Developing and applying a framework to understand mechanisms of action in group-based, behaviour change interventions: the MAGI mixed-methods study

Article history

The research reported in this issue of the journal was funded by the EME programme as project number 14/202/03. The contractual start date was in January 2016. The final report began editorial review in October 2017 and was accepted for publication in June 2018. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The EME editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

none

Disclaimer

This report contains transcripts from group session recordings obtained in the course of the research and contains language that may offend some readers.

Copyright statement

© Queen’s Printer and Controller of HMSO 2019. This work was produced by Borek et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2019 Queen’s Printer and Controller of HMSO

Background

Optimising the effectiveness of health-related behaviour change interventions is contingent on understanding the mechanisms by which such interventions can bring about change and developing techniques to alter processes underpinning this change. Recent work on behaviour change has led to the identification, classification and integration of > 80 behaviour change theories1,2 and > 90 categories of behaviour change techniques. 3,4 Some techniques are frequently employed in behaviour change interventions and can be reliably identified from descriptions of interventions. 5 Evidence indicating which theorised mechanisms and which types of techniques might improve intervention effectiveness when targeting particular behaviours is accumulating. 6–8 For example, self-regulatory behaviour change techniques, such as goal-setting and self-monitoring, have been found to be associated with increased effectiveness in interventions targeting diet and physical activity. 6,8 However, the majority of the theorised mechanisms and technique types studied to date focus on individual-level, intrapersonal change, with little or no consideration of social, interpersonal or group-based processes and factors that shape health-related behaviour patterns. Furthermore, these mechanisms and techniques are often assumed to work similarly in interventions regardless of their delivery mode or setting (e.g. when self-delivered, delivered one to one, through group sessions, online or over the telephone).

For decades, small groups have been used to facilitate personal change in health-care, community, commercial and work settings. Theories explaining, and research into, how such groups work have developed over many years and across multiple disciplines. Research has demonstrated that groups are not just an intervention delivery mode (that allow delivery of an intervention simultaneously to many people) but, additionally, provide ‘active ingredients’ in facilitating personal change. For example, as early as 1905, Joseph Pratt highlighted the importance of group identification (or group ‘spirit’), social support and shared hope in psychotherapy groups for tuberculosis patients. 9 In addition to psychotherapy,10 groups have also been used to promote personal change in human relations training (also called sensitivity training or ‘T’ groups)11,12 and self-help and support programmes. 13 More recently, many health promotion and health-related behaviour change programmes have been delivered in groups. For example, interventions supporting self-management of chronic conditions,14–16 including type 2 diabetes mellitus17 and cancer,18 are commonly delivered in groups. Groups have also been used in preventative contexts to promote breastfeeding,19 walking and physical activity,20,21 smoking cessation22 and weight loss. 23,24

There is increasing evidence from systematic reviews that group-based interventions are effective for supporting change in a number of behavioural targets. 17,22,23 Indeed, particularly for weight loss, group interventions appear to be more effective than similar interventions delivered individually. 24 Group-based interventions therefore provide a time-effective and potentially cost-effective way to address important health challenges, including those related to growing rates of overweight and obesity that are contributing to the increasing burden of chronic conditions.

Group-based interventions show wide variation in their design and delivery. Perhaps because of this, there is still limited understanding of, and evidence on, which mechanisms lead to personal change in group interventions, how short- and long-term behaviour change is best facilitated in groups and what design features, change processes or delivery methods optimise the effectiveness of group interventions. Identifying important design features, change processes occurring in groups and techniques that can be used to facilitate changes is, therefore, a first step towards improving the effectiveness of group-based interventions. Group-based delivery provides an ideal opportunity for use of change techniques involving interpersonal interaction, such as ‘providing opportunities for social comparison’ or ‘prompting identification as a role model’. 3 Furthermore, some types of change techniques are unique to group settings, such as ‘engage group support’ or ‘communicate group member identities’. 25 It is unclear, however, how pre-categorised change techniques and processes operate in groups and how they are influenced by group characteristics, context and facilitation, and which currently undefined, group-specific techniques and processes may support personal change in groups. Therefore, the lack of clarity about what works and how is even more acute in group-based than individual behaviour change interventions.

Understanding change processes in groups is crucial to the design and evaluation of group-based health interventions. Medical Research Council (MRC) guidance26,27 on developing complex health interventions highlights key questions that intervention designers need to ask, including about what the intervention aims to achieve and change, and how. Considering groups only as a delivery mode limits their potential to contribute to the theoretical underpinnings, often represented in a logic model explaining the mechanisms by which the intervention works. MRC process evaluation guidance28,29 further emphasises that, in order to understand how complex interventions work, it is important to describe and assess (1) how they are delivered and implemented (fidelity and quality of implementation), (2) their mechanisms of action (causal processes generating change) and (3) whether or not, and how, they may work differently across settings and contexts (contextual influences). As shown in Figure 1, all three of these domains have implications for delivering health interventions in groups.

FIGURE 1.

Logic model of components influencing behaviour change and outcomes in group interventions. Note: the figure draws on logic model framework presented in MRC process evaluation guidance28,29 showing generic processes that may occur in group-based interventions that are broadly organised into the key commonly included process evaluation elements of context, implementation, mechanisms of action (i.e. how interventions produce change in participants) and outcomes. 28,29

First, it is important to document and investigate how interventions are implemented in groups, including the amount (‘dose’) and pattern of group contact, training of facilitators, resources used, fidelity of delivery and if, or what, adaptations in delivery are made when the same group-based intervention is replicated in different contexts. It may also be important to explore differences between groups in relation to facilitator delivery style and participant engagement and interaction. Second, investigating change processes in groups is important in understanding mechanisms by which they have an impact on psychological and behaviour change, including potentially unexpected or adverse processes and consequences. Third, group interventions may be affected by contextual factors, including the wider sociocultural environment (e.g. social norms and values), organisational context (e.g. climate, setting or type of organisation) or individual characteristics and circumstances that participants and facilitators bring to groups (e.g. gender, available external support and social networks). These group-related moderators of intervention effects are often omitted in studies that focus on mechanisms or mediators of intervention effects in isolation, such as studies in which change techniques are considered separately from aspects of implementation and context. 30

The lack of understanding about how behaviour change interventions work, particularly when delivered in groups, is further compounded by reliance on systematic reviews and meta-analyses to explore quantitative relationships between intervention features and outcomes across previous studies. 6,8,31 Despite the importance of synthesising data across multiple studies, this type of research assumes that descriptions of interventions, which are often brief in journal articles or design protocols, are complete and accurate reflections of what was delivered in practice. A critical limitation of this approach is that it cannot account for differences in fidelity (i.e. the extent to which the intervention was delivered in line with the protocol) or style of delivery. This review of group-based weight loss interventions has shown that details of fidelity assessment in group session delivery, the methods used to facilitate groups, group processes observed and change techniques employed are rarely reported. 23 A review of group studies in nursing journals showed that information on the conduct of groups and attempts to account for group-level effects in analyses were largely absent. 32 This makes it impossible to identify the ‘active ingredients’ and change mechanisms in group interventions from study reports included in systematic reviews. It also makes it difficult to accurately replicate effective group-based interventions.

In addition, meta-analytic data are only as good as the categories used to group and differentiate between the included interventions. Consequently, if the categories are too inclusive (i.e. they count interventions as having similar features when they are, in reality, different), then the results can be misleading. This has been referred to as the ‘apples and oranges’ problem. Abraham33 illustrated how this problem may affect interpretation of meta-analytic studies in which the authors sought to identify techniques designed to alter psychological processes in behaviour change interventions. Consider, for example, a category of change techniques such as ‘encouraging social support’. This refers to a variety of facilitation techniques designed to prompt change in interpersonal relationships between the target person and some other person(s). Yet we know that there are many different types of social support that can be provided by many different people and evidence shows that these have quite different psychological effects on the receiver. 34 Similarly, meta-analytic studies may generate misleading findings if they do not include categories of techniques that are critical to real-world change. For example, a review of 72 evaluations of interventions designed to alter eating behaviour identified 19 categories of techniques employed to modify or manage impulsive processes associated with unhealthy eating behaviour, many of which had not been used in previous meta-analyses of healthy eating interventions. 35 There is, therefore, a need for research to enrich understanding and enhance specificity of how similarities and differences between behaviour change interventions are conceptualised.

This need is especially evident in relation to group-based health-related behaviour change interventions, for which research is needed to identify what processes underpin personal change in such groups and which techniques, or groups of techniques, can be employed to modify those processes. Such research can draw on an extensive literature from social psychology, education and organisational studies on how groups in general work and how they influence individuals. Unfortunately, however, this literature has been largely ignored in designing and evaluating group-based health interventions. 36 In particular, social psychological literature on group dynamics from which more specialist fields evolved (e.g. work-related teams and educational groups) describes how both intrapersonal and interpersonal processes operate in groups. 37–39 A review of this literature40 has identified a number of theories describing change processes in groups, such as social comparisons,41 social learning,42 social identity43 and social facilitation44 theories, that could be used to enhance our understanding of how groups influence individuals and how group context and facilitation can enhance or inhibit change in health interventions. Moreover, the ‘social cure’ approach to health applies social identity theory to conceptualise links between group membership and improved health. 45,46 Qualitative studies with group participants and facilitators also highlight the importance of the group context in influencing engagement with health interventions and behaviour change. For example, interviews conducted with participants in three different group-based health interventions showed that making social comparisons, developing a shared social identity and creating a supportive and friendly group context were important factors that facilitated participants’ engagement with the interventions and lifestyle changes. 47–49 Effective facilitation of groups to promote these group-level processes can be challenging, particularly for lay leaders,50 and it requires specific competencies. For example, 23 facilitator competencies, such as ‘encourage group discussions’ or ‘encourage mutual support’, have been identified as being required to deliver group-based smoking cessation interventions. 51 However, there is little evidence on which (and how) skills and competencies are employed in practice, which might lead to inadequate training of group facilitators.

The importance of employing systematic approaches to designing and evaluating group-based health interventions has been stressed previously. 36 This provided an important first step by identifying some of the key factors in group interventions related to group leaders, participants, community and environment. However, it does not show how these factors are related to change techniques and mechanisms of change. Borek and Abraham40 present a conceptual model linking our understanding of group processes and personal change to change mechanisms in group interventions. The work reported in this study extends that model and seeks to identify change techniques that may optimise the effectiveness of group interventions.

In contrast to many of the recent approaches to behaviour change, we began with an assumption – based on wider research on groups – that change processes can be influenced by, or even unique to, group delivery. Therefore, the promotion of individual change in groups may be critically different from that in individual behaviour change interventions because the former activate distinct interpersonal change processes. More generally, different delivery modes (e.g. internet based vs. face to face) may prompt different change processes and so affect effectiveness even when intervention content appears similar.

Groups provide opportunities for enhancing individual change processes and instigating social change processes, but may also impede some change processes or have adverse or unintended negative consequences. For example, groups may enhance individual problem-solving by providing opportunities to share and draw from others’ ideas, access peer support and identify with people in a similar situation. However, lack of time and/or tailoring to individual needs in a group might impede individual goal-setting and review, negative group dynamics might impede engagement and/or attendance, and poorer performance compared with other group members might lead to decreases in self-efficacy. Moreover, group facilitators’ characteristics and skills may improve effectiveness for one group but decrease effectiveness for another, depending on relationships between the facilitators and group members. 52 Techniques to alter normative beliefs may promote behaviour change among young people but reduce intervention effectiveness for older recipients. 53 Group climate and group cohesion may increase attendance and self-efficacy (in exercise classes). 54 The use of humour may help engage middle-aged men in a weight loss intervention55 but have an opposite effect among young women in a sexual health intervention. 56 Furthermore, many health-related behaviour patterns are influenced by sociocultural contexts (e.g. social norms) and are social practices enacted in social contexts (e.g. eating with others, eating out) with attached meanings, norms and values. Groups can, therefore, help change behaviour patterns that are both individual and social. For example, they can help change individual perceptions of social norms, identify solutions to common barriers encountered in social contexts, change meanings and values attached to social practices, or provide opportunities to practise relevant social skills, such as communication skills. Consequently, sophisticated models of group operation including specification of change mechanisms, group composition, facilitator characteristics and techniques employed by facilitators to promote personal change, as well as other influences of group implementation and context, are needed to optimise group-based interventions.

In summary, although group interventions are effective and commonly used in health-care and public health contexts, their mechanisms of action, representing how and why they work, have not been systematically explored. It is therefore not clear how groups operate and group processes function to engender or impede personal change, and what factors related to implementation and context influence mechanisms of change and intervention outcomes. Most current thinking about mechanisms that underpin behaviour change is based on individual-level theories. Moreover, meta-analyses of intervention components associated with effectiveness are mainly based on descriptions of interventions, which, particularly for group interventions, are limited by a lack of comprehensive reporting and inadequate categorisation of the real-world differences between interventions. Distinctions between group implementation, facilitation, change processes, change techniques and contextual factors are rarely clarified in a way consistent with the MRC framework for process evaluation,28,29 and there is little evidence on how these components are manifested in practice. The most modifiable elements of group-based interventions are the change techniques that facilitators use and their style of delivery. We do not, however, have a conceptual framework for systematically investigating what processes and techniques operate, and are effective, in group interventions, or for identifying facilitators’ delivery techniques and styles, and their influences on these processes. This is problematic for the construction of logic models in intervention development, the design of process evaluations and the training of facilitators in intervention delivery. Only with a better understanding of the change mechanisms in group interventions, and guidance on how important processes can be activated and facilitated, will we be able to guide development and delivery of interventions to optimise effectiveness. Starting with the MRC process evaluation guidance28,29 and existing literature on groups, this study is a step towards addressing these gaps in the research.

Study aims and objectives

This Mechanisms of Action in Group-based Interventions (MAGI) study aimed to develop a better understanding of mechanisms of action in group-based health-related behaviour change interventions by identifying, describing and synthesising possible processes of change in groups. It also aimed to develop and illustrate methods for exploring the influence of change processes in group-based behaviour change interventions (GB-BCIs). We focused on the example of group-based weight loss interventions targeting diet and physical activity. Our hypothesis was that behaviour change interventions delivered in groups involve change techniques and change processes that are specific to the group setting, and that may be influenced by implementation and contextual factors. The successful initiation and facilitation of these change techniques and processes would lead to increased engagement with the intervention and more effectively promote behaviour change (e.g. diet and physical activity), thereby improving intervention outcomes (e.g. weight loss). Overall, the project aimed to increase understanding in order to guide the future design, delivery and evaluation of GB-BCIs.

In order to achieve this aim, the study had three more specific objectives. These were to:

1. develop a generalisable framework of mechanisms of action in GB-BCIs by identifying, defining and categorising potentially important group design features, group processes, facilitation techniques and contextual factors in groups

2. test and refine the framework, using a coding schema derived from it, as a tool for identifying these group features, processes and facilitation techniques in the recordings of sessions from three GB-BCIs (focused on diet, physical activity and weight loss), and to provide examples to illustrate framework elements

3. develop mixed-methods approaches based on the framework to explore why some groups may be more or less successful than others, and to illustrate their use with available qualitative and quantitative data from a GB-BCI.

Study outline

These three objectives were addressed in three stages, which are reported in the subsequent chapters: Chapter 2 provides a description of the framework and its development (objective 1), Chapter 3 reports on the development and use of a coding scheme derived from the framework for analysing group sessions and provides examples of the concepts, processes and techniques included in the framework (objective 2), and Chapter 4 reports on the development of methods for applying the framework to analyse how groups work in a weight loss intervention and how such methods might be employed to explore potential links with outcomes (objective 3). Figure 2 outlines the tasks completed in the three stages over 20 months between January 2016 and August 2017.

FIGURE 2.

Outline of the key stages of the MAGI study. LWTC, Living Well Taking Control; SkiM, Skills for weight loss Maintenance; WtW, Waste the Waist.

Sources of data: three group-based interventions

The MAGI study builds on three studies of GB-BCIs: the ongoing (at the time of conducting this study) Community-based Prevention of Diabetes (ComPoD) trial (Jane Rebecca Smith, University of Exeter Medical School, September 2017, personal communication) that evaluated the Living Well Taking Control (LWTC) programme and the Skills for weight loss Maintenance (SkiM) study (Colin Greaves, University of Exeter Medical School, September 2017, personal communication), and the completed Waste the Waist (WtW) study. 57–59 All three were primarily delivered in South West England and targeted adults who were overweight [average body mass index (BMI) in the obese range]. The ComPoD and WtW studies targeted other risk factors for chronic disease, and recruited samples that were older but otherwise broadly representative of local populations in terms of their gender mix and low numbers of participants from non-white British backgrounds. The interventions all targeted lifestyle changes, such as improving diet and increasing physical activity, in order to achieve or maintain a healthy weight and prevent obesity-related diseases (i.e. type 2 diabetes, cardiovascular diseases). The interventions were delivered in small groups (up to 12 participants) by facilitators with backgrounds in health promotion, and in accordance with intervention delivery manuals. In this study, we used secondary data that were already available or able to be collected as part of the ongoing studies, including intervention delivery manuals, audio-recordings of group sessions and outcome data. In particular, we used audio-recordings made as part of the process evaluations and quality assurance in the three studies (ComPoD: ≈80 sessions, SkiM: ≈88 sessions, and WtW: ≈36 sessions). The three studies had received research ethics committee approvals (ComPoD: 14/NW/1113, SkiM: 5/SW/0126, WtW: 10/H0206/74) with participants giving consent for audio-recording the sessions for use in research. In the following sections, we describe each study, and Table 1 summarises the key details of the interventions and data used from each study.

Key terms

Throughout this report, we use a number of key terms, some of which are defined in Table 2. Other terms, in particular those derived from the literature reviews, are defined in Table 3.

Background and rationale

As noted in Chapter 1, there is a wealth of research on group processes and how groups affect individuals,37,38,64,65 and a long tradition of using small groups to support personal change, promote health and deliver education (e.g. in group psychotherapy and counselling,10,12,66 self-help and support groups,13 chronic disease self-management programmes,14,17 health-promoting interventions20–22 and team-based learning initiatives67). Delivery of health interventions in groups allows people to support and learn from each other and takes better account of the fact that many health-related behaviours are performed with, or in the presence of, other people and are subject to social influences. With the increased prevalence and social and economic burden of preventable, lifestyle-related diseases, groups therefore offer a suitable and potentially cost-effective way to deliver health-related behaviour change interventions.

To date, theories specifying processes capable of regulating and changing behaviour patterns and techniques that may be used to modify those processes have focused on intrapersonal change, occurring within individuals. However, change processes are often initiated and facilitated through social interaction, and are affected by social context, including group settings. Thus, social, interpersonal processes may direct and alter intrapersonal processes. Yet our understanding of how interpersonal interaction in groups initiates and shapes intrapersonal change is limited. This might be because research into group-promoted personal change and research into intrapersonal change processes that explain changes in individual behaviour have developed in parallel with little cross-fertilisation of ideas. Further research is needed to ascertain how health behaviour change interventions work in group settings, how intrapersonal change processes might be shaped by group context and which interpersonal change processes are critical to group effectiveness. Such research would be greatly facilitated by a synthesis of the current knowledge of group processes and change mechanisms in groups. Therefore, in the first stage of this study, we aimed to identify important elements related to the design, implementation, context and change processes operating in GB-BCIs. Drawing on existing research, we aimed to develop a framework to bring together and categorise potentially important intervention components, and change processes and techniques that explain the mechanisms of action in GB-BCIs.

Methods

We developed a framework of change processes in group-based interventions by bringing together findings from three approaches. We focused in particular on face-to-face, adult groups that target health-related behaviour and other psychological change. First, we built on reviews of relevant literature, including theoretical literature on group dynamics and group change processes, taxonomies of categories of change techniques, qualitative studies of participants’ experiences of group-based weight loss interventions, and measures of group processes. Second, we qualitatively coded the content of delivery manuals and recordings of group sessions from three recent GB-BCIs targeting weight loss. Third, we consulted experts, including group participants, facilitators and researchers. The findings from each approach helped to develop, refine and revise the framework in an iterative fashion. For an outline of this stage of the research, and how it fits in with other stages of the study, see Chapter 1. The three approaches used and how findings from them were brought together are described in detail in the following sections.

Results

Mechanisms of Action in Group-based Interventions framework

The literature reviews, qualitative analyses and consultations were used as sources for developing the MAGI framework. Appendix 7 includes a summary of the framework categories matched with the sources that they were identified from. Appendix 2 provides the evolving framework diagrams and tables, illustrating the process of refinement. The full version of the framework, which is intended to be a stand-alone document, is presented in Report Supplementary Material 1.

The identified processes, techniques and concepts helpful in explaining the mechanisms were grouped into six overarching categories: (1) group intervention design, (2) facilitation techniques, (3) group dynamics and development, (4) interpersonal change processes, (5) intrapersonal change processes and targets and (6) facilitator characteristics, participant characteristics and other contextual influences. On the basis of the reviewed literature and expert consultations, we hypothesise that the group features, processes, change targets, and techniques included in these categories are critical to the operation of groups and the mechanisms by which groups generate individual and collective psychological and behavioural change. The structure of the framework is illustrated in Figure 3 and described in the following sections.

FIGURE 3.

Main MAGI framework categories and relationships between them. Note: the green boxes (corresponding with categories 1 and 6 described below) and the green line around the diagram represent external influences on the group (e.g. design prior to group sessions, influences from outside the group sessions); the blue triangles and box between them (referring to category 2) represent the techniques that facilitators use to facilitate the group and instigate or support group processes; the blue arrows (categories 3, 4 and 5) represent within-group processes leading to change, that is, what happens during a group-based intervention to bring about behaviour change and other outcomes. Reproduced from Borek et al. 63 © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reproduced from Borek et al. 63 © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Category 1: group intervention design elements

These are features of the design of group-based interventions that are important for the functioning of the group and facilitation of change processes. These features should be considered during the intervention design stage (i.e. before the groups are set up) and decided on in alignment with the intervention logic model and intended change processes. When a group intervention is delivered, these features are likely to affect other elements of the intervention implementation (group facilitation, group dynamics and development) and change processes in the group.

Category 2: facilitation techniques

These refer to techniques that facilitators can use to facilitate the group and particular change-inducing interactions within the group. In Figure 3, we highlight the techniques, or tasks, that are important when establishing groups and starting group sessions, and when closing groups or sessions (these specific time points are emphasised by the blue triangles). The techniques for starting the groups or sessions are particularly important for establishing an interpersonal context conducive to engaging participants and inducing change processes, whereas techniques for closing the groups or sessions might help reinforce participants’ commitment to return to the next session, change processes and maintenance of behaviour change. Other techniques can also be used and their deployment determines how a group works (i.e. group dynamics and development) and which inter- and intra-personal change processes are initiated and sustained within the group. Facilitation techniques might change over time; for example, the facilitators might adapt which techniques they use, and how, depending on the needs and characteristics of the group, emerging group dynamics and change processes, or participants’ characteristics and their progress in achieving goals and intervention outcomes (this is represented in Figure 3 by the dark-blue two-way arrows).

Category 3: group dynamic and development processes

These refer to generic group properties and processes used to describe how groups work and change over time (i.e. this time change is represented by the light-blue arrow). These processes are group specific (i.e. unique to a group setting) and are relevant to any type of group, regardless of whether or not they target personal change. Positive group dynamics, and a successful progression into a cohesive group that works collaboratively to achieve group goals (the so-called performing stage of group development), optimises the social environment conducive to the operation of change processes. Conversely, negative group dynamics or impeded development may inhibit change processes and negatively affect participants’ experiences of the group (potentially also leading to low attendance or drop-out). Therefore, group dynamics and development are conceptualised as underpinning change processes in groups (in Figure 3 this is represented by the darker blue arrow being on top of the ‘group dynamics’ arrow). Group dynamics can be affected by facilitation techniques, including how groups are set up, by facilitator and participant characteristics (including the relationship and interaction between facilitators and participants) and by other contextual influences (e.g. social norms). These influences could include both planned changes (e.g. in facilitation techniques) and unplanned influences on group dynamics that the group responds to (e.g. progress of group members or attendance rates).

Categories 4 and 5: interpersonal and intrapersonal change processes

Interpersonal change processes are instigated in social or group contexts and through social or group interactions, whereas intrapersonal change processes and targets operate within an individual and may extend beyond the duration of a group session or a group (i.e. time is represented by the dark-blue arrow, which extends beyond the duration of the group and the associated ‘group dynamics’ arrow). Indeed, that this lasting change extends beyond the group is the aim of GB-BCIs. Interpersonal change processes might prompt or influence intrapersonal change processes or they may happen simultaneously. For example, when people are talking with others in the group, they engage both inter- and intrapersonal processes, as any conversation does. Both of these types of change processes may be affected by, and affect, the group dynamics and development when facilitated in groups (as opposed to other modes of delivery). As the arrows represent, they may also be instigated or facilitated by facilitator techniques, and may be influenced by facilitator and participant characteristics and the wider sociocultural context within which the groups operate.

Category 6: facilitator and participant characteristics, and other contextual influences

These refer to factors external to the group that may influence, and be influenced by, what happens in the groups. They include characteristics of group facilitators and group participants, which they ‘bring’ to the group, for example individual cognitive (e.g. beliefs) and emotional factors (e.g. anxieties), previous experiences (e.g. of groups, weight loss) and health conditions. These may influence participants’ interactions and the development of relationships in the groups. In particular, participants’ experience of, and engagement with, the intervention and behaviour change might be influenced by the relationship with, degree of rapport with, and perceptions of the facilitator. Other contextual factors, such as available support networks or social norms, may also influence the groups, and change processes. These factors and participants’ and facilitators’ characteristics may change over time as a result of participating in, or facilitating, the groups (e.g. increased assertiveness, confidence, skills; see Outcomes), which is represented by the arrows in Figure 3.

Outcomes

The outcomes of group-based health interventions include a range of intended and unintended consequences, for example changes in psychological processes (e.g. cognitions) underpinning behaviours, behaviours (e.g. diet), health-related outcomes (e.g. outcomes), well-being or quality of life (e.g. resulting from social connection), or social change across a collection of individuals (e.g. social norms or practices). Outcomes of group-based interventions may be affected, directly or indirectly, through change processes, and the underlying group context and dynamics. Moreover, observing or receiving feedback on outcomes, or progress towards them, can create a feedback loop, affecting the group dynamics, change processes, the use of facilitation techniques, and individual characteristics and contextual factors (this is represented by the black arrows going from outcomes back to the group, facilitation techniques, and facilitator and participant characteristics). Because the (targeted or unintended) outcomes are specific to each intervention, we do not further describe or discuss the different outcomes. Methods that can be used to explore potential links between group processes and outcomes are described in Chapter 4.

Wider influencing factors

Finally, wider influencing factors, such as sociocultural, economic, environmental, community and organisational factors, may influence all aspects of GB-BCIs, including their design, implementation, processes, facilitators and participants, and outcomes. For example, economic factors may affect participants (e.g. costs of accessing the group or buying health food) or intervention design and implementation (e.g. prespecified requirements set, or resources provided, by programme commissioners). Although we acknowledge that these wider determinants are very important, and recognise their impact on group functioning, these are beyond the focus of our study (and hence are not further discussed).

The MAGI framework provides conceptual guidance on questions of how key change agents shape group processes and change processes in GB-BCIs. This is illustrated in Figure 4, which highlights who these agents are, what they do and what they bring to group-based intervention design and operation. For example, group intervention designers have control over, and responsibility for, decisions about intervention design, which affect group dynamics, development and change processes. Group facilitators bring to the group their own characteristics (e.g. beliefs, experiences), professional and interpersonal skills, and facilitation techniques. Group participants also bring their own characteristics, social contexts and change-related factors (e.g. motivation, readiness to change). All of these influence, and contribute to, what happens in the group sessions, including group dynamics and change processes (represented by the blue circles in Figure 4) that lead to outcomes.

FIGURE 4.

Agency and processes in group-based interventions. Note: green boxes represent external influences on the group (e.g. design prior to group sessions, participants’ influences from outside the group sessions); the blue box represents the techniques that facilitators use to facilitate the group and instigate or support group processes; and the light and dark blue circles represent within-group processes leading to change (i.e. what happens during a group to bring about the outcomes).

Table 5 summarises group features, processes, targets and techniques included in the framework categories described above. Detailed definitions, with descriptions of their importance and hypothesised links between them (based on the literature and expert consultations), are fully reported in Report Supplementary Material 1 and are summarised below.

TABLE 5 - The MAGI framework

1. Group intervention design	2. Facilitation techniques
	2.1. Techniques to start the group/session	2.2. Generic facilitation techniques	2.3. Techniques to facilitate group dynamics	2.4. Techniques to facilitate interpersonal change processes	2.5. Techniques to facilitate intrapersonal change processes	2.6. Techniques to end the group/session
1.1. Intended changes and processes 1.2. Purpose and benefits of using a group format 1.3. Group characteristics 1.4. Participant selection and group composition 1.5. Facilitator selection and training 1.6. Intervention content 1.7. Setting and venue 1.8. Group set-up and delivery	3. Group dynamic and development processes
	3.1. Group goals 3.2. Identifying with/as a group 3.3. Group cohesion and attraction		3.4. Group climate 3.5. Group engagement 3.6. Communication patterns		3.7. Group norms 3.8. Group roles 3.9. Group development
	4. Interpersonal change processes		5. Example intrapersonal change processes and targets
	4.1. Sharing experiences 4.2. Social learning 4.3. Social influence 4.4. Agreeing or disagreeing with, or challenging 4.5. Social support 4.6. Social validation 4.7. Social identification 4.8. Social comparisons 4.9. Accountability to the group 4.10. Competition 4.11. Co-operation 4.12. Group problem-solving 4.13. Group-level feedback 4.14. Social facilitation		5.1. Committing to attend 5.2. Develop and express understanding 5.3. Self-presenting 5.4. Normative beliefs 5.5. Attitudes 5.6. Attributions 5.7. Cognitive dissonance 5.8. Intervention outcome expectations 5.9. Motivation 5.10. Self-efficacy and personal control 5.11. Setting goals 5.12. Reviewing goals or progress		5.13. Developing and practising new skills and behaviours 5.14. Identifying individual barriers and problem-solving 5.15. Self-monitoring 5.16. Individual-level feedback 5.17. Developing self-insight 5.18. Identity shift 5.19. Using self-talk 5.20. Associative learning 5.21. Forming habits 5.22. Managing stress and emotions
	6. Facilitator and participant characteristics and contextual influences
	6.1. Facilitator characteristics		6.2. Participant characteristics		6.3. Other contextual influences

Discussion

We identified a wide range of concepts, processes and techniques from a number of sources, including reviews of relevant literature, qualitative analyses of data and expert consultations. These were integrated in a framework that highlights how these various components might affect the outcomes of group-based interventions, in particular individual behaviour change. The framework consists of six overarching categories, and the relationships between key categories illustrate the proposed mechanisms of action in group-based health interventions. These six overarching categories comprise 62 more specific group features and processes that help explain how groups work and effect change. These provide a basis for designing, delivering and evaluating group-based interventions.

Group-based behaviour change interventions vary greatly in their design, implementation or targeted change mechanisms. Thus, the relevance and importance of different concepts, processes and techniques included in the MAGI framework will vary across interventions. The framework offers a set of concepts and processes, all of which are, potentially, more or less important for facilitating individual change during and beyond group participation. Practical limitations might make it difficult, or impossible, to control all of these elements in intervention design or implementation, and time and resource limitations may prevent investigation of all these processes in process evaluations. Thus, the framework provides a resource, or a ‘catalogue’, for designers, facilitators or evaluators of GB-BCIs to choose from. They can select which processes or concepts are critical in a given intervention and specifically focus on and target them when designing, delivering and evaluating GB-BCIs.

The presented framework is somewhat complex, but at the same time may not be complex enough to fully represent the complexity of within-group processes and relationships between them. The described links between concepts, processes and techniques are hypotheses based on the reviewed literature, expert consultations and our earlier research. There is a variable amount and quality of evidence supporting each process and hypothesised link, which we were unable to appraise in detail, and some processes still need to be empirically tested. In the same way as the periodic table has changed considerably since its initial development, the categorisation system that the MAGI framework represents will probably evolve as empirical evidence accumulates on how changes in group interventions occur. The framework can guide work to generate this.

In the framework, we distinguished between different categories to highlight the key domains of GB-BCIs, and distinguished between different concepts, processes, targets and techniques to aid clarity and understanding. However, these are not mutually exclusive categories; in fact, the processes categorised and described separately may co-occur and influence each other. For example, the process of sharing experiences might be closely linked with social learning (i.e. participants learning from each other’s experiences) and social validation (i.e. which may be evoked by sharing experience). Moreover, each of the interpersonal change processes happens between as well as within individuals (i.e. an individual learns, receives support, feels accountable, etc.), so they could also be facilitated in one-to-one consultations. However, these processes are likely to be reinforced by the interpersonal, social context of a group. Learning may be reinforced if it involves learning from each other, social support might be reinforced if it involves mutual peer support (thus providing benefits of providing and receiving support) and accountability might be reinforced if it involves striving to ‘not let the group down’, especially if the group has a common goal. Similarly, intrapersonal change processes also occur within the interpersonal, group context and, thus, can be affected by it; for example, goal-setting might be reinforced by sharing and discussing one’s goals with the group or impeded by not having the time or opportunity in a group to sufficiently focus and reflect on individual goals and needs. Within ‘intrapersonal change processes’, we included some examples of only individual-level change processes and targets that are particularly common to GB-BCIs or that may be particularly sensitive to group context and delivery. Intrapersonal change processes, targets and techniques have been extensively described in psychological literature and other classifications of these exist. 3,4,72,81

The inter- and intrapersonal change processes could be also facilitated in one-to-one interactions (e.g. in pairs of participants, or between a participant and a counsellor) but are likely to be affected by the group (i.e. are group sensitive). We also identified group dynamic and development processes, which are unique to the group setting (i.e. are group specific). These processes underpin change processes, and may especially affect engagement with the intervention, session attendance and drop-out rates. It is these that designers, facilitators and evaluators of GB-BCIs need to focus more on when working with group-based interventions.

Introduction

There are many possible pathways to psychological and behavioural change in GB-BCIs, as outlined in the MAGI framework (see Chapter 2). Identifying which of these processes occur in interventions, and how they are instigated and facilitated, is critical to investigating links between interventions and outcomes, and developing an evidence base on what works and how in GB-BCIs. The MAGI framework includes group characteristics, processes, targets and techniques relevant to understanding how GB-BCIs work. However, it does not provide illustrations or examples of how these processes are instigated or supported by group facilitators, in actual group-based interventions. It is also unclear how the framework could be used in practice to identify and analyse these processes and techniques.

The MRC guidance on process evaluation28,29 emphasises the importance of exploring the role of change mechanisms (how change is intended to be produced), implementation (how change mechanisms are facilitated) and context (how contextual factors affect change mechanisms, implementation and outcomes). A range of methods may be useful to do this in GB-BCIs. They can include quantitative methods, such as measuring ‘dose’ of the delivered intervention (e.g. time in groups), the presence and quality of delivery of intervention components and techniques58 or using questionnaires to measure perceptions of group processes [e.g. group dynamics134 (assessed using the Group Climate Questionnaire Short Form153)]. Qualitative methods can also be used, such as observing group sessions, interviewing group participants and facilitators48,49,97,100 or using ethnographic approaches. 133 Some studies have used qualitative methods in a focused way to test pre-existing theory on processes of change in behaviour change interventions. e.g,136 However, it is unclear how the MAGI framework and its components could inform qualitative analyses of group-based interventions.

Methods

Results

Discussion

In this stage of the MAGI study, we developed a coding schema to enable identification of the MAGI framework categories in transcripts of group sessions. This includes specific instructions on identifying and coding framework categories, and additional lower-level subcategories for precise coding of group interactions and processes. We coded 38 transcripts (10 sampled in stage 1 and 28 in stage 2) of group sessions from three GB-BCIs (LWTC, SkiM and WtW) and identified examples of the framework categories from these interventions. These examples provide evidence for the occurrence of the framework processes in ‘real-world’ groups and illustrate the framework categories. We also identified examples of techniques used by group facilitators to instigate and facilitate group dynamics and change processes.

The majority of the processes included in the framework were well evidenced, with multiple examples identified across transcripts (showing good levels of data saturation). Our findings show that facilitators use a wide array of techniques (or sets of techniques) to facilitate and manage groups. The most prevalent processes in the analysed interventions involved social learning processes and sharing of experiences, and facilitation techniques linked to these (e.g. providing or interactively exchanging information, prompting participants to relate information to shared experiences). We also identified good evidence of social influences (positive and negative, from facilitators and participants) and social support (mainly emotional) in the groups. We identified fewer examples related to other interpersonal change processes (i.e. social identification, social comparisons, accountability, competition, co-operation) and to some group dynamics (i.e. identifying with/as a group, group cohesion, climate, norms). These processes with fewer coded examples probably reflect their implicit nature (i.e. that they might not be verbalised even if they occur). Thus, other methods might need to be used to identify them in groups (e.g. participants’ self-report). They may also reflect less focus in the analysed interventions on these processes (and a primary focus on exchanging and explaining health-related information and recommendations). Finally, many intrapersonal change processes and techniques were often delivered in ways that did not fully engage the group; for example, goal-setting, problem-solving and feedback were predominantly delivered individually or between participants and facilitators, rather than through group interaction (e.g. discussing goals could engage social learning and accountability to the group).

These identified examples of processes and techniques, of course, might be different in other types of interventions or groups, depending on the intended/targeted processes and changes or participant characteristics. For example, support or self-management groups might focus more on sharing experiences, social validation and peer support (rather than provision of information), whereas some weight loss groups might engage more social comparisons, accountability and competition (e.g. through public weighing). Currently, we still lack evidence for which of these processes may optimise effectiveness in behaviour change groups, but identifying which of them occur and with what prevalence in GB-BCIs (as shown in this stage of the MAGI study) may be a useful first step to developing such evidence.

Introduction

In the previous chapters, we first described the development of a comprehensive framework of mechanisms of action in group-based interventions (the MAGI framework) and presented definitions and details of the framework components (stage 1). Next, we used the framework as the basis for developing qualitative methods to identify and analyse change processes in GB-BCIs, and to provide examples of framework components and facilitation techniques (stage 2). Evidence of many components was found, thus providing a preliminary validation of the framework. We were also able to estimate the frequency with which many processes occurred and with which facilitation techniques were used. Two further developments of this work are envisaged: first, exploring the applicability of the framework to other types of GB-BCIs and, second, investigating which facilitation techniques and processes in the framework are most important for maximising group engagement/attendance and outcomes for participants.

As highlighted previously, MRC process evaluation guidance28,29 emphasises the importance of exploring implementation, mechanisms of change, and context. These can be represented in a logic model that describes how interventions and their important components are related to each other and work to influence outcomes. The logic model articulates the ‘theory of change’ of the intervention and, in GB-BCIs, group processes identified in the MAGI framework should be included if they are thought to affect outcomes. As recommended in the guidance, a range and mix of methods, drawing on both qualitative and quantitative data, could be used in process evaluations of GB-BCIs to explore these aspects and advance understanding about what makes these interventions effective (or not).

The MAGI framework identifies a large number of, potentially interacting, processes and influences in GB-BCIs, which may vary depending on contextual characteristics. Therefore, sophisticated methods, integrating data from qualitative and quantitative sources, are important when investigating how group dynamics and processes operate and influence outcomes. As shown in Chapters 2 and 3, qualitative methods could involve observing or analysing audio- or video-recordings of group sessions. Facilitators’ or participants’ perceptions of group dynamics and change processes in groups can be also investigated through interviews and focus groups,47–49,100,125 and ethnographic methods. 133 Quantitative methods might be used in assessing the content or ‘dose’ of the delivered intervention,58 quantifying occurrences of particular types of interactions or processes, characterising different groups to provide information on contextual factors, or using questionnaires to measure participants’ perceptions of group processes (e.g. social identification, group cohesion46,54). Mixed-methods approaches to process evaluation of GB-BCIs are recommended, but it is unclear when researchers should employ particular methods, how they should mix or integrate these methods and how group-level data can be collected and presented meaningfully. These are the issues that this third and final stage of the MAGI study explored.

In the context of our three GB-BCIs, and in the light of the framework presented in Chapter 2 and data presented in Chapter 3, the hypothesis guiding this stage of the study was that the successful initiation and facilitation of key group processes leads to increased participant engagement, changes in intrapersonal change targets (e.g. motivation, self-efficacy and planning for change) and, thus, behaviour change (e.g. improved diet, physical activity) that can generate improved health outcomes (e.g. weight loss) and, potentially, other unplanned benefits (e.g. social connectedness). Hence, groups developing positive group dynamics and demonstrating a wide range of interpersonal change processes are postulated to be more effective in engaging participants and facilitating outcomes than groups where there is evidence of negative group dynamics (e.g. with dysfunctional or disruptive behaviours) and limited interpersonal change processes (e.g. focusing on provision rather than exchange of information). Indeed, some group-related factors have previously been found to be associated with improved intervention outcomes, including the use of specific change techniques,6,8,31,137 change talk,138,139 social support140,141 and social identification. 142 For example, participants’ perceptions of group dynamics have been associated with weight loss outcomes,134 and group norms have been associated with group members’ body perceptions and dieting intentions. 126 Moreover, session attendance (indicating engagement with the group and intervention) has been associated with weight loss outcomes in group interventions. 143,144

Our initial plan for stage 3 of the study was, therefore, to combine further qualitative data on processes and techniques based on the MAGI framework with quantitative data on attendance and outcomes in a sample of the groups studied, to explore why some groups were more successful than others. By characterising and comparing more and less effective groups, we hoped to provide initial evidence of, and explanations for, links between what happens in group sessions, on the one hand, and attendance, behaviour change and health outcomes (e.g. weight loss), on the other. It would also generate further hypotheses that might be explored in wider secondary data sets available from the three studies used in our research, or in future research.

Meaningful linkage of group-level qualitative data on the operation of many complex, interacting processes with quantitative data on individual-level attendance and outcomes may be impossible if appropriate data are not collected. Moreover, variation in individual outcomes within groups may be as great as variation across different groups, making it difficult to attribute outcome differences to qualitative differences in group operation. For these reasons, we did not anticipate being able to undertake meaningful quantitative analyses that could predict outcome differences. Furthermore, as the study progressed, we became aware of further limitations in the data available to us for secondary analyses (see Availability of qualitative data and revised sampling). Therefore, the aims of this final stage were reviewed and refined.

Methods

Results

Quantitative analyses of data from the Living Well Taking Control programme

Baseline characteristics of Living Well Taking Control programme groups

There were records for 565 LWTC participants, with at least some further baseline and/or follow-up data available for 538 participants (95%). Of these, 445 (83%) participants had an identifier indicating to which group they belonged and a further 35 (7%) participants without an identifier had follow-up data suggesting that they did participate in a group but that this information had not been recorded.

There were records for 75 groups in total, but only 67 (including 431 participants) had some data available for at least three participants. These were considered in further analyses. Twenty (30%) of these groups comprised participants with newly diagnosed type 2 diabetes; the rest were for participants with pre-diabetes. Figure 5 shows the number of groups of different sizes based on available records (we are uncertain whether or not any participants were missing records, for example if they did not consent to having measures recorded). Across the 67 groups, records were available for an average of six, and up to 12, participants, with over one-third of groups including six or seven participants (not including partners or supporters present, for whom no data were held).

FIGURE 5.

Number of groups of different sizes (as indicated by available records, which may be different from the actual group sizes) in the LWTC programme.

Table 16 summarises available baseline data on key group and participant characteristics. Overall, 42% of participants in the groups were men. There was one all-male group, 25 (37%) groups comprised a majority of men, two included equal numbers of men and women, half comprised a majority of women, and there were five all-female groups. The average age of participants across all groups was 64 years, but this ranged from an average of 47 years to 74 years for individual groups, with participants across the entire sample ranging from 28 years to 91 years. Twenty-eight groups (42%) included at least one participant who was aged < 50 years. The average age difference between the oldest and youngest participants in the same group was 25 years, suggesting high within-group variability. However, in some groups, participants were of a similar age (e.g. in seven groups, the age difference was < 10 years) and in other groups the age difference was very large (e.g. in another seven groups, the age difference was > 40 years).

TABLE 16 - Baseline characteristics of groups (maximum, n = 67) and participants (maximum, n = 431) in the LWTC programme

N/A, not applicable; SD, standard deviation.

Higher scores indicate greater importance/confidence.

Summary data	Characteristic
	Group size (n)	Gender (% male)	Age (years)	BMI (kg/m2)	Self-rated health (%)	Importance of physical activity (1–10)a	Confidence in physical activity (1–10)a	Importance of healthy diet (1–10)a	Confidence in healthy diet (1–10)a
Number of groups (%) for which data were available	67 (100)	67 (100)	67 (100)	67 (100)	62 (93)	56 (84)	54 (81)	58 (87)	57 (85)
Number of participants (%) for whom data were available	431 (100)	431 (100)	415 (96)	397 (92)	363 (84)	344 (80)	343 (80)	349 (81)	348 (81)
Mean (SD) across groups	6.4 (2.2)	42 (24)	63.9 (5.6)	31.3 (2.5)	72 (9.6)	7.0 (1.0)	6.5 (1.3)	8.6 (0.6)	7.6 (0.8)
Range in means across groups	3–12	0–100	47–74	26–37	47–88	5.6–9.3	2.7–9.1	7.3–9.9	5.6–10.0
Range across entire sample		N/A	28–91	19–56	7–100	0–10	0–10	2–10	1–10

Owing to the geographical location for intervention delivery (Exeter, UK), the sample were overall predominantly from a white British background. However, 12 groups had at least one non-white British participant and, in one group, four out of the eight participants were from other ethnic backgrounds. The LWTC data set analysed for the purposes of the before-and-after evaluation of the programme60 included information on participants at the Birmingham site, where nearly half of participants were from an ethnic minority background. However, in the data set from the Birmingham provider, participants did not have a group identifier, making it impossible to conduct any further group-level analyses of these data, including examination of the influence of ethnic background on group mechanisms as a means of explaining some observed differences in engagement and weight loss between those from white British and other backgrounds. 61

All but seven groups (90%) included at least one participant who was retired, with an average of three retired participants per group. Fifty-five groups (82%) included at least one participant who was working, but the number of participants working was low in many groups. However, there were two groups (probably held in the evening) in which all participants were working. Larger numbers of participants and groups had missing data on education levels, so these data were not analysed in detail; but among the groups for which data were available, two-thirds included at least one participant who was degree educated, and there was wide variation in education levels within most groups.

In three-quarters of groups (50/67 groups), the average BMI of participants was at the lower end of the obese range, but in 17 groups it was in the overweight range. In 24 groups (36%), at least one participant was severely obese (i.e. a BMI of > 40 kg/m²) and in 29 (43%) groups at least one member was in the healthy weight range (ComPoD trial entry criterion of being overweight as represented by a BMI of > 25 kg/m² did not apply to the diabetes groups and was not so stringently applied for entry to the LWTC programme outside the trial).

Participants’ perceptions of their health and ratings of life satisfaction also varied considerably within and across groups. For example, among the 61 groups with adequate data, the average self-rated health status across groups was 72%. However, this ranged from an average of 45% to 87% for individual groups and was highly variable within groups, with only six groups having ratings for all members that were < 20% apart and differences in other groups ranging from 0% to 87% (mean 44%) between the highest- and lowest-scoring group members.

Participants’ perceptions of the importance of, and their confidence in achieving, adequate physical activity and a healthy diet varied greatly across the entire sample and to a lesser extent across the groups, with most variability across groups in perceptions of the importance of physical activity. This suggests that some groups (e.g. those in which average scores were above 9 out of 10 for these items) were highly motivated, and others (e.g. with average scores of six or below for one or more items) less so. There was also evidence from 12 groups of mismatches between one or more individual participants’ ratings and that of the wider group, particularly in relation to confidence in achieving physical activity and a healthy diet. As described below, qualitative analyses demonstrated that participants’ motivations, reflected in their perceptions of importance and confidence, were explicitly revisited in the sessions, allowing triangulation of these data and insight into potential links with group processes.

These baseline data indicate variability in the size and sociodemographic, socioeconomic and health-related characteristics across the groups (i.e. between-group variability), and in the make-up of individual groups (i.e. within-group variability). Some of this variability might be explained by ‘group intervention design’ features in the framework related to 1.4 participant selection and group composition and 1.3.2 process of becoming a group member under 1.3 group characteristics. These varying characteristics could be further explored in relation to their influence on group dynamics (e.g. group engagement, cohesion), interpersonal change processes (e.g. social support) and intervention outcomes (e.g. weight loss). They could also be examined in relation to other design (e.g. venue) and contextual features (e.g. facilitator characteristics) not recorded in this data set. It is worth noting that, although facilitator details were not recorded here, the facilitator represents another level of clustering within the data set. If such data were available, potential links between participant and facilitator characteristics, and the impact that these may have on interaction and group processes, would be worth exploring. 52

In future research, groups with different features (e.g. small or large group size; high or low average BMI, and scores of importance and confidence among participants; differing numbers of members with certain characteristics) or with different levels of heterogeneity within groups (e.g. comparing more homogeneous with heterogeneous groups in terms of sociodemographic, socioeconomic or clinical characteristics) could be sampled and then analysed using qualitative methods, to explore potential differences in group processes (as described in Qualitative analyses of group processes in two Living Well Taking Control programme groups). Relationships between group-level characteristics and self-reported perceptions of group processes could also be explored via multivariate analyses. ‘Outlier’ members (e.g. the only younger person, a severely obese participant) and the impact this status has on these participants’ perceptions of the group and on wider group processes might also be explored.

Engagement and perceptions of group processes in the Living Well Taking Control programme

Table 17 summarises descriptive data on participants’ engagement (assessed via session attendance) and self-reported perceptions of group processes (i.e. group support, group identification, other social identities) in the LWTC groups. Attendance data were relatively complete (sufficient data available for 87% of groups with baseline data) and attendance at group sessions was, in general, very high (75% of participants across the whole sample attended all sessions), with little variability apparent across groups. However, there were 16 groups (28%) that included one or more participants who dropped out after the first or second session. Although we are aware from the ComPoD trial that some of these may be for reasons external to the group (e.g. ill health), it would be interesting to explore further data on the characteristics of these dropouts in comparison with other group members, and to explore whether or not qualitative analyses could illuminate how dropouts affected, and were affected by, group processes.

TABLE 17 - Participants’ attendance at and perceptions of groups in the LWTC programme

SD, standard deviation.

Summary data	Attendance		Perception of groups (1–7)
	Number of sessions attended (1–4)	Attended all sessions	Group support	Group identification	Connections/social identities outside the group
Number (%) of groups for which data were available	58 (87)	58 (87)	48 (72)	48 (72)	48 (72)
Number (%) of participants for whom data were available	360 (84)	360 (84)	260 (60)	266 (62)	253 (59)
Mean (SD) across groups	3.8 (0.3)	82 (18)	4.9 (0.5)	5.3 (0.5)	4.1 (0.7)
Range in means across groups	3–4	25–100	3.7–6.2	4.0–6.2	2.3–5.8
Range across entire sample	0–4		1–7	1–7	1–7

Of the 306 participants (54%) across the whole LWTC data set who had completed the questionnaire on group perceptions, 253 (83%) had a group identifier for a group included in this analysis, and adequate data on this measure were available for 72% of the original 67 groups. Perceptions of ‘group support’ and ‘group identification’ both averaged close to 5 out of 7 on the scale, indicating that the participants generally perceived the group as supportive and experienced a sense of psychological connection to the group. There was also evidence that, overall, participants were moderately well connected outside the LWTC group setting, with scores for ‘other social identities’ averaging 4 out of 7. Inevitably, there was some variability in these group-level variables, and 10 groups included an individual whose scores on the group support and/or identification scales were low (less than 3), sometimes in contrast to the rest of the group. Thus, unsurprisingly, not every participant experienced their group in the same way.

These measures could be linked directly to outcome data in order to test, for example, hypotheses relating perceived group support and social identification to weight loss. 134 Haslam et al. 45 present testable hypotheses concerning links between such group processes and health, and Appendix 5 provides a summary of existing measures for assessing different aspects of groups from the reviews identified during our literature searches (see Chapter 2). In the current sample, 150 participants had a group identifier, data on perceptions of the group and complete baseline and follow-up weight, permitting calculation of weight loss. These data made such an analysis possible, but this was beyond the scope of the current study. Information from these measures could also be linked to qualitative data using the methods described further in Qualitative analyses of group processes in two Living Well Taking Control programme groups.

Motivation and outcomes at follow-up in Living Well Taking Control programme groups

Relatively complete 6-month follow-up data (i.e. for at least half the group and a minimum of three participants) on selected outcomes were available for 37 groups (55%) (a minimum of 225, or 52% of, participants). As shown in Table 18, there were generally small increases from baseline in participants’ perceptions of the importance of, and their confidence in, achieving healthy lifestyles. However, there remained considerable variability in these indicators of motivation between groups and participants, with divergent scores within at least six groups, particularly in relation to confidence in achieving adequate physical activity. Health status measures were also slightly improved from baseline (as per ComPoD trial results61) but remained highly variable across groups, with differences between the highest- and lowest-scoring participants within groups ranging from 7% to 88% (mean 37%). There was also little indication that groups became less heterogeneous in terms of measures of motivation or health status as time progressed.

TABLE 18 - Motivations and outcomes at follow-up for LWTC participants and groups

SD, standard deviation.

Higher scores indicate greater importance/confidence.

Summary data	Importance of activity (1–10)a	Confidence in activity (1–10)a	Importance of diet (1–10)a	Confidence in diet (1–10)a	Self-rated health	Weight loss (kg)
Number (%) of groups for which data were available	37 (55)	37 (55)	37 (55)	37 (55)	37 (55)	37 (55)
Number (%) of participants for whom data were available	227 (53)	230 (53)	230 (53)	230 (53)	227 (53)	225 (52)
Mean (SD) across groups	8.0 (1.0)	6.9 (1.2)	8.8 (0.7)	7.7 (0.8)	76 (9)	–2.2 (2.03)
Range in means across groups	5.4–9.7	4.3–9.0	7–10	5.2–9.0	55–89	–7.6–1.7
Range across entire sample	0–10	0–10	3–10	2–10	10–100	–16.3–19.2

The average weight loss in the current sample (2.2 kg) is slightly greater than in the ComPoD trial61 and LWTC evaluation60 (in which it was around 1.8 kg). This is not surprising given high loss to follow-up in this data set and suggests that this sample is not fully representative of the entire population of LWTC participants. There is considerable variability across groups in terms of average weight loss, ranging from weight loss of 7.6 kg per participant in the most successful and weight gain of 1.7 kg in the least successful. It should be noted that a few identified outliers, whose weight loss/gain could be attributed to other factors (e.g. diagnosis of another condition), are likely to account for some of this observed variation owing to the small numbers within groups, which is a factor that would need to be considered in further analyses of group-level outcomes.

There were eight ‘successful’ groups whose participants on average lost > 4 kg, and, in six of these, all participants lost at least some weight. In contrast, there were 10 ‘less successful’ groups whose participants on average lost < 1 kg or, in four of these, gained weight. In 8 out of these 10 groups there were still examples of one or two participants who lost > 2 kg, meaning that they were not necessarily ‘less successful’ groups for these people. This suggests that our original plan to sample more or less successful groups on the basis of weight loss outcomes, and then to characterise and compare these groups through in-depth qualitative analyses, would have been feasible. However, how more and less successful groups are defined would need careful consideration.

In-depth summary of quantitative data for three Living Well Taking Control programme groups

Tables 19 and 20 present in-depth summaries of key quantitative variables for three of the six groups sampled for in-depth analysis as described in Methods, building on the data presented above and including further details. Two of these with different facilitators are subsequently considered in the qualitative analyses below.

TABLE 19 - Illustrative summary of group-level baseline characteristics for three LWTC groups

FAC, facilitator; PA, physical activity.

These two groups are considered in qualitative analyses (see Qualitative analyses of group processes in two Living Well Taking Control programme groups) as they have two different facilitators.

Younger: ≤ 54 years; middle-aged: 55–64 years; older: ≥ 65 years.

Note

Shaded rows provide a summary/comparison of the details on the separate groups described in the unshaded rows.

Group	Characteristics			Weight status	Other groups	Other measures	Activity/diet
	Sociodemographic	Socioeconomic	Clinical
1a FAC: A	Eight participants: six female, two male		Five out of eight had an existing condition	Average BMI of 33 kg/m2 (range 27–39 kg/m2)	Three out of eight attending other groups	Average 57% health rating (range 22–92%)	Average ratings (out of 10) for PA: 7 importance (range 1–10), 7 confidence (range 1–10)
	Average age 67 (range 42–80) years; two younger, six olderb	Two employed, six retired	Two high blood pressure	Two overweight, five obese		Average 8/10 life satisfaction rating (range 5–10)	Average rating (out of 10) for diet: 9 importance (range 7–10), 8 confidence (range 5–10)
	All white British	Three school to 16 years, one school to 18 years, one professional training, two degree or above (one missing)	Three out of seven had HbA1c levels in pre-diabetes range
			One smoker
2a FAC: B	Seven participants: four female, three male	One employed, three retired, one carer, one student	Six or seven existing condition	Average BMI of 34 kg/m2 (range 29–40 kg/m2)	One out of four attending other groups	Average 70% health rating (range 49–97%)	Average ratings (out of 10) for PA: 9 importance (range 7–10), 7 confidence (range 5–8)
	Average age 61 (range 48–77) years; two younger, two middle-aged, two olderb (one missing)	One school to 16 years, two professional training, three degree (1 missing)	Three high blood pressure
			Three out of seven HbA1c levelsin pre-diabetes range	Three overweight, three obese, one severely obese		Average 6/10 life satisfaction rating (range 4–9)	Average rating (out of 10) for diet: 9 importance (range 7–10), 8 confidence (range 5–10)
	One Asian participant		One smoker
3 FAC: A	Six participants: two female, four male	One employed, four retired, one unemployed	Two out of six had an existing chronic condition	Average BMI of 33 kg/m2 (range 28–38 kg/m2)	Two out of six attending other groups	Average 85% health rating (range 70–100%)	Average ratings (out of 10) for PA: 9 importance (range 8–10), 9 confidence (range 7–10)
	Average age 65 (range 54–73) years; one younger, two middle-aged, three olderb	One school to 16 years, two professional training, three degree	Two high blood pressure	Two overweight, four obese		Average 8/10 life satisfaction rating (range 5–10)	Average rating (out of 10) for diet: 9 importance (range 7–10), 9 confidence (range 7–10)
	One white/Asian participant		No HbA1c levels in pre-diabetes range
			One smoker
Similarities	Group sizes of six to eight participants	Majority retired/not working	One smoker in all groups	Average BMI in obese range (33–34 kg/m2)	Minority attending other groups (mostly exercise)		On average saw healthy PA and diet as important, and were confident in achieving
	Average age 61–67 years; one or two younger in all groups	Mixed levels of education (school to at least degree)	Two or three high blood pressure in all groups
	All or majority white British
Differences	One majority female, one majority male, one mixed	Two groups in which at least half of participants were educated to degree level	In two, majority have existing condition; in one, majority healthy			Some variation in health status and life satisfaction across groups	Some variation across groups
	Two majority older, one mixed-aged		Two have participants with HbA1c levels in pre-diabetes range				One group with participant with low PA importance and confidence scores
							Two groups with one or two participants with maximum scores

TABLE 20 - Illustrative summary of group-level attendance and outcomes for three LWTC groups

FAC, facilitator; PA, physical activity.

These two groups are considered in qualitative analyses (see Qualitative analyses of group processes in two Living Well Taking Control programme groups) as they have two different facilitators.

This participant died from cancer shortly after the end of the study.

Much of this due to large change in participant diagnosed with cancer.

Note

Shaded rows provide a summary/comparison of the details on the separate groups described in the unshaded rows.

Group	Attendance	Weight loss	Other weight loss outcomes	Other measures	Activity/diet	Perceptions of group
1a five out of eight with follow-up	No clear dropout Average 3.9 sessions attended (range 3–4)	Average 5.9 kg (range 16.3 kg to 0.5 kg loss) although one with large weight loss may be due to cancer diagnosis;b when excluded, the average is 3.3 kg	Average 2.2 kg/m2 reduction in BMI (1.3 kg/m2 excluding outlier, range –5.7 to 0.2 kg/m2 reduction), taking group average down to overweight/obese cut-off point	Average 64% health rating (range 49–96%), reflecting some improvement from baselinec	Average ratings (out of 10) for PA: 5 importance (range 0–10), 5 confidence (range 0–10), reflecting some reduction from baseline	Average ratings of 4.3 (range 2.8–5.8), 5.1 (range 4–5.8), 5.2 (4–6.3) (out of 7) on measures of group support, group identification and other social identities
	Six out of eight attended all		Average 7.7 cm reduction in waist (5.9 cm excluding outlier, range 2.0–15.5 cm)	Average 7/10 life satisfaction rating (range 5–9), reflecting small reduction from baseline	Average rating (out of 10) for diet: 9 importance (range 8–10), 7 confidence (range 5–9), reflecting little change from baseline	All reported benefits, one mentioning group aspects (being in group)
	Two participants missed one session each (sessions 3 and 4)
2a four out of seven with follow-up	No clear dropout Average 3.4 sessions attended (range 2–4 sessions)	Average 3.9 kg (range 8.4 kg loss to 1.2 kg gain)	Average 1.5 kg/m2 reduction in BMI (range 3.2 reduction to 0.4 increase), taking group average down to bottom end of obese range	Average 74% health rating (range 48–91%), reflecting little change from baseline	Average ratings (out of 10) for PA: insufficient data to explore (< 3 participants)	Average ratings of 4.6 (range 3.5–5.5), 4.9 (range 4.5–6), 5.3 (3.5–7) (out of 7) on measures of group support, group identification and other social identities
	Five out of seven attended all		Average 5.3 cm reduction in waist (range 0.5–9 cm)	Average 7/10 life satisfaction rating (range 5–8), reflecting small improvement from baseline	Average rating (out of 10) for diet: 8 importance (range 7–10), 7 confidence (range 6–8), reflecting little change from baseline	All reported benefits, three mentioning group aspects (discussion, sharing)
	Two participants missed two sessions each (one participant missed sessions 2 and 3, one participant missed sessions 2 and 4)
3 five out of six with follow-up	One no data = dropout?	Average 2.0 kg (range 5.1 kg loss to no change)	Average 1.0 kg/m2 reduction in BMI (range 1.7 to 0.1 kg/m2 reduction), with group average still in obese range	Average 60% health rating (range 48–91%), reflecting some reduction from baseline	Average rating (out of 10) for PA: 9 importance (range 8–10), 8 confidence (range 8–9), possibly reflecting small reduction in confidence (although n = 3)	Average ratings of 5.4 (range 4.5–6), 5.7 (range 5–6), 4.9 (2.8–6) (out of 7) on measures of group support, group identification and other social identities
	Three out of five participants attended all
	Average 3.6 sessions attended (range 3–4 sessions)		Average 2.0 cm reduction in waist (range 2.3 cm increase to 4.3 cm reduction)	Average 7/10 life satisfaction rating (range 3–10), reflecting small reduction from baseline	Average rating (out of 10) for diet: 9 importance (all 9), 8 confidence (range 7–9), possibly reflecting small reduction in confidence (although n = 3)	All reported benefits, three mentioning group aspects (being in group, discussion)
	Two participants missed one session each (sessions 3 and 4)
Similarities	High attendance overall	Large variation in weight loss within groups	Most people in all groups saw improvements in BMI and waist		None improved from baseline, although all started high	All reported benefits
Differences	One dropout in one group (reported 100% health, satisfaction and importance/confidence at baseline)?	Some variation in weight loss between groups		Some groups show possible reduction in perceptions of health/life satisfaction (although may be due to more healthy missing data?)	Some groups show possible reductions, especially in confidence (although may be due to missing data from more confident participants?)	Two or three groups more emphasis on group aspects by some

The groups highlighted here were chosen on the basis of data availability rather than purposefully to represent the sample, or on the basis of presence/absence of certain characteristics. As shown in Table 19, they appear to be fairly typical groups in terms of participants’ age, employment status, education level and BMI, and somewhat atypical in having generally high levels of motivation. They also illustrate the wider between-group diversity in terms of gender mix and ethnic background. Two of the three groups might be classified as ‘successful’ groups on the basis of the average weight loss achieved. However, from exploring the data at this level, the outcomes in one of the groups are known to be influenced by an outlier who lost a large amount of weight due to an unrelated condition. None could be classified as ‘less successful’ groups.

It is difficult to make any meaningful observations about the participants’ perceptions of the groups (i.e. group support and identification); however, the third group appear to have, on average, slightly lower scores for ‘other social identities’ and somewhat more positive perceptions of ‘group support’ and ‘group identification’, despite there being possible evidence of a participant who dropped out of this group (attendance data for one participant are missing for the later sessions).

The last column of Table 20 highlights additional qualitative data available from open questions (‘What did you like the most?’ and ‘What did you like the most’) on a programme satisfaction questionnaire (not analysed further in the context of this study), demonstrating that participants frequently provided (mostly positive) comments about their experiences in the group. These could provide useful insight on differing views, for example by providing explanations for differences in perceptions of the group. A single open question such as this, or more specifically focused on the group experience, has potential to provide an insight into perceptions of the group for a large number of participants.

In summary, this part of the results illustrated methods for summarising quantitative data on characteristics and outcomes for groups and group participants. We analysed data for a large sample descriptively, demonstrating between- and within-group variability, and provided examples of how these and similar data could be used for developing and exploring hypotheses about potential links between group features, group processes and outcomes. A more detailed descriptive summary of quantitative data was provided for three groups, selected on the basis of availability of quantitative data that could be linked to qualitative analyses of all session recordings.

Qualitative analyses of group processes in two Living Well Taking Control programme groups

This section describes how we developed and applied qualitative methods for analysing transcripts of group sessions (using the MAGI framework) addressing the question of ‘how can qualitative methods be used to explore potential links between group processes and intervention outcomes?’. For illustration purposes, and owing to the time-consuming nature of these analyses, we selected two out of the three groups for which data were summarised above, which had two different facilitators. We describe the steps that can be helpful in such qualitative analyses. Later, in Integration of qualitative and quantitative data, we consider mixed-methods approaches for integrating the qualitative and quantitative data.

Data familiarisation

A first step involved data familiarisation through reading session transcripts and listening to recordings. This allowed the transcripts to be checked and corrected, adding any details that might be helpful in analysing group processes, such as the amount of time spent on group activities, overlapping talk or indications of non-verbal behaviours. It also helped to gain an overall impression of the group dynamics and interaction, and to interpret and understand some non-verbal interaction (e.g. laughter, moving chairs for specific activities). Notes were made on these initial observations about each group session.

Detailed coding and analysis of sessions using the Mechanisms of Action in Group-based Interventions framework

In the second step, we analysed each transcript using the MAGI framework coding schema (see Chapter 3 and Report Supplementary Material 2). This involved two simultaneous tasks: coding transcripts and writing summaries of each session.

First, we coded the transcripts deductively in Microsoft Word (Microsoft Corporation, Redmond, WA, USA) documents (i.e. by inserting comments, e.g. Figure 6) using the coding schema (see Chapter 3). In this coding, all framework categories can be used, or there can be a focus on specific categories of interest (e.g. included in a prior logic model for the intervention, or selected on the basis of other data, such as that presented above). The coding of transcripts can also be undertaken using qualitative data analysis software (i.e. NVivo version 11, e.g. Figure 7). Using NVivo can help facilitate easy access to transcript excerpts within each coded category and can automatically display data on prevalence (e.g. which categories were used in coding and how many times). Coding within text documents can help to retain a more holistic view of the sessions; it is easier to follow the progression of longer sequences of group discussions (involving multiple processes and techniques) rather than by fragmenting them using separate codes. Thus, it can help focus on co-occurrence between framework categories that may be interrelated (e.g. between exchanging information and sharing experiences).

FIGURE 6.

Example of a group session transcript coded in Microsoft Word document.

FIGURE 7.

Example of a group session transcript coded in NVivo.

Second, to help characterise sessions, we wrote detailed summaries of each session (Box 1 shows an example). This involved listing distinguishable session activities (i.e. sequences of interaction focused on the same topic, or discernible group/subgroup activities) and adding brief descriptions of the framework processes and facilitation techniques.

BOX 1 - Example of a detailed session summary

• P–P interaction: P shares experience of buying low-fat ice-cream, another P asks where to get it, so P shares information/advice. FAC draws on P experience to reinforce key message on small portions.

• FAC provides information in interactive way – by asking questions and then confirming information (e.g. about calcium, fat in cheese). Ps ask questions; FAC draws answers out; FAC directs P’s question back to the group. Few instances of P–P interaction.

• Whole-group practical activity – sugar game (ordering foods in order of sugar content, based on reading labels), including practice of skills in the session (reading labels) and providing illustrations (visual equivalents of the amount of sugar in foods). Quite a bit of P–P interaction and collaboration (working together, agreeing on the order of foods). Ps express surprise about the amount of sugar in food and develop understanding; Ps develop shared understanding/shared experiences.

• FAC offers extra sessions as part of the intervention to explore more diet-related topics.

• FAC prompts individual goal-setting. F shows resistance (says she’s already healthy and does not set a goal) – M challenges F (‘But we are all here because we aren’t as healthy as we could be’).

• FAC asks for self-assessments of importance of diet – Ps report high importance (8–10), one F does not know (it depends on mood if she cares about it or not, suggesting resistant talk). FAC asks about confidence – Ps report lower confidence than importance (7, 5). M expresses self-understanding of where his main problem is (evening snacking). F expresses negativity.

• FAC prompts review of the current session. M talks about reading labels but perhaps a bit sarcastically (it will hold people in a queue).

• F shares a goal (intention), another shares a goal and together (FAC, M) make suggestions to make it realistic.

• FAC outlines next session.

F, female participant; FAC, facilitator; M, male participant; P, participant.

This step resulted in in-depth coding, initial analyses and summaries of the session transcripts, providing details of the content of the sessions (e.g. group activities), indications of group dynamics and interpersonal and intrapersonal change processes occurring in the sessions. This enables an in-depth understanding of how the groups worked and how within-group processes developed. However, it does not allow for easy comparisons between groups.

Summary of sessions and groups

To facilitate comparisons between groups, and help develop and explore potential hypotheses, a third step aimed to further summarise and condense the analysis of group activities, processes and techniques. This involved summarising the presence or absence of a set of group processes and techniques in a table based on the MAGI framework (Table 21 shows an excerpt, and the full table can be found in Appendix 10). Based on the coding and detailed summaries developed in step 2 (as described in Detailed coding and analysis of sessions using the Mechanisms of Action in Group-based Interventions framework), we began to narrow our focus on processes and techniques that were of particular interest. For illustration, we summarised coding of group dynamics (to explore potential differences between groups in group dynamics and development), interpersonal change processes (to explore which of these were more or less prevalent between groups and sessions), and selected other elements that were predesigned and/or comparable between sessions (e.g. group activities, facilitation techniques, motivation and self-efficacy, goal-setting and goal-reviewing). Future researchers might select fewer or more categories for comparison. For example, if the analysis is exploratory, more or all categories used in coding in step 2 could be included. On the other hand, there may be a focus on fewer categories if there are already preliminary hypotheses (e.g. based on a logic model or quantitative data analysis). In the table, we also indicated the prevalence of processes and techniques, as a count or in terms of being rare (once or twice in the session), occasional (a few times in the session) or frequent (many times throughout the session). Constructing Table 21 allowed us to explore the occurrence (presence/absence) and prevalence of different processes between sessions and groups.

TABLE 21 - Example of a table summarising coding of MAGI framework elements

FAC, facilitator; P, participant; S, session.

Notes

Prevalence: F, frequent (many times throughout the session); O, occasional (few times in the session); R, rare (once or twice in the session.

Numbers refer to the number of coded examples.

Empty cells indicate that the concept/process was not identified in the transcript.

For the full table see Table 36 in Appendix 10.

MAGI framework elements	Group session
	1				2
	S1	S2	S3	S4	S1	S2	S3	S4
3. Group dynamics, development
3.6. Communication patterns
P–P interaction/exchanges	≈4	≈30	≈14	≈20	≈2	≈15	≈23	≈15
4. Interpersonal change processes
4.1. Sharing experiences	F	F	F	F	F	F	F	F
Self-disclosure of personal issues								O
Self-disclosure of transgressive behaviour		O	R		R	R	R
4.2. Social learning
Providing, exchanging information	F	F	F	F	F	F	F	F
Providing, sharing advice	O	O	O		R	F	F	O
Brainstorming, sharing ideas		O	F	F		F	F	F
Group problem-solving, barriers		R	O	R	R	R	R
Demonstrating, modelling			O
Providing instructions how to perform behaviour			O
4.3. Social influence
FAC appeals to credible source	R		R			R	R
FAC uses persuasive arguments	O		R	R
Negative social influences in group	≈8	≈17	≈8	≈3	≈4	≈5	≈3	0
FAC addresses resistance	F	F	F	O	F	F	R
Positive social influences in group	≈4	≈2	≈9	≈2	≈4	≈3	≈5	≈10
4.5. Social support in the group
Peer support		R	R	R			R	R
Buddy up
Social connections	R	R	O	O		R	R	R
FAC encourages peer support					R	R
FAC offers support		R	R		R
FAC provides praise	O	O	O	O	O	O	O	O
FAC provides reassurance	O	R	R	O	O		O
FAC provides encouragement	O	R	R		R	R	O
5. Intrapersonal change processes/targets
5.9. Motivation (importance)
Expression of motivation	R	F	R	R	R	R	R	R
Expression of no motivation	R		R			F
High importance of changes	F		O
Low importance of changes			O
5.10. Self-efficacy (confidence)
Change in self-efficacy	F	F	O		O	F	O	R
High self-efficacy			F		O			R
Low self-efficacy
5.13. Developing/practising skills and behaviours
Ps report practice/behaviour	O	O	O	O	O	O	O	F
Ps practise skills/behaviours in session		R	R

We also created tables with short, descriptive summaries of each of the sessions and overall summaries of each of the groups according to the main framework categories (i.e. group dynamics, interpersonal and intrapersonal change processes, facilitation techniques). Table 22 provides an example summary of, and comparison between, two groups. This table complements Table 21 and helps to compare the groups, focusing on key similarities and differences. For example, analysing our two groups, we made the following observations.

TABLE 22 - Summary of the key processes in the analysed groups

FAC, facilitator; P, participant; PA, physical activity; S, session.

Group	Group dynamics and development	Interpersonal change processes	Intrapersonal change processes	FAC techniques
1	Overall positive group dynamics Introductions involve names and a bit more information about each P Group goals not specifically set; FAC outlined programme goals Majority whole-group discussions, one subgroup discussion, three practical activities After S1, there seems to be more humour and P–P interaction Some social (off-topic) talk (more in later sessions) Few instances of P–P interaction, especially in S2	Most sessions involve social learning (exchange information, advice) and sharing experiences Some brainstorming and group problem-solving FAC demonstrates exercise and provides instructions, Ps model Resistance and negativity expressed (most in S2, least in S4), fewer positive statements Several instances of P–P support and social connections (more with time) Little P–P challenge Some P–P personal validation, empathy and shared understanding	High self-assessments of importance of health and diet (lower of PA) Low self-assessments of self-efficacy, some increase (after PA practise in session) Some Ps show resistance, no motivation or intention to change Practice of behaviours reported Negative perceptions of measures Goal-setting done individually (no time in S4); most goals unspecific; some are shared Almost no goal/progress review Individual barriers expressed	Tries to establish positive group context, attentive to group comfort Recaps S3 and S4 but only briefly No proper outlines of sessions, just brief mentioning (S1–3) Explicitly encourages participation Explicitly manages time, re-focuses Couple of times directs a question back to the group Uses good illustrations and reframing Uses names at times Shares own experiences Interactive social learning Offers support
2	Overall positive group dynamics Introductions involve names only, are repeated in S2 Group goals not specifically set; FAC outlined programme goals Majority whole-group discussions, few subgroup discussions, two practical activities After S1, there seems to be more P–P interaction and peer support Some instances of social, informal interaction and humour (but less than in group 1) Ps seem very engaged, ask FAC lots of questions, some P–P interaction (after S1)	Most sessions involve social learning (exchange information, advice) and sharing experiences Ps ask lots of questions of FAC and few of each other; make suggestions to each other Several sequences of brainstorming, little group problem-solving Little resistance and negativity, Ps share positive experiences, report engagement with health behaviours Few instances of P–P support (in S3 and S4) and social connections (fewer than in group 1) Ps share comparable information Little P–P shared understanding	High self-assessments of importance, motivation to change Initial low self-efficacy about maintaining change long term; some increase in self-efficacy over time Ps report changes, show interest in classes, share ideas – motivated Negative perceptions of measures Goal-setting done individually (no time in S4), some specific goals, most unspecific, some shared Some general review of progress Individual barriers expressed, some problem-solved	Recaps S3 and S4 but only briefly No proper outlines of sessions, just brief mentioning (S1–3) Little explicit encouragement of participation (perhaps because group already interactive) Little explicit time management (perhaps because of less off-topic talk) Rarely reframes, more reinforcement Does not use names Provides opportunities for informal talk (breaks) Shares own experiences Interactive social learning Offers support and empathy

Group dynamics and development

Both groups provided evidence of positive group dynamics including high levels of participant participation, direct between-participant interaction or exchanges, humour or laughter, and informal interaction. However, in group 1 there was more informal and, at times, off-topic chatting than in group 2. Group 2 seemed more focused on the session topics, but also, unlike group 1, they had breaks in the sessions, which allowed for ‘scheduled’ informal chatting and social interaction. The number of between-participant interactions, including peer support (e.g. participants praising, encouraging or making suggestions to each other), increased after session 1 in both groups. This could indicate that participants in both groups felt more comfortable with, and concerned for, each other over time, suggesting positive group development. In both groups, the majority of group activities involved whole-group discussions and there were very few subgroup or practical activities. In both groups, there were a couple of participants who were more vocal than others, but there was no indication of dominating or disruptive participants. Overall, there seemed to be no major differences between these groups in their dynamics or development.

Analyses of techniques that facilitators used to start the groups/sessions and facilitate group dynamics could be used as the basis for feedback to facilitators. For example, some techniques, such as managing expectations or agreeing group rules, were not used in either group, whereas others, such as identifying, agreeing and referring to common group goals, might have been underutilised because facilitators referred only to the overall aims or key messages of the programme, rather than common goals.

Interpersonal change processes

In both groups, the majority of sessions involved interactive exchanges of information, advice and ideas (i.e. social learning processes) and participants sharing experiences or reporting on their (typical or changed) behaviours. Facilitators provided information and explanations (e.g. about pre-diabetes, measures taken, healthy diet), provided advice and recommendations (e.g. about portion sizes, amounts of physical activity) and answered participants’ questions related to health behaviours and measures. This was particularly true in session 1 (focused on explaining measures, e.g. visceral fat), in which there were fewer participant contributions than in other sessions. In the following sessions, the facilitators delivered information more interactively (e.g. by asking questions, then providing explanations) and facilitated brainstorming activities, in which participants shared ideas (e.g. for different ways to be active or relax). This focus on group discussions and exchanging information and ideas reflected the type of intervention and the delivery manual. However, other interpersonal change processes also occurred (although they were less specifically or actively facilitated by the facilitators). For example, in both groups, the participants offered each other more support over time (e.g. praise/compliments, encouragement, practical suggestions) and were involved in more talk indicative of making social connections. Throughout both groups, participants shared similar experiences, provided personal validations and expressed a sense of shared understanding (social validation). However, the groups differed slightly in the expressed negativity or positivity towards health-related behaviours and behaviour change. In group 1, the participants seemed to express more ‘resistance talk’ (e.g. expressing negative attitudes towards or undermining healthy behaviours, expressing no intention to change) than in group 2. In contrast, participants in group 2 seemed to express more ‘change talk’ (e.g. expressing positive attitudes towards healthy behaviours, and motivation to change and engage in healthy behaviours). This sense of expressed negativity or positivity might have facilitated different prevalent social influences in these two groups. Of interest, in both groups the facilitators addressed most, or all, of the identified negative, ‘resistance’ talk.

Intrapersonal change processes

In analysing intrapersonal change processes evident in group interaction, we focused selectively on those that were most comparable between the two groups. The two groups different slightly in participants’ verbal expressions of motivation and confidence to engage in and change health behaviours. In group 1, some participants expressed motivation to improve health and change, but some expressed no motivation or intention to change and most of them expressed low confidence in being able to change. In group 2, some participants expressed motivation to improve health and change, no one expressed lack of such motivation and only a few expressed low self-efficacy. In group 1, participants shared more reports of unhealthy (or ‘transgressive’) behaviours than in group 2, but in both groups participants reported practice of health-related behaviours or skills. In both groups, facilitators briefly explained how to set goals but ran out of time to prompt goal-setting in the final session. In both groups, most goals that participants shared seemed to be non-specific, general intentions (rather than specific goals/action plans). Finally, in group 1 there was no goal or progress review, and in group 2 there was mainly general review of progress (based around reporting behaviours rather than referring to goals that people set).

These analyses provide an example of how group processes can be analysed at a micro-level, describing what happened in each group and in each session, and summarising the information about occurrence and prevalence of the MAGI framework processes and techniques. This work allowed us to compare between sessions (thus exploring change in groups over time) and between groups (thus exploring variability between groups). Here, for illustration, we focused on only two groups, but this process could be repeated for more groups and potentially allow grouping on the basis of certain criteria (e.g. with positive vs. negative group dynamics or social influences) to link micro-level analysis to macro-level observations, such as those based on quantitative analyses. In the next section, we describe how the results of this type of qualitative analysis can be combined with quantitative data.

Discussion

In this final stage of the MAGI study, we developed and illustrated application of quantitative and qualitative methods and developed mixed-methods approaches, based on the MAGI framework, to explore differences between groups and potential links between group characteristics, processes and outcomes. We applied these methods to secondary, quantitative and qualitative data sets from an existing GB-BCI: the LWTC programme promoting weight loss through changes in diet and physical activity for the prevention or management of type 2 diabetes. We analysed quantitative data to illustrate between- and within-group differences in group and participants’ characteristics, perceptions of group processes and outcomes and made suggestions for how these might be further explored. We also showed how in-depth analyses of qualitative data (transcripts of group sessions) could identify group dynamics and processes. The final aim was to provide examples of mixed-methods approaches that could be used in future research to address questions about which group processes are most predictive of behavioural outcomes. To do this, we used the example of two groups, combining qualitative with quantitative data to illustrate how differences and similarities between groups in group dynamics and interpersonal and intrapersonal change processes can be summarised and explored, in order to make links between these processes, and with outcomes. By doing this, we demonstrated how the MAGI framework [a model of mechanisms of action in group-based interventions (see Chapter 2)] and a coding schema that supports its use in data analyses (see Chapter 3) can be applied in the context of future process evaluations of GB-BCIs.

Across 67 groups in the LWTC programme, there was considerable variability in group features indicative of MAGI framework components, and outcomes. This suggests that sampling to allow qualitative comparisons of groups on the basis of differences in these features or outcomes (as was originally planned) is likely to be feasible if the quantity and quality of data on groups are sufficient. Sampling could be based on differences in (1) group-level baseline characteristics (e.g. group size, high/low average BMI or scores for motivation) to explore how this influences subsequent group processes; (2) heterogeneity within groups in terms of sociodemographic or socioeconomic features, clinical characteristics and intrapersonal processes (such as motivation, to explore the impact of differences between group members on group processes and potentially how this affects outcomes for participants who are different from other group members); and (3) outcomes (e.g. more/less successful groups in terms of weight loss or attendance) to explore how group processes might explain differences. Using a questionnaire assessing participants’ perceptions of aspects of the group (e.g. group support, identification), we demonstrated that there is scope for group-level quantitative analyses to examine links between group characteristics and processes, and processes and outcomes in GB-BCIs. We also showed that detailed, descriptive summaries of quantitative data relating to group characteristics, group processes and outcomes for small numbers of selected groups could be useful for consideration alongside summaries of group-level findings from qualitative analyses and shed light on limitations of purely quantitative approaches (e.g. that a single ‘outlier’ in a group, which might be missed in larger-scale quantitative analysis, can have a big influence on a group average).

We found that qualitative analysis based on the MAGI framework can, first, provide context that enhances interpretation and understanding of the quantitative data, and, second, illuminate how groups work in practice (i.e. which processes occur and are facilitated to bring about intended changes relative to intended protocols). Moreover, we demonstrated that mixed-methods approaches have the potential to provide a more complete assessment of some elements of the MAGI framework; for example, components that may not be easily observed (e.g. group dynamics) can be measured via self-report, whereas other parts that are difficult to capture via self-report (e.g. occurrence and prevalence of interpersonal change processes) can be assessed through qualitative analysis of observations. Our illustrations of triangulation, following a thread, and matrix approaches to data integration provide examples of ways in which group-level quantitative and quantitative data can be brought together to explore links between framework components and outcomes. They further highlight the complexity surrounding how groups work, and suggest ways forward to unravel some of the mechanisms underpinning change in GB-BCIs.

Summary of findings

The overall aim of this study was to enhance understanding of mechanisms of action in GB-BCIs. We focused on health-related interventions that targeted diet, physical activity and weight loss because data from groups conducted as part of these interventions were available to us and the evidence suggests that GB-BCIs may be particularly effective in helping participants lose weight. We intended, however, to develop a theoretical understanding of the operation of GB-BCIs more generally.

We defined three study objectives that divided our research into three stages, namely to:

1. develop a generalisable framework of mechanisms of action in GB-BCIs by identifying, defining and categorising potentially important group design features, group processes, facilitation techniques and contextual factors in groups

2. test and refine the framework, using a coding schema derived from it, as a tool for identifying these group features, processes and facilitation techniques in the recordings of sessions from three GB-BCIs (focused on diet, physical activity and weight loss), and provide examples to illustrate framework elements

3. develop mixed-methods approaches based on the framework, to explore why some groups may be more or less successful than others, and illustrate their use with available qualitative and quantitative data from a GB-BCI.

In stage 1 (addressing objective 1), the MAGI framework was developed to identify, categorise and define group features and processes. Our overarching diagrammatic representation of the framework (see Figure 3) presents some of the postulated complex, bidirectional relationships between key aspects of groups over the lifetime of an intervention. The central, blue-coloured boxes and arrows represent types of mechanisms by which interaction in groups is able lead to, initiate and support individual changes in proximal (e.g. behaviour change) and distal (e.g. improved health) outcomes. These reflect mechanisms of change based in the group itself (‘group dynamics and development’), interactions between members of the group, including facilitators (‘interpersonal change processes’), and within individual participants (‘intrapersonal change processes’). The surrounding boxes represent influences on these mechanisms resulting from the initial ‘group intervention design’ (in green), ‘facilitation techniques’ used by group facilitators (in dark blue), and factors from outside the group which influence group interaction (‘facilitator and participant characteristics and other contextual influences’ from participants’ immediate social environment). All aspects represented in the framework sit within, and may be influenced by, the ‘wider sociocultural, economic, environmental, community and organisational’ context.

Our summary table of the framework (see Table 5) and definitions underpinning it (see Report Supplementary Material 1) detail between 3 and 22 subcategories within each of the six categories. These subcategories include specific mechanisms underpinning group dynamics and development (e.g. group goals, group cohesion) as well as interpersonal (e.g. social support, social comparisons) and intrapersonal change processes (e.g. developing understanding, setting goals). Intrapersonal change processes were not the key focus for this study because they have already been extensively discussed in the psychology literature. Nonetheless, as our research suggests that a considerable portion of time in GB-BCI sessions is focused on initiating such intrapersonal change, we included a non-exhaustive list of subcategories representing intrapersonal change processes and psychological change targets that may be observed and influenced in GB-BCIs. For example, enhancing participants’ attitudes towards, or their self-efficacy in relation to, a specified behaviour change may be seen as prerequisites to generating behaviour change in GB-BCIs.

The inductive qualitative analyses of 10 diverse group sessions conducted during stage 1 generated codes that mapped onto initial framework elements stemming from the reviews of the literature and early consultations, providing preliminary support for its applicability. The coding schema (see Report Supplementary Material 2), developed alongside the framework during stage 2, includes further lower-level subcategories reflecting different ways in which subcategories were manifested in the group sessions examined (e.g. for social support, peer support, buddy-up, social connections, reciprocity). However, these codes are likely to be indicative rather than exhaustive and, for this reason, were not included in the framework itself. The framework definitions (see Report Supplementary Material 1) also include some observations and hypotheses stemming from the literature, consultations and analyses of group sessions about links, interactions and interdependencies between specific framework elements. In stage 2, facilitation techniques identified through coding of transcripts were mapped onto group dynamic, inter- and intrapersonal change processes they appeared to instigate or facilitate, providing initial evidence for mechanistic links.

In stage 2, the coding schema developed from the framework was used to identify and document the frequency with which different framework subcategories from across all of the broad framework categories were observed, and ‘real-life’ examples of facilitation techniques were used to initiate or support them in a group-based weight loss intervention (addressing objective 2). No empirical examples were identified that could not be categorised within the final framework categories. It should be noted, however, that the analyses of transcripts, development of the coding schema and further consultations contributed, in an iterative manner, to the refinement and evolution of the framework. The framework categories and many of the subcategories (1) were apparent to a greater or lesser extent in intervention manuals and session transcripts, (2) paralleled aspects of groups highlighted by facilitators, (3) linked to hypotheses generated from analyses of data in stage 3 and (4) were not questioned by researchers consulted about the framework. This is indicative of overall content validity of the framework, at least for interventions focused on diet, physical activity and weight loss.

The stage 2 analyses demonstrated that the majority of group sessions involved predesigned whole-group discussions and social learning processes, in particular exchanging information, advice and ideas, and sharing of experiences. Some group processes were less common, for example establishing shared group goals or providing group-level feedback. Commonly observed intrapersonal processes, for example goal-setting, problem-solving and feedback, were predominantly facilitated on an individual basis within the group, rather than through wider group interaction. As well as examples of group features and processes, stage 2 analyses identified a wide range of techniques used by the facilitators to instigate, facilitate and manage group dynamics and inter- and intrapersonal change processes. In the framework, these were divided into (1) techniques for starting the group or session (included to highlight tasks for setting up a group and to make this generalisable to rolling groups where new members potentially join at each session), (2) generic facilitation technique types, (3) techniques for facilitating group dynamics, (4) techniques for facilitating interpersonal change processes, (5) techniques for intrapersonal change processes and (6) techniques for closing the group or session (including techniques designed to promote maintenance of behaviour change beyond the group intervention).

Some ‘group dynamics’ subcategories (e.g. group goals, cohesion and climate) and ‘interpersonal change processes’ (e.g. social comparisons, group competition and co-operation) were rarely or never observed in the session recordings. This may reflect the nature of the groups studied (e.g. little focus on developing group dynamics, or certain interpersonal processes) and difficulties in identifying processes from audio-recordings. Such processes may be better captured via participants’, facilitators’ or, potentially, observers’ perceptions. For example, in stage 3 we illustrated how a questionnaire assessing participants’ perceptions of three aspects of the group that mapped onto framework elements (i.e. group support, group identification and external social identities) can be used to generate data on key group processes. Appendix 5 includes examples of other questionnaires that can be used to assess processes defined by the framework.

The framework was developed on the basis of a broad conceptual review of the literature. 40 Consequently, although the framework was tested using GB-BCIs targeting diet and physical activity, literature on groups shows that the group features, facilitation techniques and mechanisms that we have defined are probably relevant to a wide range of GB-BCIs (e.g. to groups providing mental health support, education, team-building). Our in-depth consultations with group participants and facilitators were confined to those involved in the interventions studied here but feedback from other experts indicated that the framework captured their broader experiences of groups.

In stage 3, although our data did not permit formal investigation of group features and mechanisms that could distinguish between more or less effective groups (as originally planned), we were able to suggest questions, illustrate novel applications of mixed-methods approaches for integrating qualitative and quantitative data based on our framework and provide a resource for undertaking future detailed work to do this in future research (addressing objective 3). The additional quantitative data on up to 67 groups in the LWTC programme demonstrated large variability across groups in terms of their features (e.g. group size, mix of participants with different characteristics within groups), participants’ perceptions of interpersonal change processes (e.g. group support, group identification) and group-level outcomes. This was true to a lesser extent for attendance, which was generally high across all groups. For key characteristics and outcomes, we were able to identify groups in which the make-up of participants was more or less homogeneous, and groups that were typical or atypical in relation to the wider sample, for example single-gender groups, groups with drop-out and groups that were more or less successful in terms of their group-level weight loss outcomes. As per our original plan, we suggest that groups of different types or with different levels of success could be sampled on the basis of these group-level features, analysed qualitatively and compared to explore whether or not there are any potential differences with regard to group dynamics, use of particular facilitation techniques or occurrence of interpersonal change processes. We illustrated mixed-methods approaches to integrating quantitative and qualitative data to generate and address hypotheses including triangulation, ‘following a thread’ and matrix or other case-based approaches. We also recommended minimum data that should be collected for any group programme to allow such analyses in future research.

Strengths

A key strength of this research is that, building on our prior conceptual review of decades of multidisciplinary research,40 we incorporated key theoretical explanations of personal change in groups into a manageable framework that can be used to guide good practice and adequate data collection. As our aim was to identify and map all potentially relevant concepts, we did not plan to conduct systematic reviews to identify, select and appraise evidence on all of the ≥ 90 group features and processes that ultimately featured in our framework owing to the diverse nature and size of the literature, uncertainty regarding what would count as evidence to support their inclusion and time constraints. However, we used systematic approaches to selecting constructs when building the framework and employed systematic methods when searching the smaller literature on qualitative studies on people’s experiences of weight loss groups.

A further strength was the consultative checking for content and face validity and refinement of category definitions with around 40 experts and non-experts, including group participants, facilitators and researchers (see Appendix 4). We disseminated the framework more widely than initially proposed to gain feedback at practitioner- and researcher-focused conferences and internal seminars. The feedback we received at all stages was overwhelmingly positive, emphasising the importance of the work in the health field and beyond, and potential usefulness of the framework for a variety of purposes (e.g. ‘I think this level of detail is fantastic. This will be really useful for those reading it moving forward’; see Appendix 4). In a further extension to what was originally planned, we also began to explore, via informal discussions with colleagues in education, psychology and management, potential applications to small group-learning and research teams.

In our qualitative analyses, great care was taken to check transcripts and discuss interpretations within the team, and in the early stages we drew on as large and varied a sample of transcripts as were available. This represented a relatively large sample for a qualitative study of this type, given how complex, in-depth and time-consuming the data and analyses were. An inductive approach was initially taken in the analyses, to ensure that observations stemmed from the data and were not constrained by the framework developing from the reviews of literature. The approach to analysis became more deductive as the study progressed and the framework was iteratively refined and expanded on the basis of observations from the coding. In stage 3, analyses of quantitative and qualitative data were undertaken by separate researchers without insight into the other data set to minimise bias, before the data sets were brought together.

The development of a formal, potentially widely applicable, coding schema for our framework provides a usable resource to supplement the framework. The coding schema was applied independently to one or more transcripts by five researchers, one of whom was not directly involved in the study and one of whom had limited experience in qualitative analysis. This demonstrated that the coding procedures can be learned by coders with some level of expertise and facilitated refinement of instructions for use. Similarly, our revised stage 3 work illustrated some of the practical challenges of generating and linking meaningful group-level data and conducting mixed-methods analyses of these. We also developed a training workshop on implications and potential uses of the framework for designers, facilitators and evaluators of GB-BCIs. This resource can underpin future dissemination and application of the framework for a range of audiences.

Limitations and further considerations

When using the group session recordings in stages 1 and 2, the cataloguing, checking, transcribing and analyses proved more time-consuming and resource intensive than anticipated. The stage 2 analyses combined transcripts used in stage 1 as well as newly sampled stage 2 transcripts to maximise the number of sessions from which examples of facilitation techniques and group processes could be drawn. In stage 1, we also trialled coding of different types of interactions in the sessions (i.e. when facilitators, female and male participants spoke) and quantified the amount of interaction (i.e. numbers of ‘turns’ and proportions of transcripts in which these participants spoke). We were unable, in the time available, to undertake such coding with further transcripts but future research could expand this approach.

In stage 2, our experience of coding, double-coding and relating the codes to the framework revealed multiple ways in which transcripts of group sessions can be coded. For example, words, phrases or multiple talk sequences can be coded and, for many sections of text, multiple codes apply. This makes reliability of the coding difficult to assess, but higher-level reliability between coders in terms of presence/absence or frequency of identification of codes could be investigated in future applications. The coding of transcripts relied primarily on one researcher (AJB), although others double-coded a selection, which helped to assess general ability to identify the framework categories in the transcripts, and led to refinements to coding categories and improved instructions for use. The expertise of coders in understanding distinctions between psychological constructs used to understand group process may also have an impact on reliability. Coders also need to understand (1) the level at which they are coding (i.e. whether they focus on identifying more general processes, such as (4.2) social learning, or more precise examples of these processes, such as (4.2.1) providing, exchanging information) and (2) the different approaches to coding (i.e. implicit/interpretative or explicit/semantic). By their very nature, coding systems specify a priori a particular meaning or function to the phenomenon being studied and involve some level of abstraction from the specific context. This is both an advantage and a disadvantage of coding systems: they enable quantification of essentially qualitative communication processes but the code may not quite capture what is seen in the data or multiple codes may be potentially applicable. 157,158

Some of the researchers involved in the design of the interventions and intervention manuals (CG: ComPoD, SkiM, WtW; FG: WtW; LP: SkiM) were also involved in the framework development and coding. This might have influenced their coding of the intervention content and intended processes, but is unlikely to have biased the content or shape of the MAGI framework (which was developed from a range of sources and in consultation with over 31 consultees), or the coding of transcripts (which was primarily conducted by AJB and JRS, the researchers without prior involvement in the analysed interventions). We acknowledge, however, that common intervention designers (e.g. across WtW and SkiM) and facilitators (between the ComPoD and SkiM studies) probably make these interventions more similar to each other than other weight loss interventions; future research should test and validate the framework in a wider range of weight loss and other GB-BCIs.

We have already described limitations in the data available for the stage 3 analyses (see Chapter 4), which necessitated a shift from our original plan. Potential issues with the quality and completeness of the session recordings (e.g. poor quality of WtW recordings, only seven LWTC groups for which all session recordings were available) and whether or not they would allow us to sample more and less successful groups (as originally intended) were flagged up early in the study. It was only later that the lack of quantitative data to link to for the groups with full session recordings became apparent. However, qualitative and mixed-methods studies commonly use adaptive designs, as subsequent steps can be dependent on earlier data, analyses and findings. These limitations were not unexpected given our reliance on secondary data, collected in one study by intervention providers operating outside a research context, and not for the purpose for which the data were used here. In future, this can be addressed by better recording of group identifiers for group programmes, and prospective data collection for process evaluation alongside GB-BCIs in research contexts with analyses of group features in mind.

The framework, its constituent definitions and the coding schema were designed to be comprehensive while at the same time presenting a manageable, easy-to-understand representation of the complexity of groups. We hope that as a result of its gradual refinement the framework and coding schema may be used as ‘catalogues’ of options from which different audiences can select broad categories to focus on (e.g. group intervention design, facilitation techniques) depending on their purpose (e.g. designing an intervention, training facilitators). Researchers might also select categories on the basis of hypotheses about prespecified group-level mechanisms (e.g. guided by a logic model) or stemming from initial findings about important aspects from the interventions studied.

The framework represents the dependency of some group processes on others (e.g. certain intra- and inter-personal change processes may happen simultaneously) and the potentially multiple, bidirectional and iterative links between processes over the course of a group session or intervention. Consequently, the group dynamics and interpersonal subcategories are, to some extent, ordered to reflect dependencies and definitions. Nonetheless, the framework is inevitably a simplification of the mechanisms of change at work in GB-BCIs.

We did not conduct a formal Delphi consensus exercise to agree on framework components and categorisations, but feedback from researchers on the near-final version of the framework highlighted some overlap and confusion between change targets, processes of change, and change techniques, which we subsequently tried to define more clearly. For example, the intrapersonal change category in our framework includes cognitive processes, such as goal-setting and self-monitoring, that are also listed as change techniques in taxonomies4 despite the fact that in definitions it is clear that the techniques actually involve ‘prompting’ or ‘encouraging’ goal-setting/self-monitoring (as change processes). 3 We have tried to be clear to distinguish facilitation techniques from the change processes that they instigate or support on the basis of evidence-based explanations of how altering change targets leads to behavioural change. 3 We recognise that some of the change targets, such as increased self-efficacy or motivation, are inter-related and influenced by multiple inter- and intrapersonal change processes and, therefore, may be difficult to separate in practice. However, they are retained as separate subcategories in the framework because they are well defined and conceptually distinct in the literature. Such individual-level change targets may also be viewed as mediating or intermediary outcomes of GB-BCIs in process evaluations,28,29 potentially able to explain subsequent behaviour changes. This highlights the complexity, but also the need for better conceptual clarity and careful use of terminology, in the wider field.

A final limitation of our study, which we were aware of from the outset, is that some of the processes included in the framework may not be identifiable directly from recordings of group sessions (i.e. through verbalised expressions). For example, ‘group cohesion’, a key subcategory of group dynamics underpinning other group dynamic and interpersonal processes, cannot easily be determined from audio-recordings. Interviews, observations or video-recordings of groups may provide further insight (e.g. SkiM groups were video-recorded, subsequent to our analyses, to explore this possibility). As highlighted in stage 3, participant and facilitator self-reports of these more abstract concepts may also be useful as a substitute for, or in addition to qualitative assessments, providing scope for triangulation.

Implications

Recommendations for research

This study implies a series of recommendations for research development and practice:

1. Specification of minimum data sets for group-based interventions. To facilitate future research and capitalise on opportunities for secondary analyses of data sets, research funders and commissioners should insist on provision of minimum data sets for group-based interventions delivered within, and ideally outside, research contexts, that include in each participant record:

   • a group identifier, which allows linkage of groups to individual records on participant characteristics (e.g. sociodemographic, socioeconomic, clinical), baseline measures and outcomes

   • a facilitator identifier that links to participant or group identifiers, ideally, with further key information on the facilitator (e.g. demographics, background, experience)

   • information on presence of a supporter in the group (when relevant)

   • attendance or absence at individual group sessions

   • ideally, one or more open questions on the experience of the group where this can be incorporated into self-report measures.

In line with recommendations for reporting of group-based69 and other interventions,164 intervention manuals should also outline key group intervention design features and intended facilitation techniques/style so that these can also be examined in retrospect.

1. Conduct systematic reviews to appraise evidence related to the framework concepts, and synthesise qualitative studies exploring group-based interventions. We identified a vast literature on group features and processes that informed our framework but further reviews could systematically appraise the evidence underpinning each concept to justify its inclusion or estimate its importance. A series of in-depth studies of participants’ experiences of weight loss groups were identified and it would be useful to undertake a formal systematic review and qualitative synthesis of these and qualitative studies examining participants’ experiences of other types of groups (e.g. for disease self-management goups165). Such reviews could be used to examine the robustness and comprehensiveness of our framework across different GB-BCIs and thereby lead to extensions and refinements.

2. Mapping available quantitative measures of group dynamics and processes. We identified measures, including questionnaires and multi-item scales, that allow characterisation of group characteristics, functioning and processes that are difficult to observe in group sessions but may be captured via participants’ self-reports. Mapping how these correspond to framework components would reveal the extent to which measures are available or, alternatively, need to be developed to adequately assess key group processes. Further work on assessing the conceptual clarity and psychometric properties of these measures would guide selection for use in research and clarify measures in need of refinement or further development.

3. Further developing qualitative methods for coding and analysing group sessions. Our coding schema from stage 2, methods for in-depth qualitative analysis demonstrated in stage 3, and preliminary approaches to coding interaction patterns in groups (see Appendix 8), could be further developed and tested. For example, it would be important to establish methods to assess reliability of the coding, determine whether or not this can be improved through training, and check reliability across different types of group interventions. Our coding approaches could also be adapted/extended for use with video-recordings and observations of group sessions.

4. Further developing mixed-methods and other research approaches to exploring group mechanisms. Building on stage 3 of our research, further specification and examples of how to integrate quantitative and qualitative data (e.g. using triangulation, following a thread, matrices) would facilitate more detailed and sophisticated analyses of mechanisms of action in GB-BCIs. Consideration could also be given to the need for more complex, systems-based approaches to researching groups and the role of realist approaches.

5. Exploring group mechanisms through process evaluations. The MAGI framework maps closely onto the summary diagram in the MRC process evaluation guidance,28,29 highlighting the potential importance of this work for evaluators of GB-BCIs. With some development (recommendations 3–5), our suggested qualitative, quantitative and mixed-methods approaches could be used by researchers to analyse group sessions by focusing on all or certain framework categories/components selected on the basis of logic models, prior hypotheses, previous research (recommendation 2) or data from other sources (e.g. facilitator observations) for the particular type of intervention being studied. As originally planned in our study, and demonstrated in stage 3, sampling could be used to make comparisons between different groups or facilitators to generate explanations for differences in engagement or outcomes, and so build evidence on what works, when and for whom in GB-BCIs. In feasibility studies, or ongoing interventions, such information might also be fed back to facilitators to improve delivery, or to designers to make adaptations.

6. Undertaking further quantitative group-level analyses using our own, and other, existing large secondary data sets from GB-BCIs, and other group interventions where a group identifier has been included. This work should:

   • establish and apply appropriate statistical techniques (e.g. multilevel modelling) to account for and explore group-level, and potentially facilitator-level, influences on outcomes

   • address specific research questions about mechanisms of action in these interventions, for example around how group size, group composition (within- or between-group variability in gender, age, clinical characteristics, etc.) may affect perceptions of group dynamics, interpersonal processes (e.g. social identification) and outcomes.

7. Adapting/extending the MAGI framework to other groups and populations. Work such as that described above could clarify whether or not the framework requires extension and refinement when applied to other types of GB-BCIs (e.g. targeting smoking, alcohol use, management of chronic illness) or in other contexts (e.g. mental health, education settings, research teams166) and populations (e.g. children, families, adults of different ages), including virtual/online groups.

8. Exploring the impact of group facilitators’ characteristics and skills/competencies on outcomes. Examining how facilitator characteristics and facilitation approaches (including techniques used, communication style, fidelity to protocol, and adaptation or tailoring to different groups) determine the potential of GB-BCIs to instigate personal change can help to answer questions concerning who should facilitate which groups, and what kind of training is needed to optimise outcomes.

9. Developing and evaluating group facilitator training toolkits. The above would provide the foundation for applied research that could develop and pilot training programmes, including online resources, to help facilitators identify and competently employ specific techniques designed to optimise participant engagement, group dynamics and interpersonal processes in GB-BCIs. These could be evaluated as add-ons to planned trials of GB-BCIs, or potentially in stand-alone trials.

Conclusions

The research reported here enhances our understanding of mechanisms of action in group-based interventions. The proposed MAGI framework identifies, categorises and defines group features, group processes (group dynamics, inter- and intra-personal change processes) and contextual influences, which can affect each other and facilitate or impede engagement, personal change, alteration of behaviour patterns and other intervention outcomes. The study provides evidence of these processes and examples of techniques used to facilitate them in ‘real-life’ GB-BCIs focused on diet, physical activity and weight loss, validating the framework in this context. Hypotheses and methods for further exploring potential relationships between group processes and outcomes are also proposed and illustrated. Thus, the framework and methods provide a comprehensive resource for designers, facilitators and evaluators of GB-BCIs, and further implications of our work for these and other audiences (e.g. group participants, commissioners and policy-makers) are outlined.

Other co-applicants on the original grant

Mrs Jaine Keable from Westbank and Associate Professor Matthew Jones from the University of the West of England for their support in the early stages of the study, and for providing access to additional data on the LWTC programme.

Group participants

Mrs Sue Sedgman, Mrs Jackie Morant, Mr Douglas Osman and Mr Andrew Wilkie.

Group facilitators/programme providers

Miss Amy Clarke, Miss Sian Derrick, Mrs Ruby Entwistle and Mrs Anna Murch.

Researchers/practitioners

Dr Amanda Avery, Dr Yael Bar-Zeev, Dr Enzo Di Battista, Dr Tegan Cruwys, Dr Liz Glidewell, Dr Cindy Gray, Dr Marta Moreira Marques, Dr James Nobles and others who provided us with feedback at seminars and conferences.

We would especially like to thank Dr Leon Poltawski for his helpful advice throughout the study, his feedback on the framework and coding schema, his participation in the double coding and for his help with accessing the SkiM data.

We also thank the ComPoD Trial Steering Committee (chairperson: Professor Sharon Simpson) for their oversight of the study.

Contributions of authors

Dr Aleksandra J Borek (Postdoctoral Research Associate in Psychology Applied to Health, MAGI Study Researcher and co-applicant) contributed to study design, conducted the literature reviews, led development and revision of the framework and coding schema, coded the transcripts, undertook all qualitative analyses and data interpretation, led consultations, drafted most of the report [summaries (Abstract, Plain English summary and Scientific summary), background (Chapter 1), stage 1 (Chapter 2), stage 2 (Chapter 3) and qualitative part of stage 3 (Chapter 4)] and revised draft and final versions. The initial framework built on a previous conceptual review developed as part of Dr Borek’s doctoral research.

Dr Jane R Smith (Senior Lecturer in Primary Care, MAGI Study Chief Investigator) led the funding application and development of the original protocol, managed the study and oversaw all aspects of the research, contributed to the development of the framework, participated in the double-coding of transcripts, undertook analyses of quantitative data, contributed to interpretation of data, supported consultations, drafted sections of the report [stage 3 (Chapter 4) and Discussion (Chapter 5)] and revised draft and final versions.

Professor Colin J Greaves (Professor in Psychology Applied to Health, MAGI Study co-applicant) co-supervised Aleksandra Borek’s doctoral work on which this study is built, contributed to the study design and development of the framework (particularly identification of facilitation techniques), provided access to data, commented on the coding schema, contributed to interpretation of data and provided comments on most sections of the report.

Dr Fiona Gillison (Senior Lecturer in Exercise & Health Psychology, MAGI Study co-applicant) contributed to study design and development of the framework (particularly identification of facilitation techniques), commented on the coding schema, participated in double coding of transcripts, advised on analysis, contributed to interpretation of data and provided comments on all sections of the report.

Dr Mark Tarrant (Senior Lecturer in Psychology Applied to Health, MAGI Study co-applicant) co-supervised Aleksandra Borek’s doctoral work on which this study built, contributed to study design and development of the framework (particularly in relation to social psychological theoretical literature), commented on the coding schema, advised on quantitative analyses, contributed to interpretation of data and provided comments on most sections of the report.

Dr Sarah Morgan-Trimmer (Research Fellow in Process Evaluation, MAGI Study co-applicant) contributed to study design and the development of the framework, participated in the double-coding of transcripts, advised on qualitative and mixed-methods analyses, contributed to interpretation of data and provided comments on most sections of the report.

Professor Rose McCabe (Professor of Clinical Communication, MAGI Study co-applicant) contributed to the study design and reviewed the framework, commented on the coding schema, advised on qualitative analyses and approved the final report.

Professor Charles Abraham (Professor of Social & Health Psychology, MAGI Study co-applicant) was the senior supervising researcher for the MAGI study. The project was an extension of the doctoral programme of Aleksandra Borek and the MAGI framework is an extension of the framework developed during that work. 40 Charles Abraham designed, won funding for, and was lead supervisor for this doctoral programme. He contributed to the MAGI study design and, with Aleksandra Borek, led the conceptual development of the framework. He co-authored and edited the final study report.

Authors are listed in order of their contribution to the study and report, apart from Charles Abraham, whose designation as last author reflects his role as the senior supervising researcher, providing overall oversight of the programme of work.

Publication

Borek AJ, Abraham C, Greaves CJ, Gillison F, Tarrant M, Morgan-Trimmer S, McCabe R, Smith JR. Identifying change processes in group-based health behaviour-change interventions: development of the mechanisms of action in group-based interventions (MAGI) framework [published online ahead of print June 13 2019]. Health Psychol Rev 2019.

Data-sharing statement

This is a primarily qualitative study using secondary data and, therefore, there are no data available for further access or sharing. All available data are contained within the report. All queries should be submitted to the corresponding authors.

Patient data

This work uses data provided by patients and collected by the NHS as part of their care and support. Using patient data is vital to improve health and care for everyone. There is huge potential to make better use of information from people’s patient records, to understand more about disease, develop new treatments, monitor safety, and plan NHS services. Patient data should be kept safe and secure, to protect everyone’s privacy, and it’s important that there are safeguards to make sure that it is stored and used responsibly. Everyone should be able to find out about how patient data are used. #datasaveslives You can find out more about the background to this citation here: https://understandingpatientdata.org.uk/data-citation.

Disclaimers

This report presents independent research. The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the MRC, NETSCC, the EME programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the EME programme or the Department of Health and Social Care.

Study selection criteria

Search strategy

Databases (accessed via Ovid)

• PsycARTICLES Full Text.

• EMBASE.

• Ovid MEDLINE In-Process & Other Non-Indexed Citations and Ovid MEDLINE.

• Ovid MEDLINE Daily update.

• Ovid MEDLINE Epub Ahead of Print.

• PsycINFO.

• Social Policy and Practice.

Dates

Searched from year 2000 to 28 June 2016 (date of last search).

Search strategy*

1. overweight.ti,ab

2. obese.ti,ab

3. 1 or 2

4. lifestyle.ti,ab

5. diet.ti,ab

6. ‘physical activity’.ti,ab

7. exercise.ti,ab

8. ‘weight loss’.ti,ab

9. 4 or 5 or 6 or 7 or 8

10. qualitative.ti,ab

11. interview$.ti,ab

12. 10 or 11

13. 3 and 9 and 12

14. Limit 13 to English language (limit not valid in Journals@Ovid, Social Policy and Practice; records were retained)

15. Limit 14 to human (limit not valid in Journals@Ovid, Social Policy and Practice; records were retained)

16. Limit 15 to humans (limit not valid in Journals@Ovid, Social Policy and Practice; records were retained)

17. Limit 16 to yr = ‘2000-Current’

18. Remove duplicates from 17.

*Following a reviewer’s suggestion, we also ran this search with the search term ‘focus group$.ti,ab’. The search returned four papers, one167 of which was potentially suitable for inclusion. However, on the basis of the full text, the study would not be included in the review as it did not include results of the focus groups (which were used as part of intervention development and are only mentioned in the methods section of the paper reporting the results of the intervention trial). Another of the four identified papers reported a survey and two were conducted with children/adolescents, so are also not suitable for inclusion.

FIGURE 19.

Flow diagram of selection of qualitative studies.

References of the included qualitative studies (numbers in superscript correspond with the reference numbers in the main list of References):

1. Adolfsson B, Carlson A, Undén AL, Rössner S. Treating obesity: a qualitative evaluation of a lifestyle intervention for weight reduction. Health Edu J 2002;61:244–58. https://doi.org/10.1177/00178969020610030682

2. Ahern AL, Boyland EJ, Jebb SA, Cohn SR. Participants’ explanatory model of being overweight and their experiences of 2 weight loss interventions. Ann Fam Med 2013;11:251–7. https://doi.org/10.1370/afm.144683

3. Ahlgren C, Hammarström A, Sandberg S, Lindahl B, Olsson T, Larsson C, Fjellman-Wiklund A. Engagement in new dietary habits – obese women’s experiences from participating in a 2-year diet intervention. Int J Behav Med 2016;23:84–93. https://doi.org/10.1007/s12529-015-9495-x84

4. Allen JT, Cohn SR, Ahern AL. Experiences of a commercial weight-loss programme after primary care referral: a qualitative study. Br J Gen Pract 2015;65:e248–55. https://doi.org/10.3399/bjgp15X68440985

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The themes and subthemes reported in Table 32 were derived from coding the results of the qualitative studies. The themes and subthemes were subsequently refined to match with the refined version of the MAGI framework (in structure and naming of categories), and the qualitative studies were re-coded when necessary.

TABLE 32 - Summary of the themes initially identified in qualitative studies

Higher organising themes (factors affecting participants’ experiences of weight loss groups)	Identified subthemes (concepts and processes) [studies in which they were identified (numbers correspond with the list above)]
Individual factors that may affect experiences of groups and weight loss)	Beliefs about reasons for obesity, barriers to change [1, 4, 5, 10, 11, 21 and 24]
	Comparing types of interventions [1, 2, 4, 5, 8, 10, 11, 13, 16, 21 and 24]
	Expectations of the programme or weight loss [1, 7, 12 and 16]
	Motivation for participation, weight loss, or barriers (costs, diagnosis/tipping point, health vs. attractiveness) [1–9, 11, 16, 17, 19, 21, 24 and 26]
	Perceptions of groups or weight loss [4, 8, 24 and 27]
	Preference for groups, views about benefits of groups [2, 5, 7, 10 and 15]
	Social support outside the group [1–3, 5, 7, 11, 14, 19–21, 24, 25 and 27]
	Taking responsibility (agency, locus of control) [2]
Group design factors that can/should be decided on before the group start)	Access to other facilities [9, 12 and 21]
	Contact time – during the programme [1–5, 9, 12, 14, 25 and 27]
	Contact time – at the end of the programme, follow-up [1, 2, 5, 6, 12, 25 and 27]
	First (few) sessions [12 and 16]
	Group composition [8, 9, 12, 13, 16 and 18]
	Group size [12]
	Long-term approach, weight loss maintenance [2, 6, 9 and 18]
	Participation in research study [2–4, 9, 17, 21 and 27]
	Significant others attending the group [1, 7 and 9]
	Structuring, flexibility of delivery [6, 8 and 9]
	Tailoring [2, 5, 6, 7, 8, 9, 12, 18, 21 and 25]
	Venue [2, 8, 12, 16 and 27]
Facilitator-related factors (affecting group delivery and participants’ experiences)	Facilitators and facilitation (interpersonal qualities, professional qualities, facilitation style/approach, facilitator social identity) [2, 6, 8, 10, 12, 13, 16, 18 and 24–27]
Group context (factors related to group context but not directly related to change)	Group climate [2, 8, 9, 10, 12, 13, 15, 16, 17, 24 and 26]
	Group cohesion [2, 8, 12, 13, 16, 17, 19, 21 and 25]
	Humour [12, 15 and 16]
	Identification (like-mindedness, shared experiences/problems, social identities) [1, 5, 7, 8, 9, 10, 12, 13, 16, 17, 18, 21, 24, 25 and 26]
	Socialising, ‘me time’ [13, 16, 24 and 27]
Change processes (factors related to change in groups, benefits of group participation)	Accountability [2–4, 5, 6, 8, 13, 17, 20, 21 and 25]
	Competitiveness [7, 9 and 21]
	Feedback, measurements [4, 9, 12, 13, 17 and 27]
	Information, knowledge (learning) [1, 2, 7, 9, 10, 12, 18, 19 and 24–27]
	Learning from each other, imitation (social learning) [2, 3, 6, 7, 9, 18, 19 and 26]
	Motivation in the group [1, 2, 5, 6, 7, 12, 13, 21 and 24]
	Peer, group pressure [1, 2, 18 and 21]
	Problem-solving [1 and 2]
	Role models, social comparisons [7, 12, 13, 18 and 19]
	Sharing, interaction [1, 2, 8–13, 15, 17, 21, 24 and 25]
	Social support in the group [1–3, 5–15, 17–21 and 25–27]
Practical delivery strategies and content (used in delivering weight loss groups)	Activities, practical skills [1, 3, 6, 10, 12, 14, 15, 21, 25 and 26]
	Content of intervention or sessions [1, 2, 6, 8, 10, 12, 21 and 27]
	Homework [1]
	Participants’ materials [6, 9 and 25]
	Weighing [2–4, 8, 11, 12, 13 and 27]

Consultations with researchers and practitioners

Internal seminar at the University of Exeter Medical School, Exeter [June 2016, after initial draft framework was developed (version 1)]:

• The seminar was advertised in the department and was open to all staff members.

• Eleven participants (and four study team members) had expertise in behaviour change or experience of research in group-based health interventions.

• In the seminar, we presented the emerging framework and discussed each of the framework categories, including their importance, implications and examples. The discussions validated the emerging framework, and provided examples used in the framework definitions.

• The participants highlighted (with examples from own studies) the importance of group composition, shared social identities (in particular if they are stigmatised), characteristics of facilitators (e.g. being overweight themselves), setting group rules, participants’ contact outside the groups (e.g. setting up social media groups).

• They also raised the issue of whether or not, and how, the framework might apply to other types of groups (e.g. online, knitting groups).

Pre-conference workshop, UK Society for Behavioural Medicine, Cardiff [November 2016, after draft framework was developed and revised (version 2)]:

• The workshop was advertised on the conference website and was open to any interested participants.

• Nine participants attended, including researchers and practitioners.

• The participants were initially asked to brainstorm important, in their opinion, components and processes in group-based interventions. The identified elements were compared with the emerging framework, which was presented in the workshop. All of the components and processes identified by the workshop participants could be matched with the framework elements. The processes and components were discussed, and participants shared examples from their own research and practice supporting the importance of framework components and providing suggestions about links between them. The participants brainstormed facilitation techniques that could be used to facilitate selected group dynamics and change processes.

• The feedback on the framework, collected at the end of the workshop, was generally positive and validated the framework. For example, the participants gave an average of 6.3 (out of 7) to the question of how useful they through the framework was to them. Some provided positive overall feedback (e.g. ‘Really interesting workshop and discussion. Chimes with a lot of issues raised in my recent work.’). They also identified potential applications of the framework for design/development and evaluation of group-based interventions, and as a resource to learn about processes in groups (e.g. ‘[The framework is] very useful – putting a name to all the group processes helps to know exactly where to intervene and how we might be able to manipulate these factors’).

• Key implications: validation of the framework; suggestions for how the framework could be used in design, delivery and evaluation of group-based interventions.

• E-mail and in-person consultations with/feedback from an internal researcher (from the University of Exeter Medical School; August and September 2017, after near-final version of the framework was ready).

• We shared the framework and the coding schema with Dr Poltawski, who has expertise in group dynamics, group-based health interventions and was involved in the SkiM study.

• He used the coding schema to code a session transcript, and provided feedback on the framework categories and definitions.

• The feedback was used to refine definitions of several of the framework definitions and coding schema (including facilitation techniques). Dr Poltawski raised also few important points that were incorporated in our write-up.

E-mail consultations with/feedback from external researchers/practitioners (August to September 2017, the near-final version of the framework – the final version was developed on the basis of the comments from researchers and facilitators):

• We contacted 12 researchers with expertise in group-based/behaviour change interventions who we met during the conferences where we presented the framework (see below) and who expressed interest and relevant expertise in GB-BCIs. Eleven of them replied agreeing to provide feedback, and we received feedback from eight researchers: Dr Amanda Avery, Dr Yael Bar-Zeev, Dr Enzo Di Battista, Dr Tegan Cruwys, Dr Liz Glidewell, Dr Cindy Gray, Dr Marta Moreira Marques and Dr James Nobles.

• The framework was shared and feedback (either more general or very detailed, depending on availability) was invited.

• All provided feedback was carefully considered, discussed with the study team, and when agreed, changes were made to the framework or framework definitions. We used the feedback to clarify distinctions between, and consistency of, the terminology (e.g. techniques, processes), made revisions to the writing of the results of stage 1 (e.g. adding clarifications and points raised in the feedback), and made some changes to the diagram [see difference between Figure 17 (diagram 8) and Figure 18 (the final diagram 9)]. A detailed record of the changes made in result of these consultations was kept.

• We also asked for general feedback on the framework and about potentials usefulness and applicability of the framework. The views about the framework were generally positive (e.g. ‘I think this level of detail is fantastic. This will be really useful for those reading it moving forward . . . To me, this really highlights the complexity of a group-based programme and the factors at play throughout the intervention time frames. Therefore, this will be beneficial to research teams and also to practitioners, however the level of detail required by all will vary – hence why I really like the definitions and explanations, very useful!’).

• The researchers identified potential applicability of the framework to the following:

  • designing group interventions

  • characterising and reporting of group interventions and their content and processes

  • recruiting and training facilitators (in an adapted form)

  • evaluating complex group interventions and their specific components.

Consultations with group facilitators

Consultation with LWTC/SkiM facilitators [August 2016, after initial draft framework was developed (version 1)]:

• The facilitators included Miss Amy Clarke and Miss Sian Derrick, who were personally invited to the consultations as they were delivering the LWTC and SkiM group sessions at the time of this study.

• This meeting involved an open discussion about facilitating groups, how they work, important processes that occur, techniques that facilitators use, challenges to facilitation and facilitators’ training needs.

• The facilitators provided many examples of different groups, group processes, and techniques that they use. For example, they reported on the importance of certain processes, such as managing disagreements, conflicts and ‘difficult’, disruptive participants; benefits and challenges of co-facilitation; homogeneous group composition (seen as helping with group cohesion); and participants making social connections with each other (also outside the groups). They reported using particular techniques with quiet groups and groups that were not engaging, such as using room layout (participants facing each other), subgroup discussions and activities, and practical activities (e.g. doing simple exercises). They raised the issue of positive or negative effects of successful participants (‘role models’) and social comparisons (e.g. those doing much better than the rest of the group seemed to be ‘excluded’ from the group rather than seen as role models). They also highlighted a need for facilitator training in managing difficult participants and in responding to self-disclosures of mental health issues.

• The notes from the meeting were then compared and matched with the emerging framework to validate the framework, checking for any new processes/concepts and contribute to writing the framework definitions.

Consultation with LWTC/SkiM facilitators (September 2017, the near-final version of the framework – the final version was developed on the basis of the comments from researchers and facilitators):

• The facilitators were Miss Amy Clarke, Miss Sian Derrick, Mrs Anna Murch and Mrs Ruby Entwistle, who were personally invited to the consultations as they were past and current facilitators of the LWTC or SkiM interventions.

• The framework, and the identified facilitator techniques, were shared and discussed with the facilitators in detail.

• The facilitators provided feedback, and further examples of how the framework processes occur in the groups and of what facilitation techniques they use. They highlighted the importance of many framework components. They also identified ways in which the framework could be helpful to facilitators, which included training new facilitators (raising awareness of many available processes and techniques), training (or ‘refresher’ training) existing or experienced facilitators (giving them ‘names’ to capture the processes and techniques that they know from experience, and raising awareness of ways to further improve their understanding of certain processes), using it to structure feedback to existing facilitators (or co-facilitators’ feedback to each other), and preparing participants for what to expect from groups. They also reflected on the impact that facilitating groups had on themselves (e.g. prompting them in making changes in their own lifestyles of careers). They also recognised the importance of the wider societal factors, or determinants, affecting health and well-being (outside the groups).

Consultations with group participants

Patient and public involvement representatives from the ComPoD trial [June 2016, after initial draft framework was developed (version 1)]:

• Including Mrs Sue Sedgman and Mr Douglas Osman, both of whom were personally invited to the consultations as they participated in the LWTC programme and acted as Patient and Public Representatives in the ComPoD trial.

• The emerging framework was shared with the participants and discussed in detail. The participants provided examples from the groups that illustrated (or could be matched with) the framework processes. They also described how these elements might have influenced each other and outcomes. They highlighted group goals and facilitation style/techniques as particularly important.

• Based on this consultation some elements were added to the framework (e.g. pre-session information and contact, participants’ and facilitators’ materials).

Patient and public involvement representative from the ComPoD trial [October 2016, after draft framework was developed and revised (version 2)]:

• Included four patient and public involvement representatives, all of whom were personally invited to the consultations as participants and patient and public representatives in the ComPoD trial.

• The framework and MAGI study was briefly explained, and participants shared their experiences of attending the groups and opinions about how they thought the groups worked, and what processes or components were most important. They highlighted the importance of pre-session information/contact; experiences of dealing with research staff and facilitators (i.e. importance of positive characteristics of facilitators); and positive expectations of the intervention and outcomes (e.g. they felt that the programme should be advertised as having much wider positive impact on health and well-being than just prevention of diabetes or weight loss). Other elements were discussed as important, such confidence and responsibility for self, setting and venue, purpose and benefits of using groups, group composition, social comparisons and competition, and facilitator characteristics.

• The notes were compared with the MAGI framework to match with the framework categories and check for any new categories.

Consultations and discussions with the study team members

• Pre-study planning meeting (December 2015).

• Study team meeting 1 (January 2016).

• Study team meeting 2 (June 2016).

• Study team meeting 3 (November 2016).

• Study team meeting 4 (June 2017).

• Study team meeting 5 (September 2017).

• Between study team meetings, Jane R Smith and Aleksandra J Borek consulted individual study team members (CA, CG, FG, MT, SMT and RMC).

In addition, the MAGI framework was presented at the following conferences, which offered opportunities for additional discussions with researchers and practitioners:

• Congress on obesity conference, Nottingham (September 2016, oral presentation): Table 27 (framework version 2) and Figure 10 (version 1) were presented.

• International Congress of Behavioual Medicine conference, Melbourne, VIC (December 2016, oral presentation): Table 29 (framework version 4) and Figure 15 (version 6) were presented.

• International Society for Behavioral Nutrition and Physical Activity conference, Victoria, BC (June 2017, oral presentation): Table 31 (near-final framework version 6) and Figure 18 (final, version 9) were presented.

• European Health Psychology Society conference, Padua (August 2017, poster): Table 31 (near-final framework version 6) and Figure 18 (final, version 9) were presented.

• Society for Social Medicine conference, Manchester (September 2017, poster): Table 31 (near-final framework version 6) and Figure 18 (final, version 9) were presented.