Health Science Department, Keene State College, 229 Main Street, Keene, NH 03435-2903, USA
Received date: April 28, 2014; Accepted date: August 18, 2014; Published date: August 30, 2014
Citation: Boyer J, Droppa M, Finneran J, Smith M, Bernius A (2014) Appreciative Inquiry: An Innovative New Strategy to Decrease Prescription Drug Abuse on a College Campus. J Addict Res Ther 5:195. doi:10.4172/2155-6105.1000195
Copyright: © 2014 Boyer J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Introduction: This article explores the use of an innovative research tool called Appreciative Inquiry (AI) as a new method of inquiry to help devise prevention strategies to decrease the non-medical use of prescription drugs by college students. In 2011, 1.7 million college-age adults age 18 to 25 used prescription drugs for non-medical purposes, the second highest group for this type of abuse. Recently, New Hampshire (NH) prioritized AI as an evidence-based strategy for prescription drug abuse prevention. The purpose of this study was to investigate whether AI could effectively engage a college campus to decrease prescription drug abuse among its students. Methods: A study was performed at a NH college in 2013 involving 47 college students, faculty, administrators, and community partners. Central to the process was the concept of AI, a participatory research method that enables communities to discover its strengths, enhance interconnections, and use social capital to tackle significant issues. Results: Several grassroots strategies emerged to decrease prescription drug abuse including a vision for the college to be a national leader in prevention. Conclusion: Based on our findings, AI is valuable tools to help communities such as a college campus devise strategies to decrease prescription drug use among its population.
Appreciative inquiry; Substance abuse; Prevention strategies
Prescription drug abuse, the intentional use of medication without a prescription or the use of a medication in a way not intended by the prescribing doctor, is the nation’s fastest-growing drug problem . On college campuses, the non-medical use of prescription drugs is a growing but unaddressed problem. In 2011, 1.7 million college-age adults age 18 to 25 used prescription drugs for non-medical purposes, the second highest group for this type of abuse . Within the last 12 months, approximately 16% of college students have reported using prescription drugs that were not prescribed to them . While alcohol abuse and binge drinking still top the list of substance abuse issues among college students, about one in four students has used prescription drugs for non-medical reasons. By students’ sophomore year, half of their classmates have been offered the opportunity to abuse a prescription drug. Moreover, 54% of undergraduates taking stimulant medication under the direction of a doctor have been asked to sell trade or give away their medication . Taking prescription drugs inappropriately has been linked to other high-risk behaviours among college students. For example, approximately 90% of college students who used Adderall (a medication used to treat attention deficit hyperactivity disorder and narcolepsy) non-medically were also binge drinkers and more than half were heavy alcohol users . Finally, non-medical use of prescription drugs can lead to problems of depression and suicide .
The most highly abused prescription drugs by college students are stimulants (e.g. Adderall, Ritalin, Concerta); sedatives and tranquilizers (e.g. Valium, Xanax); and opioids (e.g. Vicodin, OxyContin, Percocet). Students have reported abusing prescription medications to improve their grades and concentration, enhance athletic performance, reduce stress, forget about problems, feel good, get high, diet, and ease nervousness in social situations. A majority of these drugs are obtained from a doctor, friends or relatives .
In New Hampshire (NH), the designation of the non-medical use of prescription drugs as a public health crisis began in 2004 when the Governor’s Commission on Alcohol and Drug Abuse Prevention noted an alarming increase in prescription drug-related deaths. In 2012, the Commission reported that drug-related deaths in NH–the majority of which were prescription drug related–outnumbered traffic related fatalities in four out of the last five years. Also alarming was the fact that the rate of young adults (18-25 years) reporting non-medical use of prescription pain medication in NH was the second highest among the states and territories .
Previous and current methodologies for substance abuse prevention among college-age adults have included environmental management and individual efforts. Colleges have used ecological methods to prevent alcohol and other drug use. Some of these methods include strengthening campus policies, provision of alcohol-free activities, responsible beverage service, restrictions on industry marketing, substance-free housing, social norms and Greek life interventions [6,7]. Individual strategies have included brief motivational counseling, interventions that challenge alcohol expectancies, cognitive-behavioural skills training, and educational programs designed to address awareness of problem drinking and drug use.
While some of these strategies are already in effect at colleges and universities, the NH Governor’s Commission asked key stakeholders and organizations in the state to identify, promote and support additional evidence-based programs, policies and practices that communities can adopt to deter prescription drug abuse. Appreciative Inquiry (AI) was identified as one such strategy . AI can offer a means of discovering what works best for a specific college because it invites stakeholders who know the campus best to participate in solutions. The strength of AI as a prevention strategy lies in its community-building processes that are geared toward changing community environments, such as a college campus, in a positive and empowering way . This philosophy aligns with the principles of civic health and engagement where residents of a community participate in activities that strengthen social capital, enhance interconnections, build trust, help each other, discuss public issues and challenges, stay informed about their communities, and participate directly in crafting solutions to various social challenges .
The NH Governor’s Commission has called for a reduction in the percentage of individuals 12 years and older who report non-medical use of pain relievers in the past year by 15% between 2012 and 2017 . Therefore, the purpose of this study was to investigate whether AI could be used to help a NH college devise strategies to decrease the non-medical use of prescription drugs among its young adults. It was hypothesized that the AI would result in several grassroots prevention strategies.
Appreciative Inquiry (AI)
AI was developed in the 1980s by David Cooperrider’s dissertation research regarding organizational development . It is a participatory research method that asks participants to look at the positive assets of their community and use these assets to find solutions. In other words, “We strive to not focus on our weaknesses and the problem to ‘fix’ them, but to use that lens to look behind our problems to identify what is possible and to find the generative energy to attain it” [10, p. 9). This strength-based focus is a significant shift from the problem-solving approach where substance abuse prevention expert’s focus on what is wrong with a community. AI values the best of a community by allowing participants to envision ‘what might be’; to dialogue ‘what could be’; and discuss ‘what will be’. The inquiry is cooperative and involves a systematic discovery of what gives life to a community and when it is most effective and capable in economic, ecological and human terms . It is especially useful in bringing a community together; gathering information about the strengths of its population; and building on those positive attributes to further strengthen the community. Intensely participatory in nature, it requires involvement from a variety of social systems .
AI engages participants in prevention work by walking them through several interactive and participatory phases designed to gather information, brainstorm ideas, and eventually deliver a strategic plan. These phases are referred to as the five D’s: Definition, Discovery, Dream, Design and Delivery . In Definition, participants are guided through facilitated discussion and group activities to define the focus of the inquiry process. In Discovery, information regarding the community’s strengths is gathered from participants and summarized within groups. Partner interviews are used to gather in-depth information. In Dreaming, participants brainstorm the strengths of their community and begin imagining an ‘ideal future’ for it. In Design, a process unfolds that helps transition a community from its current state to its ideal future. Questions include: ‘How could our community make its dream a reality?’ and ‘What processes would need to be in place?’ During the final phase of Delivery, the dream is executed through a variety of strategies designed by participants. Delivery is typically an ongoing phase as AI facilitators work on strategy implementation, assessment, and evaluation .
AI has mainly been used in corporate settings and at all levels of the education system including higher education . For example, researchers used AI to explore how emotionally-intelligent leadership affects the organizational climate at a community college . In 2011, researchers used AI to make innovative changes to educational curricula in a South African community . In another study, researchers incorporated AI methods to perform strategic planning for a school of nursing. They found that the process increased the sense of community, captured ideas of all participants instead of a few, built relationships and identified areas of shared interest for development .
AI has not been extensively used in substance abuse prevention work. Researchers have used AI to examine drug abuse among a group of marginalized youth in a South African community. As a result, the youth initiated a life-skills group for youngsters and began building a community center. The authors suggested their success came from using AI to value and appreciate the youth instead of focusing on their problems or negative attributes . Other researchers found that AI helped change discourse around mental health by empowering staff and creating a more recovery-oriented culture among mental health agencies . In an effort to extend the research literature on innovative prevention practices in the substance abuse field, this study aimed to use AI to devise strategies to decrease the non-medical use of prescription drugs among college-age adults.
Participants and Procedure
This study took place during the 2013 spring semester at a college in NH. Study protocol was approved by the college’s institutional review board. It involved four 90-minute AI sessions that took place on four separate evenings on the college’s campus over a period of three weeks. The sessions were facilitated by an AI team: two faculty members from the college’s health science department who had been trained in the AI method by a senior epidemiologist from the NH Department of Health and Human Services and two community-based experts with previous AI experience. Although an AI typically needs a minimum of eight hours’ meeting time per session , the varying schedules of the college community allowed for six hours. This modification was not determined by the AI team to have altered the AI process in any significant way.
To test the hypothesis that an AI would result in prescription drug abuse prevention strategies for college students, a sample of participants (N=47) was recruited by email and in person during student class sessions. The participants were from a public college on the East Coast and its surrounding community. Participants were primarily white (98%) and female (83%). A majority were undergraduate students (62%). The remaining participants (38%) consisted of faculty and administrators from residential life, campus safety, student affairs, the multicultural affairs office, the campus health and wellness center, and community-based substance abuse prevention organizations. None of the participants was younger than 18 years and all of them voluntarily consented to participate. Participant interest in the study was varied and included the opportunity to be involved in timely research, a desire for an increased understanding of prescription drug abuse due to personal or family exposure to the problem, and the potential to help the college campus and surrounding community. A participant’s experience with active addiction or recovery from addiction was not considered for inclusion or exclusion purposes because it was deliberately not assessed. This was to protect confidentiality and to ensure participation by all segments of the campus population. Sustained participation over the course of the study was maintained by the potential to earn extra grade credit for student participants, refreshments during the meetings, and gift card drawings. No participants withdrew during the course of the study.
Session 1: Definition and Discovery
In the first phase (Definition), participants were introduced to the college’s prescription drug abuse problem through a series of informational slides and statistics. This defined the focus of the overall AI. In the second phase (Discovery), participants were partnered and asked to interview each other about what they valued in a healthy campus community and how they believed the college supported a healthy lifestyle. Participants were divided into five groups to summarize the information gathered from these interviews. Each group created a ‘Positive Core Map’ that portrayed the ‘Best of a Healthy College’ in summary phrases (Table 1).
|Group 1||Being of service to others||Student involvement outside the college||Social activities to improve communication||Safety and challenge|
|Healthy habits||Appreciate your college||Close community|
|Group 3||Advocacy||Structured programming||Community outreach||More awareness about healthy behaviors|
|Group 4||Wellness facilities and student clubs||Counsellor/ Res Life monthly check-up & interviews||Non-judgmental attitudes by peers||Support systems|
|Group 5||Supportive environment||Motivation to do one’s best||Building social connections by community involvement||Emphasis on healthy behaviours|
Table 1: Positive Core Map: Each Group’s Summary of the Ways in which their College Community Supports Healthy Lifestyles.
Session 2: Dream
The Dream phase began with more partner interviews. Participants were asked to imagine a drug-free college campus and discussed what would have to happen to make this a reality. Participants were encouraged to creatively explore positive possibilities using the greatest potential of the campus . In keeping with the core concepts of AI, the focus was not on what needed to be changed but on how the college could amplify and expand its strengths to reach its drug-free goals. In groups, participants built ‘Dream Statements’ that captured each group’s vision for a drug-free college (Table 2).
|Group 1||The college opens the community’s eyes to a new drug-free horizon!|
|Group 2||With an Increase in collaboration and funding, the college improves prevention programming and support systems.|
|Group 3||Supporters watched today as over half of the college’s students took a pledge to be H.I.P. (Healthy, Involved, Positive)|
|Group 4||Going the extra mile, the college community leads the way to prescription drug reform through new ways of resource support and prevention for communities across the nation.|
|Group 5||Stigma No More: College community unites to provide support and alternatives leading to national prescription drug reform.|
Table 2: Dream Statements: Each Group’s Vision for the College Regarding Prescription Drug Abuse.
Sessions 3 & 4: Design
In the Design phase, participants were asked to imagine how the college could move from ‘where we are now’ to ‘where we would like to be’. Participants were divided into five groups and asked to write chapter headings for an imaginary book. Each heading stated how the college could make the Dream of a drug-free campus a reality. Groups elaborated upon their chapter headings by listing specific actions that would need to take place in order to make the ‘dreams come true’.
The Design phase resulted in several strategies to decrease prescription drug abuse among college students. They included the need for the college community to pull together and increase awareness among top administration officials around prescription drug abuse. More prevention funding was needed, particularly for peer education programs. It was recommended that faculty and staff be better trained to recognize students who are at risk for prescription drug abuse. The college should also reach out more actively to neighboring communities and substance abuse organizations for help and host or sponsor neighborhood meetings, educational, and fundraising events to highlight prevention efforts. Table 3 lists the prevention strategies identified by AI participants.
|Chapter 1||College increases Awareness through Education and Marketing|
|Increase the number of peer educators and Res Life employees|
|Educate all new teachers/staff/faculty at the college|
|Increase awareness about stress relievers ( yoga, meditation, music)|
|Chapter 2||Coming Together as a Committed Community with Support and Resources|
|Apply for grants and inventory needs and resources|
|Meeting with neighbourhood associations|
|Chapter 3||Innovation Leading the Way|
|Develop peer support|
|Community endorsement/more resources/grants|
|New policies for prescription drug disposal and education|
|Chapter 4||Striving and Thriving: Promoting and Enhancing a Healthy Environment|
|Maintain what we already have in place|
|Continue to get grants and other financial resources|
|Students learning from students|
|Chapter 5||Achieving the Dream: From Small Things Big Things Grow|
|Importance of community unification and involvement|
|Marketing the cause (media)|
|Inspirational speakers for the public|
Table 3: Design Phase Results: How to Make the Dream Statements a Reality.
Participant involvement in this study ended with the Design phase. In the final and ongoing phase, Delivery, the AI facilitation team is working to ‘deliver’ the strategies identified by participants. This process is described in more detail in the Conclusion.
As anticipated, the AI resulted in several grassroots strategies to decrease prescription drug abuse. The process was helped by the fact that the study’s participants had the opportunity to civically engage with one another  and was able to focus on their community’s attributes as opposed to its weaknesses which can often feel demoralizing. Using AI’s positive approach encouraged more creativity, enthusiasm and community building. This empowered as opposed to disillusioning participants because the inquiry was not about analyzing problems or trying to fix them . In a debriefing session following the Design phase, study participants told the AI facilitation team how meetings they usually attended tended to focus on the negative or on what needed to be improved. They expressed how empowering and refreshing it was to focus on the ‘best of what is’ and ‘what could be’. This was reflected in the Dream Statements and chapter headings where participants engaged in frank and visionary discussions about how to construct solutions to end student prescription drug abuse by focusing on the college’s strengths as opposed to its weaknesses.
Evaluation and Assessment
To assess the effectiveness of the AI study, and how participants perceived it, a four-member evaluation team (two health science faculty members and two health science students who had been involved in the study) conducted face-to-face interviews with several study participants. The team developed a questionnaire (Appendix) based on Ethnographic Inquiry  to encourage participants to describe their experiences with the study. A selective sampling method was used to recruit students, faculty, community organization representatives, and workshop facilitators who voluntarily consented to be interviewed. Ten interviews were conducted and digitally recorded. The recordings were kept in a locked cabinet in the locked office of a member of the AI team. Grounded Theory  was used to analyze the interviews in order to discover themes that emerged from the participants’ experiences. Six themes were identified.
Theme 1: Creation of a framework that empowered a community gathered around strength-based and solution-focused participation
The AI team was careful to reject an ‘expert’ model and placed the responsibility for identifying the college’s strengths and assets on the participants. In this way, participants were able to engage in creating their own drug prevention strategies. Some participants found it challenging to shift attention away from a problem-focused orientation. A student facilitator observed that early in the process: “It was hard not to problem solve. It was a challenge to think differently. Some participants were impatient to just fix the problem.” (R. L., personal communication, November 4th, 2013). Many interviewees did note that the shift to focusing on positive strengths seemed to promote a sense of cohesiveness and identification within the larger group.
Theme 2: Change in perception toward the college
Interviewees noted that the work of the AI group was not focused on further defining the problem of prescription drug abuse but on identifying what was already working on campus to minimize the problem’s harms. One community organization representative who participated in the AI was “…surprised to discover that my perceptions of the college as being a ‘wet’ college, a drug campus, was incorrect” and in fact, “…there was great engagement on the part of the students to participate in this topic and that the majority of students didn’t (normally) participate in these things.” (P. M., personal communication, November 7th, 2013).
Theme 3: AI practical applications for clinical counselling and counsellor education
One community organization representative, who provides clinical services to persons with addictive disorders and teaches graduate students, remarked that AI strategies could be useful in combination with counselling approaches such as Motivational Interviewing . She stated that AI’s processes for identifying one’s Dream for recovery could help build a therapeutic alliance with clients dealing with negative self-efficacy and shame. She noted AI could also useful in her classes with graduate students to remind them to assess client strengths as well as their problem areas. (P. M., personal communication, November 7th, 2013).
Theme 4: Sustaining the work of an AI-empowered community
Several of the interviewees noted that the conclusion of the AI study was, in some ways, only the beginning of a drug prevention journey. A question about maintaining momentum from the AI was raised. How could the work of an AI be sustained over subsequent weeks, months, and years? Some interviewees suggested that an AI group be re-convened some months after its initial meeting to determine how strategies identified in the Design phase had been ‘delivered’. (K.S. & J. L., personal communication, November 12th, 2013).
Theme 5: Applicability of AI with other populations
One community organization representative from the clinical field noted, “Everybody here seems really healthy,” and wondered if the AI study had overlooked involving more persons with prescription drug abuse issues. She wondered how the AI model might work with clinical populations and thoughts having more representation from health care professionals would have added to the study’s impact. (J. W., personal communication, November 5th, 2013).
Theme 6: AI promotes and establishes community empowerment and engagement
Interviewees talked about the foundation of shared value, “meaty” and substantive drug prevention strategies, and the positive enthusiasm generated by direct experience with the AI process. Some recognized the need to sustain this type of work within the larger community. In other words, how does this work find the organizational and political capital to move beyond the boundaries of an AI study? One observation was the recognition that a vibrant, diverse, civically-engaged, and solution-focused community did emerge from the AI process. The strength of this inter-connected community seemed to be defined by the degree to which each member was able to contribute his or her unique skill in shaping drug prevention strategies.
Study participants may not have fully represented the college campus population. When an AI is performed in a corporate or organizational setting, the process is facilitated by the ability to use a workday . This reduces scheduling conflicts and increases motivation by participants to attend. In a college setting, there is no regular work day. Classes are held at varying hours; students and faculty have to commute or work off-campus; and staff members are typically held to a nine-to-five schedule.
Secondly, the research literature surrounding the evaluation and assessment of AI needs to address several complex and unanswered questions: Are there certain groups or populations for whom AI is a more effective strategy? Does the AI process lend itself to quantitative measures of organizational or community change around drug abuse? How important are stakeholders at higher levels of an organization or community to sustaining the work generated by an AI- inspired group? These questions could be the focus of future study.
The purpose of this study was to use an innovative and relatively new method of inquiry in the substance abuse prevention field to help a college campus devise strategies to decrease prescription drug abuse among its students. According to the study’s results and a formal evaluation of study participants, AI was instrumental in helping to form strategies. In fall 2013, the AI facilitation team was awarded grant funds to help create an infrastructure both off-and-on campus to support further research efforts around prescription drug and other substance abuse issues using AI. One proposal is to hold a ‘town-gown’ AI summit in fall 2014 where college and community residents come together to further develop and implement strategies identified in this study. Another is to create permanent campus committees to support and encourage buy-in from cabinet-level college administrators for these strategies.