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Heide Aungst, MA, Monica Baker, Christina Bouyer, Bruce Catalano, LISW, Maria Cintron, Nicholas B. Cohen, MD, Patricia A. Gannon, MD, Jules Gilliam, BA, Heidi Gullett, MD, MPH, Kristen Hassmiller-Lich, PhD, Steven C. Horner, Ruchir N. Karmali, MS, Ólöf Birna Kristjánsdóttir, RN, PhD, MSc, Rachel Martukovich, MA, Jelena Mirkovic, PhD, James E. Misak, MD, BA, Shirley M. Moore, PhD, RN, FAAN, Natalie Ponyicky, RN, BS, Ann Reichsman, MD, Mary C. Ruhe, CNP, RN, MPH, Cornelia Ruland, RN, PhD, Debra S. Schaadt, MSW, Kurt C. Stange, MD, PhD, Una Stenberg, MSW, PhD, Sarah A. Sweeney, MD, Anna van der Meulen, Richard F. Weinberger, MD, Jewel Williams, and Joy Yokie, MLIS.
Author Information and AffiliationsMost health care focuses on patients' risk factors, diseases, and deficits. Identifying, amplifying, and applying patients' strengths is a potentially transformative strategy for motivating positive change and expanding resources for chronic disease management and prevention. However, there has been little research on effective methods for discovering patient strengths, bringing them into health care encounters in which they might be helpful, or assessing their impact on patient-oriented outcomes.
Identify patient-identified personal strengths relevant to chronic illness management.
The study was conducted in 2 phases by researchers from Case Western Reserve University, the University of North Carolina, the University of Oslo, and Cleveland, Ohio; primary care physicians; nurse practitioners; nurses; social workers; and patients with multiple chronic illnesses. In phase 1, we conducted focus groups and individual interviews of 76 patients from safety net practices. In phase 2, we invited particularly insightful participants to join a Design Team of patients, caregivers, and health care professionals, and purposively expanded the group to include diverse perspectives relevant to understanding how to incorporate patient strengths in primary health care, for a total of 19 participants. The Design Team had ten 2-hour meetings and conducted small pilot studies to refine a list of strengths and a new computer tool for assessing them. The Design Team also identified clinical situations in which patient strengths would be particularly helpful, developed design criteria, and attempted to model patient-oriented outcomes of a strengths-based approach in health care.
Patients from disadvantaged backgrounds found it difficult to articulate their strengths. However, interviews that started with positive life experiences, or that introduced participants to a newly developed computerized Strengths Collector tool that began with video stories, helped patients identify their strengths relevant to improving chronic disease management and prevention. Relevant patient strengths were related to personal attributes, interpersonal relationships, and community resources.
Participants identified 6 scenarios in which a strengths-based approach might be particularly helpful: diabetes management, high use of health care, chronic pain management, group health care visits, when patients feel a need to get “unstuck,” and when clinicians sense that focusing on strengths would be a useful way to reframe care.
Design criteria for implementing a strengths-based approach related to overcoming an external context focused on delivering commodities of disease care; organizational factors affecting relationship development; professional skills, roles, and philosophies; and the ease of implementing the strengths-based intervention.
Because of limited published data on outcomes from a strengths-based approach, we were unable to quantitatively model outcomes.
Through stories and examples, patients from disadvantaged backgrounds can identify strengths relevant to improving their health. A strengths-based approach may be particularly helpful in uncovering previously hidden motivations and resources in health care situations that require ongoing behavior change.
A major challenge in health care is to provide services that fully engage patients and caregivers and, in so doing, motivate positive behavior change. Clinicians need an array of tools to meet the epidemic of chronic and behaviorally mediated disease, for which both the cause and the solution have as much or more to do with lifestyles than with medical diagnoses and treatment.1 Therefore, a growing number of evidence-based interventions for preventing or ameliorating disease focus on patients' behaviors and motivations.2 In reaction to unsustainable health care costs and the evolving epidemiology of health and illness, the health care system in the United States is focusing more on population health,3,4 chronic disease self-management,5,6 and interprofessional approaches to health care and education.7
The traditional medical arsenal of diagnosis, prescription, and advice addresses only a small portion of what is needed to meet the current and emerging health care needs resulting from chronic illness. Additional tools and ways of connecting with resources outside of health care are needed to effectively prevent and manage chronic illness8 and to activate patients stressed by health and other life challenges.9
Conventional disease management may be especially inadequate for the growing number of people living with multiple chronic conditions.10,11 Patients with multiple chronic conditions are the norm rather than the exception in primary care,12 and interventions to fully engage this population are limited.13,14 A recent report, sponsored by PCORI, multiple government agencies, and patient advocacy groups, Understanding the Context of Health for Persons With Multiple Chronic Conditions: Moving From What Is the Matter to What Matters, emphasizes the need for a “person-driven, goal-directed research agenda” and the need for relevant research methods that are “participatory, flexible, multilevel, quantitative and qualitative.”15
Health care traditionally follows a deficit-focused model that emphasizes problems—diseases, risk factors, and unhealthy behaviors.16 This model is helpful for diagnosis and treatment of acute conditions and for diagnosis of chronic conditions. However, a focus on deficits can be demotivating and counterproductive in addressing long-term problems for which the patient needs to make lifestyle and other changes over time. A different frame may sometimes be needed to contend with problems such as managing chronic illness, supporting preventive behavior change, dealing with chronic pain or addiction, or even getting unstuck from a perpetual health care cycle of monitoring and nagging.
In contrast to the deficit-focused model, a strengths-based approach—one that focuses on a patient's assets—can potentially address ongoing problems that otherwise might seem intractable.17-19 Rotegard and colleagues define health assets as “the repertoire of potentials—internal and external strength qualities in the individual's possession, both innate and acquired—that mobilize positive health behaviors and optimal health/wellness outcomes.”20 Strengths might include social support (eg, family, friends, a faith community), resources in the community (eg, programs, clinicians, useful transportation support), knowledge (eg, health literacy, facility in navigating health systems), or individual skills or attributes (eg, persistence, creativity, love of cooking). Knowing a patient's strengths could help personalize treatment plans. Furthermore, when patients identify and act on relevant strengths, they may unleash previously hidden potential to improve their health.
Strengths-based approaches have emerged in social work,19,21 community development,22 positive psychology,23 nursing,24,25 business,26,27 and other fields,28,29 but, with a few notable exceptions,30-32 they have had limited formal exposition in health care. Strengths-based approaches are rooted, and sometimes hidden, in a variety of theories from these disciplines including the Biopsychosocial Framework,33,34 the Broaden-and-Build Theory,35 Salutogenesis,36 and Intentional Change Theory.27 However, how to apply these theories in health care, particularly in primary care, where most patient care is provided,37 is not well established.
Primary care has great potential to be a force for integrating, personalizing, and prioritizing care38-42 within a fragmented, depersonalized, and often wasteful health care system.43,44 Primary care also has been associated with a reduction in inequality in health care and health.45,46 Although a strengths-based approach is relevant to all patients, it might be most transformative for disadvantaged and vulnerable populations, for whom attaching additional deficit labels may be particularly harmful and for whom identifying and tapping into hidden strengths may be particularly refreshing and valuable.
Therefore, we aimed to determine how to elicit strengths from people from disadvantaged backgrounds, and to consider how these strengths might be most effectively brought into primary health care to enhance patient-oriented outcomes, as compared with the usual deficit-focused care. We aimed to meet the following objectives:
Using recommendations from prior literature,47 we share below the types and number of stakeholders involved, and how we conceived and achieved the balance of stakeholder perspectives. We describe the methods used to identify and recruit stakeholders, and the methods, modes, and intensity of engagement. Consistent with PCORI criteria for reporting and a recent systematic review,47 we describe the perceived or measured impact of engagement on the relevance of the research question; the study design, processes, and outcomes; the study rigor and quality; the transparency of the research process; and the adoption of research evidence into practice.47
Stakeholders from prior PCORI-supported research (ie, patients, caregivers, and primary care clinicians with payer, policy, training, and health care system experience)48 were informally involved in designing the research proposal submitted to PCORI for this study.
In our experience, patients from disadvantaged backgrounds living with multiple chronic conditions would be most likely to benefit from a strengths-based approach; additionally, we assumed that primary care settings, with their focus on the whole person, would be particularly well suited to implementing this approach. We therefore built on local connections from prior PCORI-supported research and from practice-based research networks, including the Safety Net Providers Strategic Alliance,49,50 to engage a sample enriched for participants with relevant lived experience.
Our project had 2 phases. For phase 1, which involved focus groups and individual interviews to identify patient strengths, we recruited patients through posters displayed in 3 community health center sites on the east and west sides of Cleveland.
For phase 2 of the project, which involved formation and ongoing meetings of Design Team, we recruited a diverse sample of patients, caregivers, and staff from primary care practices by following 2 steps. First, we ascertained the willingness of participants in phase 1 to participate (all but 1 were interested), and invited those who were articulate and thoughtful, and seemed able to participate in a group that included physicians. We also attempted to maximize diversity in participants' medical history, social background, race, ethnicity, and sex. Second, we invited a diverse sample of clinicians and practice staff from our practice-based research networks, the Research Association of Practices and the Safety Net Providers Strategic Alliance. For this step, we focused on people who exhibited a reflective, participatory manner and were respectful of differences; we also invited individuals who brought additional viewpoints that supplemented their clinical expertise, such as health care systems experience or work for an insurance company, purchaser, payer, policymaker, or training institution. At the first meeting of the Design Team, we asked participants which important and relevant voices were not represented, and on the basis of their suggestions, we invited additional participants.
As shown in Table 1A, our phase 1 focus groups and individual interviews were conducted with a diverse sample of 76 participants. As shown in Table 1B, our phase 2 Design Team consisted of a diverse group of 19 participants; 10 were invited to the team primarily as patients or caregivers and 9 primarily as health care professionals, but all brought unique and rich perspectives that defied classification into a single category. We did not formally collect descriptive information, but participants brought experience living with multiple chronic conditions, single serious illnesses, disability, addiction, and poverty; caring for ill family members; and engaging with and/or providing social work, nursing, and medical services in diverse settings.
Selected Participant Characteristics by Study Phase.
Data in the tables show that the Design Team in phase 2 of the study contained a smaller percentage of African American participants than the focus groups and interviewees in phase 1. This could be the result of a number of factors. One possible factor is a high representation of African Americans among the patients served by the safety net practices from which the patients were drawn, in an attempt to achieve good representation of people from socioeconomic disadvantage. Use of selection criteria that included diversity and ability to articulate complex views in a diverse group, and possible implicit bias among the academic team making the selection also could be factors. In addition, expansion of the initial group from patients and caregivers to also include in the Design Team health care professionals, among whom African Americans are less well represented, could have contributed to the differing racial mix.
Design Team members participated intensely in the study. They brought their lived experiences, participated actively in large and small group activities during ten 2-hour Design Team meetings, and tested ideas developed during the meetings in their own professional circles, bringing the results of this experience back into the group research process. They interacted in person and remotely with the Norwegian team that developed the Strengths Collector tool and with the University of North Carolina team that developed the design criteria for a strengths-based approach to health care.
Table 2 shows results of evaluations of the process completed by Design Team participants during their final meeting. In general, these results showed that participants felt the group process was successful, had a strong sense of the importance and potential of a strengths-based approach to make a difference for health care and health, and believed much more work will be needed to make a strengths-based approach practical in the current health care system.
Design Team Members' Evaluations of the Process.
These stakeholder assessments parallel the informal assessments of the academic researchers on the team and show a generally successful group process. They reflect both the progress in meeting study objectives and the challenges of limitations in the relevant scientific literature and of attempting to develop a novel approach that disrupts the usual time- and money-driven, deficit-focused approach to health care in the United States.
One Design Team participant, a clinician, was an outlier with respect to his ratings as compared with the average ratings shown in Table 2, giving ratings of only 1 or 2 (low) on the 5-point Likert scale. He had identified himself on his evaluation form, and the principal investigator met with him after the final meeting. The clinician provided very helpful advice to talk less during meetings, and to make greater use of small subgroup sessions during Design Team meetings to give people more time to speak and to foster more group creativity. The principal investigator and the clinician also discussed the challenges of using a participatory group process while simultaneously trying to meet prespecified objectives—that is, fostering the group process and meeting the needs of (in our case, very diverse) group members, while also making progress in accomplishing the task. The correct balance changes from moment to moment and differs for individuals in the group. Too much focus on the group process makes people more likely to drift away because they don't feel like they are accomplishing anything together. Too much focus on the task can make people feel unheard and more likely to drift away because they don't have enough chance for social interaction or to be heard.
This section provides an overview of how we attempted to meet the 4 study objectives:
To meet these objectives, we conducted a 2-phase study. Phase 1 used focus groups and individual interviews to meet objective 1. Phase 2 involved collaborative engagement of stakeholder and academic partners to meet objectives 2, 3, and 4.
In phase 1, to meet the first study objective of identifying patient-identified personal strengths relevant to chronic illness management, we used an iterative cross-sectional design involving appreciative inquiry51-55 focus groups and individual interviews. Some of the stakeholders from this phase continued on to participate in the next phase.
In phase 2, to refine the results of objective 1 analyses, and to meet objectives 2, 3, and 4, we engaged a stakeholder Design Team and content expert academic partners working together in an iterative process. This phase entailed developing and refining a strengths-focused, computer-supported, interactive, tailored patient assessment tool; elucidating a strengths-based approach to health care; identifying situations in which such an approach might be most helpful; and assessing the anticipated patient-oriented outcomes with this approach as compared with those seen with the usual deficit-focused approach to care.
The study protocol was registered with HSRProj.
The academic team from Case Western Reserve University coordinated the overall project. The academic team from the University of Oslo/Oslo Hospital brought expertise and evolving experience in strengths-based approaches and communication to all parts of the project, and took the lead in developing the computerized strengths assessment tool (to meet objective 2), building on their previously developed platform.56-59 The academic team from the University of North Carolina participated in all parts of the project, but provided particular expertise in design and simulation modeling (to meet objectives 3 and 4).
Patient participants for the initial appreciative inquiry focus groups and individual interviews were purposively60 recruited from signs posted at Cleveland safety net practices caring largely for underserved populations. Health care professionals were recruited from 2 primary care practice-based research networks: the Safety Net Providers Strategic Alliance49,50 and the Research Association of Practices.61 This strategy allowed us to focus on patients from disadvantaged populations with high rates of chronic illnesses, and to engage clinicians experienced in caring for them as well as having the larger systems perspectives needed for understanding, implementation, and dissemination.
From among these initial participants, and from a sample of participants in our prior PCORI project who had been involved in conceptualizing this project, we identified a diverse Design Team of patients, caregivers, and health care professionals, aiming to engage diverse participants living with or caring for others with multiple chronic conditions and people with varied experiences of health, health care, and community and health care system contexts. At the first Design Team meeting, we asked what other voices or expertise needed to be at the table to meet the study objectives, and we recruited a few additional participants accordingly.
Participants were compensated for their time, as allowed by our IRB.
The study setting of Cleveland, Ohio, represents a community with robust health care systems, strong communities, and high levels of health inequality and socioeconomic disadvantage. The practice-based research networks, particularly the safety net practices, allowed us to achieve diversity in stakeholders while focusing on patients and caregivers dealing with multiple chronic conditions and socioeconomic challenges, and clinicians with experience caring for diverse patients and knowledge of diverse systemic perspectives.
The academic partners of Case Western Reserve University, the University of North Carolina, and the University of Oslo provided expertise in, respectively, participatory and primary care research methods, systems dynamics modeling and design methods, and computer-assisted, patient-centered communication.
We worked together to develop and evaluate the feasibility of different approaches to bringing patient strengths into health care. This involved discovering how to elicit patient strengths, including development and refinement of a computerized tool to derive a patient-generated list of strengths. In developing the intervention, we also examined when using a strengths-based approach might be particularly helpful; elucidated what such an approach might look like, who could perform the various tasks, and what relationship development is needed for this approach to health care; and explored what the patient-oriented processes and outcomes might be.
We then attempted to compare this strengths-based approach with the usual deficit-focused approach for various care scenarios, contrasting the processes of care and patient-oriented outcomes as evidenced in the scientific literature for the 2 approaches.
Loss to follow-up was not relevant for the first phase, in which people participated only once. During the 2 years of the Design Team process, we did lose 1 patient participant, whose chronic illnesses progressed to the point that she was no longer able to travel to participate in meetings.
A main study outcome was the difference in patient-oriented outcomes seen with strengths-based versus deficit-focused health care; this was a focus of the Design Team's deliberations and was supported by the University of North Carolina's academic team's literature reviews and analyses. Through group discussion and small pilot investigations between meetings, the Design Team considered the scenarios in which a strengths-based approach would be particularly helpful. As the team designed the strengths-based approaches (outlined in Tables 3 and 4), they used their diverse experience and relevant literature to identify patient-oriented outcomes pertinent to the evolving understanding of strengths-based approaches. This process involved ongoing iteration which included understanding what relevant patient strengths are, how strengths can be elicited from patients and incorporated into different health care scenarios, and what relevant outcomes of this process would be.
Design Team Meeting Content and Homework.
Examples of Design Team Activities.
The phase 1 focus groups and individual interviews used an appreciative inquiry approach. Appreciative inquiry focuses on people's positive lived experiences and uses the energy from those peak experiences to imagine and work toward a more positive future.54,62-64 These focus groups and interviews iteratively worked to apply appreciative inquiry principles by asking participants to consider times in their lives when their best attributes were brought forth in a way that made a difference. Perhaps because of this positive approach, all but 1 of the participants in the focus groups expressed an interest in participating in the Design Team. As described above, all but 1 Design Team member, who had to drop out because of progression of her chronic illness, stayed on the team through the 2 years of meetings.
The University of North Carolina members of the team, aided by 2 reference librarians, performed multiple literature searches to inform the Design Team process. These searches aimed to quantify the effects of various aspects of a strengths-based approach on relevant patient-oriented outcomes identified by the team.
For example, among many search strategies, refined with medical reference librarian assistance, one of the more selective and focused (resulting in 112 items) was the following:
((“Patients/psychology”[Mesh] OR (“Patients”[mesh] AND (“Health Services Needs and Demand”[mesh] OR “Physicians, Primary Care”[Mesh] OR “Primary Care Nursing”[Mesh] OR “Primary Health Care”[Mesh] OR “Patient Care Team”[MeSH])) OR (“Patients”[Mesh] AND “Health Knowledge, Attitudes, Practice”[Mesh])) AND (“strength based” OR “strength-based” OR “strengths based” OR “strengths-based” OR “health asset” OR “health assets” OR “inner strength” OR “inner strengths” OR “individual strength” OR “individual strengths” OR “ego strength” OR “personal strengths” OR “personal strength” OR “personality strength” OR “character strength” OR “character strengths” OR capabil* OR resilience or “strength”[ti] OR “strengths”[ti] OR “assets”[ti]))
In phase 1 of the study, the academic team from Case Western Reserve University met after each focus group and individual interview to review and then discuss transcripts and notes. Using a combination of template,65 editing,66 and immersion crystallization67 techniques, the team identified themes68 related to identifying categories of patient strengths, how to ask about strengths, and when strengths might be helpful in clinical situations. Emerging themes and insights were used on an ongoing basis to refine the focus group and interview protocol. The academic teams from the University of Oslo and the University of North Carolina provided input by email and telephone. The combined academic teams refined their analyses and planned phase 2 of the study during a multiday research retreat.
In phase 2 of the study, similar analytic methods were used between the Design Team meetings to iteratively make sense of emerging findings and to use that understanding to plan future meetings and to provide supportive materials for the team. During this phase, the team from the University of Oslo used insights from the Design Team meetings to develop and iteratively refine a computerized tool to elicit patient strengths (later named by the Design Team as the Strengths Collector). In addition, the team from the University of North Carolina reviewed video recordings of Design Team meetings using editing66 and immersion crystallization67 techniques to identify themes68 related to meeting objectives 3 and 4. The academic team used additional retreats to synthesize emerging findings and to begin work on scholarly output to be further refined with the Design Team.
The Design Team held ten 2-hour meetings and conducted small pilot investigations between meetings. The content and homework (ie, tasks and small pilot investigations conducted by team members between meetings) for each meeting are outlined in Table 3.
Table 4 provides examples of the types of activities that occurred during meetings, which alternated between large and small group discussion and quiet time for personal reflection.
During its 10 meetings and small pilot investigations conducted between meetings, the Design Team worked to refine the strengths list and the new computer tool for assessing patient strengths. The Norwegian members of the team developed and iteratively modified the computer tool. Each participant was given an iPad containing the tool, to use in the small pilot investigations that involved asking people about their strengths, and sometimes applying them to improving their health or health care. The Design Team then identified clinical situations in which patient strengths would be particularly helpful, and developed design criteria that would be useful for implementing or for making a business case for a strengths-based approach in health care. Academic partners provided literature tie-ins and analyses between meetings and subsequently to develop scientific and communications output.
The study was approved by the Case Western Reserve University IRB. Despite challenges, we closely followed the approved protocol for objectives 1 through 3, and we attempted to follow the protocol for objective 4. For meeting objectives 1 and 2, the challenges in helping people discover and report their strengths led to important findings on the process of strengths elicitation, and to helpful refinements in the Strengths Collector tool. In working to meet objective 3, an important discovery was the challenge for the Design Team to produce design criteria and to specify details in the process and in patient-oriented outcomes, as much of the process and outcomes depends on the specifics of patients' strengths and situation. The challenge of defining a generic approach speaks to the need to tailor strengths-based approaches to the individual patient. The main deviation from the original study plan was due to the discovery of very limited quantitative details in the scientific literature on patient-oriented outcomes from a strengths-based approach. We needed quantitative data on outcomes to be able to construct models. The literature proved to be sparse and largely unhelpful in this regard (Hassmiller et al, unpublished data); as a result, we were unable to quantitatively model outcomes, as had been planned to meet objective 4.
In this section, we share the challenges of helping patients discover their strengths and how we responded to those challenges in developing a computerized Strengths Collector tool. Then we describe the features of a strengths-based approach, and situations in which it may be particularly useful. Finally, we elaborate on what we learned about designing approaches for bringing patient strengths into health care and share a video example.
Patients from disadvantaged backgrounds found it difficult to articulate their strengths, particularly when directly asked what their strengths were. However, interviews that focused on times when things went well in their lives helped patients identify strengths that might be relevant to improving chronic disease management and prevention. Once an example was brought to mind, they often could then identify particular attributes that they brought to bear to deal with a challenge or to make a positive change.
For example, when we asked patients to “Think about a time when you drew on strengths within or outside you to create a positive change in your health,” we got answers that focused on doctors, shots, pills, tests, costs, or waiting rooms. When we asked the patients to “Think about a time in your life when something good happened—it may be because of who you are, or the people around you or community resources made a difference,” patients told us great stories about using their strengths—they just never used the word strength. Stories and examples also aided understanding.
Helpful starting-point questions included the following:
A manuscript by the lead interviewer articulates her personal experience in learning to elicit people's strengths, and the epiphany of taking an approach that focuses on specific instances when things went well in someone's life (Aungst et al, unpublished data).
Parallel work by the academic team, conducted in anticipation of modeling patient-centered outcomes, examined the literature to identify strengths-based aspects of established methods for changing health behaviors (Martukovich et al., unpublished data). Three approaches relevant for primary care are motivational interviewing,69,70 solution-focused brief therapy,71 and chronic disease self-management.72 In motivational interviewing, a collaborative counseling style is based on partnership, compassion, acceptance, and evocation to elicit and strengthen motivation to change.73 In solution-focused brief therapy, the counseling style focuses on patients' successes, strengths, and resources by exploring and understanding exceptions to their problems, and inspiring patients to envision their desired future and to do more of what is working.74,75 In chronic disease self-management, a peer group develops and maintains positive behavior changes and helps patients manage illnesses by building self-efficacy through weekly meetings where patients develop and receive feedback on action plans.76,77 A strengths perspective also is formatively used in social work,21 nursing,24,25 and positive psychology.23
A refined list of patient-identified personal strengths falling into 3 categories—personal attributes, supportive relationships, and community resources—is shown in Table 5 and highlighted in the word cloud in Figure 1. The more items in a category in Table 5, the more prominent that category was in discussions and interview comments.
Patient-Identified Strengths to Help With Chronic Illness, Behavior Change, or Life Events.
Word Cloud of Patient-Identified Personal Strengths.
It is a paradigm shift to bring patient strengths into health care settings that already feel time-pressured because of the emphasis on deficit-focused, disease- and risk factor–based care. To drive a wedge into this usual paradigm, we developed an interactive computer tool to elicit patient strengths outside of the time pressures of the health care encounter, so that a patient-developed and -prioritized list of strengths could be a starting point for a different kind of health care built on patients' strengths. This tool, named the Strengths Collector by the Design Team, was created by the Norwegian members of the team, based on iterative input from the Design Team. It was built on a technology platform developed previously for a highly successful tool designed to elicit patient symptoms.57-59 It functions on an iPad, to enable easy use in a clinical setting.
When tested by the Design Team, the initial prototype required a fair amount of interpersonal interaction to help users understand the strengths concept, articulate their own strengths, and then envision how those strengths might be applied to health care and health.
Therefore, the team developed scripts for 4 types of patients who begin engaging with the tool in different ways. As shown in Figure 2A, these 1- to 2-minute stories were videotaped with professional actors, and serve as the front end of the computerized Strengths Collector tool. After viewing 1 or all of the video vignettes, the person using the tool is asked to rate the degree to which each item on a list of strengths describes him or her, as shown in the screenshot in Figure 2B. Users are also are given the chance to write in additional strengths. The tool then presents the resulting list of strengths and asks the user to rate the degree to which they are relevant to the reason for his or her health care visit. The tool then presents a prioritized list to the patient, and if desired, to the patient's health care provider.
Screenshot of Strengths Collector Tool: Personal Video Introductions.
Screenshot of Strengths Collector Tool: Strengths Selection Page.
The tool is available in the public domain at the Apple App Store (https://apps.apple.com/us/app/strengths-collector/id1324951675). As noted, it is particularly suited for use on an iPad.
The Design Team identified the following characteristics of a strengths-based approach to health care:
Patient-oriented outcomes from a strengths-based approach relate to greater engagement in health care, furthering understanding on both sides of the clinician–patient relationship, and greater motivation and meaning for needed behavior change. These outcomes include the following:
We also identified the possibility of negative outcomes. These relate not so much to the identification of patient strengths, which was universally a positive experience in both phases of the project. Rather, the possibility of adverse effects relates to what might happen if sufficient respect is not paid to the identified patient strengths. If a person's strengths are trivialized by the health care provider, or if they are used in a heavy-handed or dismissive way to coerce or insist on challenging changes without sufficient support, the result could paradoxically be reduced motivation. Peoples' strengths often are held close to their hearts, so a strengths-based approach requires sensitive application to be safely used.
The Design Team identified situations in which a strengths-based approach might be particularly useful. Table 6 shows these situations from the point of view of the patient, the clinician or practice, the clinician and patient together, and the health care system or organization, based on the type of visit. Each of these points of view can be a useful starting point for a strengths-based discussion.
When to Consider Bringing Patient Strengths Into Health Care.
The situations described in Table 6 span a wide variety of people and circumstances. What they have in common is a sense that the usual approach based on what is wrong―risk factors, diseases, or poor health habits―is not working, and that changing the focus to assets, rather than deficits, might be helpful. Applying a strengths-based approach could be as simple as a physician asking a patient about a time when something went well in his or her life, and then reflecting together with the patient about how that experience might be brought to bear on the current circumstances. It could be as complex as a patient asking for a different kind of conversation, and then the physician and patient developing a series of reflections, small experiments, and shared learning together over time.
The Design Team also identified 6 specific scenarios in which a strengths-based approach might be particularly helpful, as shown in Table 7.
High-Yield Scenarios for Bringing Patient Strengths Into Health Care.
There are many other possible scenarios in which a strengths-based approach might be helpful. Many of these relate to subtle circumstances best discerned by individual patients, clinicians, other health care professionals, or caregivers. However, the Design Team felt these 6 scenarios represented situations in which a strengths-based approach is likely to provide value from diverse stakeholder perspectives.
Figure 3 depicts the process used to develop design criteria—the steps that must be taken to successfully bring patient strengths into health care. In this process, Design Team members used an iterative process over time that involved refining the categories of strengths, defining situations and approaches in which bringing these strengths into health care might be helpful, and considering patient-oriented outcomes that might be affected by a strengths-based approach. The bullet points at the bottom of the figure show aspects of the process of a strengths-based approach; the bullet points on the right side of the figure show patient-oriented outcomes identified by the Design Team as likely to emerge from applying those processes. These can be used as a starting point for future empirical research to test the effects of strengths-based approaches on patient-oriented outcomes.
Designing Strengths-Based Care: Bringing Together Evidence and Stakeholder Perspectives.
Table 8 outlines important design criteria—factors to be considered—in planning strengths-based interventions in primary care. These relate to the external context and incentives, organizational processes and systems, aspects of the involved professions and their philosophies of care, and the nature of the strengths-based intervention. These criteria can be used to design a strengths-based intervention across a wide variety of contexts and situations (Karmali, in preparation).
Design Criteria for Strengths-Based Interventions in Primary Care.
Table 9 shows a simple application of the design criteria to 4 scenarios—patients living with chronic low back pain, patients living with diabetes, high/frequent users of the emergency department, and patients wanting to have a different kind of conversation. This application uses a modification of the PICOTS framework—Patient population (for the particular scenario), Intervention (a strengths-based approach), Comparator (usual, deficit-focused care), Outcomes, Time frame (duration of the intervention), and Setting.78,79 For each scenario, the Design Team specified 3 settings: a single primary care visit, longitudinal primary care, and settings outside of a visit with a single primary care clinician. These depictions are not intended to be proscriptive, but to give a sense of how the same strengths-based approach might play out if used in these diverse ways.
Application of Design Criteria to Various Scenarios, Using the PICOTS Framework.
An example of the implementation of a strengths-based approach can be seen in the video available at https://vimeo.com/196765613. This video (a screenshot is depicted in Figure 4) shows the enactment of the patient-initiated scenario, in which a patient sees a poster in the waiting room inviting a different kind of conversation. As prompted by the poster, she asks the receptionist what to do, and is given an iPad containing the Strengths Collector tool. The Strengths Collector tool produces a prioritized list of her strengths that is given to her clinician, and a different kind of conversation and plan for her chronic disease management ensue. Both the patient and the clinician are more hopeful and differently engaged after the encounter. The general approach is applicable to the other scenarios, and to involving other staff members.
Screenshot From an Enactment of a Patient-Initiated Scenario.
Our study findings reveal the transformative potential of a strengths-based approach to uncover previously hidden motivations and resources in health care situations that require ongoing motivation and wide support for behavior change. They also bring to light the limitations in current evidence regarding the effect of a strengths-based approach on patient-oriented outcomes.
We identified 3 domains of patient strengths and generated a list of example strengths within those domains that are grounded in the experience of people from disadvantaged backgrounds. Participants additionally developed techniques for helping patients identify their strengths relevant to improving their health or health care, particularly in the realms of chronic disease management and prevention. We have also developed and refined a computerized Strengths Collector tool, and placed it in the public domain in the Apple App Store.
The study also identified aspects of a strengths-based approach that may be useful in its application and articulated 6 scenarios in which engaging patient strengths in health care may be particularly fruitful. We additionally identified patient-oriented outcomes that may result from applying a strengths-based approach to health care, but we were unable to unearth sufficiently relevant quantitative outcomes to develop models comparing strengths-based versus deficit-focused health care.
Realizing the transformative potential of a strengths-based approach will require a paradigm change from the usual deficit-focused health care. Such a paradigm shift may be best targeted toward situations in which the limits of a disease- or risk factor–based approach, and the promise of an asset-based approach, are readily apparent. We have identified 6 such scenarios—diabetes management, high use of health care, chronic pain management, group health care visits, when patients feel a need to get “unstuck,” or when clinicians sense that focusing on strengths would be a useful way to reframe care. We encourage others to consider and experiment with these and other situations in which a focus on assets may be more productive than a focus on deficits.
It is not easy for patients from disadvantaged backgrounds to identify their strengths. Negativity of thought patterns, experience with cumulative disadvantage, adverse health care experiences, and being raised to not self-aggrandize all conspire to deemphasize strengths. However, through stories and examples, patients from disadvantaged backgrounds can identify strengths relevant to improving their health care and health. In the focus groups and individual interviews, participants typically thanked us for the opportunity to consider their strengths. Even outside of a health care application, the mere process of identifying and reflecting on sometimes hidden strengths may have therapeutic value in itself, by engendering a sense of worth, efficacy, hope, and connection.
These patient-identified strengths relate to personal attributes, interpersonal relationships, and community resources. The computerized Strengths Collector tool that we developed and placed in the public domain may be useful in starting a different kind of health care conversation that launches a positive path toward improving chronic disease management and prevention. Respecting the intensely personal nature of patient-identified strengths requires sensitive consideration of the vulnerability that a person shows in articulating his or her strengths. Future interventions will likely benefit from a training component to ensure that health care professionals are equipped to sensitively and effectively help patients build a different kind of conversation, self-identity, and future story, based on using the strengths within themselves and in their connections to others.
We hypothesize, on the basis of the developmental work described here, that improved health care and health from a strengths-based approach will be mediated through greater patient empowerment, motivation, and engagement, and through stronger relationships with family, friends, community resources, and clinicians. We further hypothesize that these mediating factors from a strengths-based approach will result in more empowered, engaged patients who are enabled to manage ongoing illnesses in ways that tie care processes to what is meaningful in their lives. More personalized, engaged care; healthier behaviors; adherence to care aspects that tie into meaning; and better overall health are likely patient-oriented outcomes of a strengths-based approach.
The Design Team stakeholders identified the potential healing effects of a more holistic understanding of the patient by considering the patient's priorities and values, richer communication, and trust that links motivation and instrumental help with challenging behavior change, leading to greater adherence to those evidence-based clinical care guidelines that are relevant to their lives. The resulting transformed relationships could serve as a salve for an increasingly burned out health care workforce, as well as for an increasingly isolated, depersonalized, and fragmenting patient experience of health care.
Systems support will be required if a strengths-based approach is to achieve a regular place in the health care armamentarium. The 6 scenarios we identified and the design criteria revealed in this research would be a good place to start. In addition, the video shared here provides a model for clinicians, practices, and patients who wish to begin experimenting with trying out a strengths-based approach and learning what works in what situation for which patient. Further research is needed to empirically test a strengths-based approach and to assess the resulting patient-oriented, health care team, and health care system outcomes.
This research, focused on primary care, advances work from positive psychology,23 social work,21 and nursing,24,25 and articulates the potential befits of a strengths-based approach. Brief discussions in this report, and a longer treatment in another manuscript (Martukovichet al, unpublished data) depict how 3 approaches—motivational interviewing, solution-focused brief therapy, and chronic disease self-management—that have made some inroads into primary care might be adapted to selectively use a strengths-based approach in the places where most patient care is provided.37 The limited evidence on patient-oriented outcomes among these approaches did not allow us to make a business case for a strengths-based approach, but the practical work accomplished in this PCORI study makes it possible to conduct further empirical research and reflective implementation, and pursue ongoing learning.
Relating to the list of strengths uncovered in this work, a recent concept analysis of patient strengths based on an extensive literature review80 identified internal strengths in relational, motivational, protective, and volitional domains, and external strengths in the domains of support, expectations of others, and physical and environmental elements. These categories are somewhat similar to our personal, interpersonal, and community strengths domains.
Other research and theory is congruent with the idea that a strengths-based approach in health care would require a fundamental shift in perspective—to increase focus on patients' assets, resources, and personal strengths as opposed to the currently more dominant consideration of patients' emotional, behavioral, and/or physical deficits.34,81 From previous descriptions of a strengths-based approach,19,21,23,25,29,82-85 5 key themes have been emphasized across fields that amplify our findings and put them into context:
Administering validated strength assessment scales and inventories
Using open-ended clinical interview questions aimed at eliciting strengths
Interviewing friends, family, and coworkers about an individual's strengths
Using standardized measures of resilience when a person is under duress
Encouraging individuals to use strengths to develop deeper levels of engagement with the world around them
Using narrative techniques such as storytelling to depict positive, strengths-filled moments
Honing an individual's ability to convert intangible strengths into tangible behaviors86,96
A recent review by Lau and colleagues102 puts our work into the context of understanding the diverse factors that influence the implementation of complex interventions in primary care. The design criteria that we developed articulate the relevant external context and incentives, organizational processes and systems, aspects of the involved professions and their philosophies of care, and nature of the strengths-based interventions. These criteria provide a starting point for additional implementation science research, as well as for patients, clinicians, practices, and health care systems interested in early implementation and rapid-cycle learning.
As discussed in the explication of the design criteria, the barriers to implementing strengths-based approaches are substantial in the current system, which measures and incentivizes delivery of commodities of health care103 and thus unintentionally devalues investment in relationship aspects of care.100 We believe, however, that the selective implementation of strengths-based approaches in situations in which the current system often is ineffective—such as in the 6 scenarios defined—can start to create overlapping ripples of demand for greater use of these approaches. The first are likely to come from patients, caregivers, and clinicians who see the transformative power of patient strengths. If those directly involved in strengths-based care see value, they may stimulate later change from health care system leaders who see the potential for cost savings and better outcomes. Further empirical research is needed, however, to conduct implementation with diverse patients in diverse health care situations and settings, and to evaluate impact on patient-oriented outcomes.
We focused on assessing strengths in patients from disadvantaged backgrounds and applying a strengths-based approach in the primary care setting. The results may generalize to other populations and settings, and findings from collaborating studies in Norway (Kristjansdottir et al., in press),80,104-106 a country with a more robust safety net and less socioeconomic inequality, suggest that it may be easier to elicit strengths from people having more advantaged backgrounds. But the challenges of overcoming the tradition and philosophy of deficit-focused care appear to transcend socioeconomic boundaries.
Similarly, strengths-based approaches undoubtedly are applicable to situations other than the 6 high-yield scenarios identified in this research. Although we would recommend further empirical research starting with these scenarios, the design criteria certainly can be applied to identify other situations in which bringing patient strengths into health care could have a positive effect on patient-oriented outcomes.
Our findings may be transportable to specialty settings, particularly those that have a whole-person or relationship focus to their patient care, and those that have less time pressure than most current primary care settings. They may be less transportable to acute care settings or to narrow specialties or those that don't provide longitudinal care. The findings may be easiest to implement in primary care settings that allow more time for relationship development, such as direct primary care,107,108 but the challenges of breaking into the current “productivity”-oriented environment, and its workflows focused on cranking people through protocols, are likely to be substantial.
As previously noted, our study findings are focused on patients from disadvantaged populations, for whom it may be a challenge to elicit strengths, but who may have the most to gain from a strengths-based approach. Our findings also are particularly applicable to people living with chronic illness, for which long-term health behavior change is a vital part of treatment.109 The large and growing number of patients with multiple chronic conditions,110 which is the norm rather than an exception in primary care,12 are particularly likely to benefit,13,14,111,112 as are frequent users of emergency or other health care, whose needs may not be well served by deficit-focused approaches.113,114 Patients for whom health behavior change could result in significant health benefits also are prime potential beneficiaries of a strengths-based approach to health care.8
Related work by Norwegian colleagues has examined strengths elicited from patients with cancer115 and from patients receiving care in intensive chronic disease management programs (Kristjansdottir et al, in press). Differences in culture, ethnicity, and social and health care systems, as well as the types of diseases under treatment, make comparisons challenging, but overall, the more advantaged Norwegian patient populations appeared to have an easier time identifying personal strengths and attributes.
In a study of Norwegian patients' insights into the design of technology to support a strengths-based approach to health care, patients with different chronic conditions (eg, chronic pain, morbid obesity, and chronic obstructive pulmonary disease) were interviewed and formed design teams.106 In this setting of universal health care and strong social services, patients recommended using technology in preconsultation settings (eg, at home) to help identify strengths and attain personal health-related goals. Patients recommended preparing in advance for strengths-based consultations and empowering patients to take a more active role. They suggested using technology to elicit patient strengths in specific contexts that include individual or group consultations with health care providers, individual clinical consultations, and also encounters outside health care settings (eg, self-management programs). For functionality and design, they recommended providing examples of strengths reported by other patients with chronic conditions and offering an option to extend the list with personal examples. They recommended offering an option to briefly summarize health-related history, and using intuitive, easy-to-use but also engaging user interface design. Like our US patients, the Norwegian patients with chronic disease felt that technology could facilitate meaningful patient–clinician communication that not only focuses on symptoms and problems, but also takes into account patients' strengths and resources.106 Ongoing work by the Norwegian team to develop a more game-like Strengths Collector tool could advance the tool developed for this PCORI research, by making assessment of strengths interesting to a wider range of people, including young people.
It was challenging for the Design Team to envision specific strengths-based interventions and to detail their components, in part because of the great benefit of tailoring care to the particulars of the individual.116 The need for a strengths-based approach to focus on context led to design criteria that lack details—a weakness for modeling processes and outcomes, but a strength in recognizing the benefits of personalization and in avoiding false specificity, and for creating broadly generalizable principles that can be applied and reinvented in different contexts.
Our biggest challenges were limitations in the scientific literature of information needed to assess the quantitative impact of strengths-based approaches on patient-centered outcomes. As a result, we were unable to fully meet objective 4—comparative effectiveness analyses of strengths-versus deficit-based approaches to health care. These gaps in evidence are a call for further research on the relationship between strengths-based approaches and patient-oriented outcomes. We had hoped to be able to use the parameters of a strengths-based approach, identified by our stakeholder Design Team in meeting objective 3, to define the various components of this approach based on literature relating the engagement of patient strengths in health care to patient-centered outcomes. Then we planned to iteratively feed this information back to our Design Team to ultimately develop a business case for the use of operationalizable strengths-based approaches to influence patient-centered outcomes. The aforementioned limitations in the literature forced us to work more by analogy, using aspects of approaches that in the literature have some components of a strengths-based approach, and some linking to patient-centered outcomes. We reframed some of the planned scholarly output to reflect what can be learned from the literature (Hassmiller et al, unpublished data), as well as what we learned from our participatory approach with our stakeholder Design Team (Karmali et al, unpublished).
The approaches and scenarios identified in this study would benefit from further refinement and evaluation in other settings, and they need empirical evaluation in real-world practice, with assessment of important contextual factors. A reasonable approach would be to begin with pilot studies, and then proceed to more definitive trials with sufficient numbers of participants to detect moderate and small effect sizes of strengths-based care as compared with deficit-focused care. Further comparative effectiveness research testing a strengths-based approach versus usual (typically deficit focused) approaches would be helpful. Particularly ripe for such investigations are chronic conditions for which management can benefit from patient motivation and engagement of other people and community assets.
Further usability testing of the Strengths Collector tool and of the processes and outcomes of its use is needed. Before it is tested in clinical trials, it should be assessed for reliability, concurrent validity relative to other assessment techniques (such as interviews), and effectiveness in improving quality of care, satisfaction, health, and well-being outcomes, relative to standard care and/or noncomputerized assessment methods.
The pursuit of a more game-like tool and studies among people with different chronic diseases and from different socioeconomic strata and sociocultural groups would be worthwhile endeavors. The Norwegian members of the team are leading such an effort.
It would also be useful to conduct a qualitative study of clinicians and patients assessing what happens when we try to bring strengths into health care encounters, to identify what works for whom in what situations and settings. Subtle and selective application of a strengths-based approach by clinicians and health care teams with sufficient time and training, and by empowered patients, caregivers, and families, is likely to have great benefit, however challenging such an informal approach would be to evaluate.
Compared with usual deficit-focused health care, a strengths-based approach has potential to better motivate and engage patients in behavior change and chronic disease management, and to launch a different kind of health care conversation, relationship, and trajectory. A strengths-based approach may be particularly helpful when long-term change is needed or when the patient or clinician feels stuck—situations that are frequent among people managing multiple chronic illnesses.
Patients from disadvantaged backgrounds often find it difficult to articulate their strengths but focusing on positive life experiences and then relating that insight to health can unleash a patient's recognition of his or her strengths related to personal attributes, interpersonal relationships, and community assets. The computerized Strengths Collector tool developed in this study and placed in the public domain can help people identify and prioritize strengths relevant to improving chronic disease management and prevention. Asking about strengths indirectly, such as by eliciting stories of when things went well for patients, is an approach that can be used informally in many health care situations to begin a conversation that emphasizes assets, rather than deficits, as a starting point.
There are 6 scenarios in which a strengths-based approach might be particularly helpful: diabetes management, high users of health care, chronic pain management, group health care visits, when patients feel a need to get “unstuck,” and when clinicians sense that focusing on strengths would be a useful way to reframe care. A video included in this report (shows 1 way of conducting a strengths-based, patient-initiated intervention, and provides a helpful overview of the approach. Design criteria for implementing a strengths-based approach in clinical practice include awareness of the current external focus on deficits, diseases, and risk factors; organizational factors related to relationships and resources; professional competencies and attitudes; and the nature and ease of implementing the strengths-based intervention.
The literature discussing the effects of strengths-based interventions on patient-oriented outcomes in primary care is limited and often somewhat tangential or indirect, so these approaches, while promising, must be considered investigational. The ways of asking about strengths and incorporating them into health care identified in this research provide a useful starting point for further investigation of the effects of strengths-based approaches on patient-oriented outcomes.
Supported by award No. 732 from PCORI. Also supported in part by the National Center for Advancing Translational Sciences, NIH grant No. UL1TR000439. Contents do not necessarily represent the official views of the NIH or of PCORI, its board, or its Methodology Committee. The authors appreciate the community members who participated in the stage I focus groups and interviews. We also are grateful to the following students who contributed important work to the project: Amir Alishahatiabriz, Samuel Baxter, Daniel Erim, and Sarah Lewis. We also appreciate Terence Oliver, who produced the video.
Research reported in this report was [partially] funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (#732) Further information available at: https://www.pcori.org/research-results/2012/identifying-personal-strengths-help-patients-manage-chronic-illness
Aungst H, Baker M, Bouyer C, et al. (2019). Identifying Personal Strengths to Help Patients Manage Chronic Illness. Patient-Centered Outcomes Research Institute (PCORI). https://doi.org/10.25302/3.2019.CER.732
The [views, statements, opinions] presented in this report are solely the responsibility of the author(s) and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute® (PCORI®), its Board of Governors or Methodology Committee.
This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License which permits noncommercial use and distribution provided the original author(s) and source are credited. (See https://creativecommons.org/licenses/by-nc-nd/4.0/
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