and living with her husband who is retired; no children are living in the household at this time. She has had a good recovery from her myocardial infarction and plans to return to work as a part-time baker in a large grocery store. She has a body mass index of 32, hypertension, and a sedentary lifestyle. It has been recommended that she increase her exercise for her cardiovascular and overall health. Mrs S is meeting with her nurse practitioner in a comfortable conference room in the clinic during a routine follow-up visit. Questions consistent with the AI process are as follows:
Introduction of the AI process with Mrs S
I believe that it is within the power of every individual to have a positive effect on his or her life and health. Today we can learn about your spirit, strengths, and inner knowledge by hearing your stories about health and healthy living. I would like to focus on the positive. I want to focus on the things that are or have gone right with your health and how we can increase them and bring them into the future to help you to stay in good health.
Discover phase
I am going to ask you to share some stories with me about your health experiences. I will keep some brief notes as we go along and I will ask you some clarifying questions. The purpose of this interview is not to discuss any problems, but rather to bring out the positive energy and hopes and dreams of what your health can be and how we can use your past positive experiences and energy to bring those good things into the future.
So, take a few minutes and share a story about a time when you felt really good about your physical activity and moving your body. What did you appreciate about that time?
What was it about you that made this exercise happen? Why did your body feel so good? What was it about others that made this happen? What other things supported this positive experience?
Dream phase
Imagine that you are so physically active that you feel very fit and healthy. What would you feel like on a daily basis? What would you be doing? How do you think you would look? How do you think it would help your heart? How would it be helping your overall health? What would you see yourself doing for exercise that would make you feel good while doing it? What could you do that would be different from the way things are now? What steps would those around you need to do to help you? What steps would I need to do to help you?
Design phase
Now, let's summarize the big points of your story and your dream of an active, healthy lifestyle for yourself. What major things have we learned about you that will make your dream come true?" "What could you do right now?Mrs S then develops the following provocative propositions: (1) I will exercise daily and have lots of fun with my husband while doing it. (2) I will go up a flight of stairs and not be out of breath. (3) My clothes will not be tight and will look good on my figure.
Deliver phase
That's a great vision for yourself. It seems to be a reasonable one too. Let's think together about some first steps to move you closer to that vision. What are some things that you can do in the next week that would move you closer to doing some physically active things that would include your husband and be fun?
CHALLENGES AND POTENTIAL OF AI AS A HEALTH PROMOTION INTERVENTION
Several challenges present themselves as the AI process is adapted to enhance health behavior change: adapting AI from organizational applications to individual ones, the feasibility of the AI approach in existing healthcare delivery environments, and the philosophical compatibility of the AI approach with health professionals' existing paradigms of providing care.
Adapting AI as a feasible intervention approach for health behavior change requires determining the kind of client situations that might lend themselves best to this approach, among other considerations. Can AI be used with a dyad of clients working on the same health concern, with groups, or with whole families? Can some of the AI process be done electronically (as before-visit preparation) to decrease the time of a face-to-face visit? The role of the clinician needs to be further clarified. For example, do both client and clinician need to agree with the possibility statements? Can the process be enhanced by clinicians' disclosure of their hopes and dreams regarding their client's care? Lastly, should AI be used solely as a new paradigm of enhancing health behavior, or should (and can) it be combined with existing models of health behavior change? Since AI is a philosophical approach to care with a specific set of strategies, caution should be taken to adhere to the AI framework of seeking ways to have clients identify and do more of what already works for them. The questions associated with this dialogue process drive the AI; clinicians should not just insert positive questions into the traditional problem-solving mode of diagnosing and treating clients and believe that they are using the AI process.
The issue of the philosophical compatibility of AI with the predominate paradigms of healthcare and health promotion is important. One might be concerned that AI glosses over problems. The AI approach does not deny problems, but it does support the view that changing a situation may be more effective when individuals focus on strengths rather than on problems. To those who are skeptical that the use of AI ignores problems, it is suggested that if clients and clinicians hold in their minds what is wrong, they should be encouraged to also hold in their minds what should be present to make it right. AI provides a method to bring what is right and appreciated to the forefront to build a healthier future. The positive affirmation that produces the results in AI depends on data collection and theme analysis, not on "feel good talk." Finally, there are some positive outcomes for the healthcare system at large that could result from the use of AI philosophy as an approach to care delivery. Used successfully, AI has the potential to produce greater capacity for sustainable change among our clients and contribute to the joy in our work as clinicians. It is also possible that AI can contribute to a new breed of loyalty among clients, clinicians, and healthcare systems.
It is recognized that AI will constitute a huge paradigm shift for clients as well. Because the AI approach may be disorienting to clients, it may be desirable to introduce this process in healthcare environments with traditions of counseling based more on affirmation models than on deficit models of healthcare, such as cardiac rehabilitation centers or diabetes education programs. Clearly, studies to further design and test the effectiveness of AI to produce lasting health behavior change are needed.
SUMMARY
AI is considered a method of creating change. Health professionals are looking for effective ways to help clients make health behavior changes. Health professionals cannot assume that the only path to improving healthy lifestyles is looking for clients' problems in compliance and solving them. AI suggests that looking at opportunities and strengths and drawing on the hopes of people is another path to creating healthy lifestyles. AI involves a paradigm shift-from one of deficit thinking to one of affirmation thinking. As deficit thinkers, we can be constrained by our inability to see larger and more expansive realities that are often right under our noses. AI is a tool for understanding clients, their values, and their situations as they know and understand them. Using AI assists us to recognize client wisdom and appreciate the contributions they have made and can continue to make for their advancement. When we construct our inquiry around the aspects that help people remember their capabilities and competencies, we meet fundamental criteria of human motivation and position our work as that of coaches and collaborators.
REFERENCES