Abstract
Group-based interventions in health care have demonstrated a positive influence on patient outcomes by strengthening patient-healthcare professional relationships and providing an avenue for patient empowerment through shared experiences and belongingness. Groups have been shown to enhance social and psychological support, improve self-management behaviors, and encourage peer-support. However group settings also present challenges, such as discomforts in sharing within a group context and managing diverse group dynamics. We outline the efficacy and dynamics of group-based activities in health care settings. This includes key behavioral components of groups, such as creating a safe, supportive, and cohesive environment in group activities where confidentiality is paramount. By recognizing principles for group and moderator behaviors, individuals are more likely to maximize the potential of these interventions.
“A cornerstone of effective group dynamics in lifestyle modification programs is the creation of a safe and supportive environment, underscored by a strong commitment to confidentiality.”
Introduction
Strong data support group-based activities to improve behavioral outcomes. Group-based activities in health care have been shown to significantly enhance patient–clinician interaction and patient satisfaction, offering individuals improved access to care and comprehensive health care teams. 1 Groups enable meeting with others who may have similar conditions or shared experiences and have been utilized for a range of conditions, including diabetes, chronic pain, and prenatal care.2,3 Investigators have demonstrated that groups both improve patient care and outcomes through interactive education and social support, improving quality of life metrics. 4 As discussed by Scriven, et al, in this issue, the Complete Health Improvement Program relied heavily on group activities and helped patients to achieve significant reductions in cardiovascular disease risk factors including blood pressure, triglycerides, low-density lipoprotein, blood glucose, and other behavioral outcomes. 5 This is consistent with many other interventions (e.g., Diabetes Prevention Program, Look AHEAD) that rely on groups to either treat disease or reduce the risk of it.6,7
The use of group-based intervention has strong ties in the psychological arena. 8 Group-based interventions in psychotherapy have been shown to be equivalent to individual approaches in terms of levels of acceptance, remission, premature termination, and overall effectiveness for various mental disorders. 9 However, in these studies, considerable training has been provided to those delivering the intervention (e.g., coursework in group dynamics, practicum supervision) compared to training that typically occurs in a lifestyle medicine intervention. For example, in a translation of the Diabetes Prevention Program, health care providers (e.g., exercise specialists, dietitians, pharmacists, physicians) were given a two-day workshop before they began providing group-based care. 10 As most health care providers are only trained on building rapport for a 1:1 encounter, one of the largest barriers to using group-based techniques in a health care setting is a lack of training in this area. 11 Although training all lifestyle medicine practitioners in a manner consistent with psychologists is not feasible, an understanding of group fundamentals should assist those providing care to better traverse the intricacies of behavior change within the group dynamic. With this in mind, this manuscript attempts to provide a brief overview of critical components to consider when providing group-based care.
Components of an Effective Group
Creating a Safe and Supportive Environment
A cornerstone of effective group dynamics in lifestyle modification programs is the creation of a safe and supportive environment, underscored by a strong commitment to confidentiality. This commitment ensures that personal stores, health information, and sensitive discussions shared within the group remain private, reinforcing the trust and security essential for open communication. This environment is particularly important for personal recovery for peer support for psychotic disorders to facilitate open communication among participants. 12 Decades of data have highlighted that breast cancer survivor group interventions, where safe and supportive environments are critical, positively benefited quality of life and potentially lengthened years in life longevity. 10 In a supportive social setting where confidentiality is upheld, individuals are encouraged to actively share their thoughts, feelings, and personal concerns without fear of judgment or breach of privacy outside of the group’s parameters. This openness fosters deeper engagement, enhances mutual understanding, and supports the recovery process.
Enable Group Cohesion
Group cohesion, as defined by the American Psychological Association, is creating a sense of unity or togetherness. This unity encompasses social bonds and significantly enhances the effectiveness of group interventions and the effectiveness of treatments. 13 To achieve this, fostering an environment is key, promoting a sense of belonging and identification with the group, which is especially important in the early stages. Studies have shown that groups with members who share similarities and backgrounds often experience stronger bonds, leading to more effective therapy sessions, as this enhances both engagement in the group and the effectiveness of the therapy. 14 While the dynamics of shared learning and the sense of belonging within a group are pivotal for successful outcomes, the influence of the group’s leadership cannot be overlooked.
Moderator Characteristics
The role of a moderator, who is often a trained therapist or facilitator, is crucial in shaping the interactions and ensuring the environment is supportive for shared learning and mutual support. Moderators’ approach and skills significantly influence group cohesion and the effectiveness of the therapy. Investigations, such as that by Watzke et al, provided insights clinician differences in approaches in regards to therapy in group sessions. 15 They found that those who utilized cognitive-behavioral therapy fostered more self-efficacy and empathy while those practicing psychodynamic therapy were more confrontational and interpretative interventions, focusing on dynamic and interactional components. 15 Group size, treatment, and disease or condition have been underscored as important variables of which moderators much be aware and adjust to enhance group cohesion. 9 Further, the therapeutic alliance between group members and the moderator is of paramount importance. A robust alliance is consistently linked with positive outcomes in therapy, underscoring the need for moderators to build and maintain strong rapport with group members for successful outcomes in group therapy. Equally important the role of the moderator is also the alliance between group members and the leader. 16
Other Considerations
The Agency for Health care Research and Quality (AHRQ) suggests that group-based activities in health care offer several advantages over traditional individual care. 17 These include reductions in medical expenses, hospital admissions, and emergency room visits and improvements in patients and health care provider satisfaction and treatment adherence. These may stem from the social and psychological support they provide that help patients take ownership of their health. 18 This was demonstrated in a qualitative study of individuals living in rural Chiapas, Mexico. 19 At the time of the study, 85% of the population lived in poverty, and the majority had limited low education levels. Investigators evaluated the efficacy of group care for individuals with diabetes and found that groups enabled participants to openly share their perspectives. They experienced a feeling of shelter and a fostering environment of comfort and trust. 19
The inclusion of families, especially for some groups, has been shown to beneficially impact health outcomes, and group activities can be enhanced by inviting families and loved ones to attend. Family and community involvement allows groups to serve both as a clearinghouse for shared experiences and a meeting place, offering recuperation and mutual support and encapsulating the concept of togetherness. 20 This was exemplified in the Families Improving Together for Weight Loss trial, which showed that group interventions were of a significant value when they included the active participation of caregivers. 21 In this trial, caregivers and adolescents engaged in group discussions on topics like positive parenting, communication skills, self-monitoring, and goal-setting, emphasizing the importance of supportive environments.
Summary and Conclusions
Group settings have been observed to influence behavior, which has been applied in the health care setting. In the context of behavioral medicine, groups have shown effectiveness in empowering individuals in lifestyle modifications. The shared setting of group activity facilitates peer learning and support, which is crucial for behavioral change and adherence to treatment plans. Group activities in health care foster a stronger patient-healthcare professional relationship from the supportive learning environment surrounding topics important in the growth and everyday life of children, adolescents, and adults. Such environments allow individuals to freely share their experiences, underscoring the value of group activities as an avenue for comfort and empowerment. From a behavioral perspective, some of the greatest benefits of groups may be their capacity to impact both self-efficacy and quality of life. 22 Challenges of group-based activities may be lessened by both group members and moderators increasing awareness and actively addressing concerns prior to initiation to create a safe, supportive, and cohesive environment.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is a publication of the Department of Health and Human Performance, University of Houston (Houston, TX) and supported by the NIH/NIDDK (R01DK129474).