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Amanda Avery

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Group work and patient education are vital aspects of improving health outcomes in all settings, by supporting patients and clients to manage their conditions, as well as to promote and support behaviour change for improved health. Concise, accessible, and easy-to-read, this new title in the popular How To series is designed to support nutritionists, dietitians, nurses and other healthcare professionals to facilitate healthy lifestyle change through group education. How to Facilitate Lifestyle Change covers the entire group education process, from initial planning, to delivery and evaluation. Topics include agreeing aims and objectives and structuring a session, to considering practical aspects such as setting, managing challenging group members and participant expectations, as well as evaluating and refining a session plan for future use. It also provides an overview of the key evidence base for group learning, relevant theories and models, peer support, and e-learning opportunities. Including case studies to illustrate the real-life application of each topic, practice points, helpful checklists, and a range of practical tips, How to Facilitate Lifestyle Change is the ideal resource to support anyone involved in group patient education and facilitation of health behaviour change.

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Table of Contents


Title Page




Chapter 1: Introduction

1.1 Overview

1.2 The need for lifestyle change

1.3 Why group education?

1.4 What is the evidence for group education?


Chapter 2: Behaviour change

2.1 Introduction

2.2 What is behaviour change?

2.3 Why is behaviour change so important for lifestyle change?

2.4 Behaviour change theory and models

2.5 Behaviour change interventions

2.6 Behaviour change techniques


Further reading

Chapter 3: What makes a good facilitator?

3.1 The good facilitator

3.2 Communication skills for a group facilitator

3.3 How do effective groups form?

3.4 How do different people behave in groups?

3.5 And finally…


Chapter 4: Planning and organization

4.1 Introduction

4.2 What are the priorities for group education?

4.3 Needs assessment

4.4 Subject areas for group education

4.5 Target participants

4.6 Recruitment

4.7 Preparing for a group education session

4.8 How to deliver a training session


Further reading

Chapter 5: Delivering the session

5.1 Introduction

5.2 Starting the session

5.3 Educational activities

5.4 Ending a session


Further reading

Useful websites

Chapter 6: Resources

6.1 Introduction

6.2 Resources for inclusive education

6.3 Practical considerations when selecting which resources to use

6.4 Types of resources

6.5 General considerations when using resources

6.6 Case studies


Useful websites

Chapter 7: Evaluation

7.1 Introduction

7.2 What is evaluation?

7.3 Why evaluate?

7.4 What to evaluate?

7.5 Who should evaluate?

7.6 How to evaluate: tools and methods


Further reading

Useful websites

Chapter 8: Managing group interaction and how to overcome challenges

8.1 Introduction

8.2 Facilitating group interaction

8.3 Cultural sensitivity in group education

8.4 How to manage discussion of sensitive subjects

8.5 Avoiding challenging situations

8.6 Working with group members that exhibit behaviours that you find challenging to manage

8.7 Answering questions and maintaining your credibility when challenged

8.8 Managing the use of mobile devices

8.9 Timekeeping

8.10 Getting people to attend

8.11 Group dynamics

8.12 Working with co‐facilitators


Further reading

Chapter 9: Personal development in group facilitation skills

9.1 Introduction

9.2 Reflection

9.3 Peer observation

9.3 Additional training needs



End User License Agreement

List of Tables

Chapter 02

Table 2.1 Questions to guide the planning of behaviour change interventions.

Table 2.2 Detail required when describing interventions.

Table 2.3 Health‐related goals and action plans.

Table 2.4 Examples of common triggers for unhealthy behaviour and possible strategies.

Table 2.5 Common barriers to behaviour change.

Chapter 03

Table 3.1 Some common emotional situations in group education.

Table 3.2 Summary of how effective groups form and the role the facilitator plays.

Chapter 04

Table 4.1 Information to collect when using a venue for a food‐related education session.

Chapter 05

Table 5.1 Examples of ‘getting to know you’ icebreakers.

Table 5.2 Examples of hopes, fears and expectations.

Table 5.3 Types of questions that can be incorporated into an education session.

Table 5.4 Examples of role play and simulation scenarios.

Chapter 06

Table 6.1 What to consider when selecting resources for inclusive education.

Table 6.2 Resource ideas and availability.

Chapter 07

Table 7.1 Reasons for undertaking evaluation.

Table 7.2 Questions for process evaluation.

Table 7.3 Linking process and impact evaluation to objectives and learning outcomes.

Table 7.4 Evaluation methods.

Table 7.5 Formats for reporting evaluation results.

Chapter 08

Table 8.1 How to manage participants that exhibit behaviours that can be challenging.

List of Illustrations

Chapter 02

Figure 2.1 The COM‐B system.

Chapter 09

Figure 9.1 Gibbs Reflective Cycle, source Gibbs (1988).



Table of Contents

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How to Facilitate Lifestyle Change

Applying Group Education in Healthcare

Amanda Avery, RD

Senior Fellow of the Higher Education AcademyAssistant Professor in Nutrition and DieteticsDivision of Nutritional SciencesUniversity of NottinghamLoughborough, UK

Kirsten Whitehead, PhD, RD

Senior Fellow of the Higher Education AcademyAssistant Professor in DieteticsSchool of BiosciencesDivision of Nutritional SciencesUniversity of NottinghamLoughborough, UK

Vanessa Halliday, PhD, RD

Senior Fellow of the Higher Education AcademyLecturer in Public HealthSchool of Health and Related Research (ScHARR)The University of SheffieldSheffield, UK

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Working and learning together within a small group is a less resource intensive and a more accessible and acceptable form of education for many individuals. Groups can be considered to be very much like teams where there are people taking part who have similar ambitions and needs, aiming to achieve similar goals.

The publication of this guide is timely, with the current highest emphasis on prevention and health improvement this century. The Five Year Forward View, published by Simon Stevens (Chief Executive of NHS England) last year, states that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health. The World Health Organisation, the European Platform for Health and the USA Centers for Disease Control and prevention all also recognize that many of the non‐communicable diseases, which are contributing to health and societal burden, are preventable or better managed through improved self‐care. Chapter 1 provides startling global statistics of the need for lifestyle change to be championed and delivered at every opportunity through a range of scalable solutions using a life‐course approach. The principles of behaviour change then set the scene for the reader to walk through the stages of group education with the three authors.

Today, the range of professionals delivering lifestyle advice is wider than ever before, as we embrace concepts such as Making Every Contact Count. The skills that lifestyle educators and health professionals require in order to deliver effective group education and support are clearly transferable from other interactions, such as one to one consultations, but require adaptation and a broader focus. This concise and highly practical resource guides the reader through each stage requiring consideration; from planning to delivery of a session with appropriate resources through to evaluation.

Groups have additional advantages over the traditional one‐to‐one approach in that the participants can become committed and motivated to help others. Facilitators can harness peer support and encourage the lay person, with training and support, to facilitate groups as a critical and effective strategy for lifestyle change, as well as ongoing health care and the benefits being cascaded at a local community level.

I trust that as you utilize this resource, you will be inspired and better informed about how to implement group education and that this additional competence will contribute to your ongoing personal development. The advice offered for overcoming challenging situations and the ambivalent group member, will be best reflected upon in practice!

Additionally, and most importantly, I hope that your group participants will benefit from your best practice and the motivating power and extra resolve developed through peer support facilitating sustained behaviour change. I celebrate the publication of this book with the authors, who are all outstanding dietetic practitioners, communicators and educators.

Dr Fiona McCulloughDirector of Dietetics, The University of NottinghamPrincipal Fellow of the Higher Education AcademyChair of the British Dietetic Association


The prevention and management of non‐communicable diseases, that are being seen across all societies and which result from poor lifestyle habits, requires scalable and effective solutions. Small changes, in the healthier direction, to improved dietary habits, increased physical activity levels, decreased sedentary behaviours, safer alcohol intake and a decreased number of people smoking may considerably reduce the prevalence of the major non‐communicable chronic diseases. These include obesity, type 2 diabetes, cardiovascular disease and many cancers. Group education is likely to provide a better option for scalability when compared to individual one‐to‐one consultations and may also be more effective through the facilitation of a supporting environment that encourages changes in behaviour.

Published literature demonstrates that group education can provide benefits in terms of knowledge, self‐efficacy and health outcomes. Self‐management support through the provision of group education, focussing on behaviour change, can help to improve self‐efficacy. This in turn can have a positive impact on people’s clinical symptoms, attitudes and behaviours, quality of life and patterns of health care resource use. Well‐delivered group education, including the peer support, aims to help people learn how to manage their own care more effectively.

There is much to consider when planning and organizing group education. Is the session to be delivered to other healthcare professionals or lay trainers who are going to cascade the information to patient/community groups or is it going to be to the patient/community group themselves? Where is the most appropriate setting to deliver the group? Is it going to be accessible to all those who you are targeting? Does the venue have appropriate facilities? How are you going to meet your overall aim and objectives with the group participants achieving the desired learning outcomes? How are you going to make sure that every group participant is engaged and feels included rather than excluded? What might be different if you are facilitating a group for children rather than adults? How do you make sure that the content and format is appropriate for all groups of society from different ethnic and cultural backgrounds? What resources might be required? There is so much to consider.

This book aims to cover all of these areas so that the facilitator of group education can feel more confident about their approach. It starts by looking at some successful examples of group education, some of the underpinning theory of behaviour change before considering the practical aspects of planning, delivering and evaluating group sessions. The evaluation cannot be overemphasised given the need to prove cost‐effectiveness and appropriate use of healthcare resources. Although some people are more naturally effective at facilitating groups and have certain personal qualities, facilitation skills can also be acquired. A good facilitator needs not just to be well prepared but also to be flexible to the needs of an individual group – no two groups are going to behave in the same way! The facilitator needs to be able to think creatively and use a variety of techniques. The effective facilitator does not directly tell people what to do but, instead, provides the nurturing environment whereby they are able to come up with their own personal solutions to maintain optimal long‐term health. They are good listeners and skilled at summarizing. They are also good at establishing ground rules for the group.

It is hoped that the reader will find the practice points, top‐tips, checklists and practical examples helpful when preparing, facilitating and evaluating groups themselves. We have aimed to include diversity with examples from across the life‐course, different settings, different presenting health conditions and different lifestyle changes being targeted. Much of the content is drawn from our own experiences of what we have found most helpful to our practice over the years. We acknowledge that all group facilitators can continue to develop skills and continue to reflect on what went well and what we might do differently next time. We all need to consider our continuing professional development and we hope that this book will be a resource to support that development for all of those who read it.


We would like to acknowledge the support of our families during the writing of this book.

We would like to give special thanks to Ruth Stow for reading the draft and offering suggestions for improvements.

Chapter 1Introduction

Amanda Avery

1.1 Overview

This introductory chapter sets the scene explaining why there is a need to find scalable and effective solutions to both prevent and manage the increasing number of non‐communicable diseases, such as obesity and type 2 diabetes (T2DM), which result from poor lifestyle habits. Group education, if delivered well, has the potential to provide a solution but the group participant needs to be empowered to feel able to make the desired lifestyle changes. Evidence of successful group education is provided and key characteristics of the successful groups highlighted in the form of ‘Top Tips’. These features are then discussed in more detail in subsequent chapters.

1.2 The need for lifestyle change

Non‐communicable diseases (NCDs) are the major cause of both mortality and morbidity globally, killing more people each year than all other causes combined. Of the 56 million deaths that occurred in 2012, more than two thirds (68%) were due to NCDs, comprising mainly of cardiovascular diseases, cancers, type 2 diabetes and chronic respiratory disease. Liver disease, resulting from both alcohol abuse and non‐alcohol fatty liver disease, is increasingly contributing to this list of NCDs. The combined burden of these conditions is greatest in low and middle income populations, where they impose large avoidable costs in human, social and economic terms. Despite this inequitable distribution in prevalence, much of the human and social impact caused through NCDs could be reduced. This could be by both primary and secondary prevention and through a better understanding of cost effective and feasible interventions that acknowledge the socioeconomic determinants of health (WHO, 2014).

NCDs are, in the main, caused by four behavioural risk factors that represent modern day lifestyles:

tobacco use

unhealthy diet

insufficient physical activity/sedentary behaviours

the harmful use of alcohol (WHO, 2010).

These four behavioural risk factors are discussed in more detail as they are likely to be the focal topics for group education.

Tobacco use

Smoking tobacco and the exposure to second‐hand smoke is estimated to cause about 71% of all lung cancers, 42% of chronic respiratory disease and nearly 10% of cardiovascular disease. Smoking also increases the risk of diabetes and premature death (WHO, 2012).

Unhealthy diet (and malnutrition)

The World Cancer Research Fund estimated that 27–39% of the main cancers can be prevented by improving diet, physical activity and body composition (WCRF/AICR, 2007). Approximately 16 million (1.0%) disability‐adjusted life years and 1.7 million (2.8%) deaths worldwide are attributed to a low fruit and vegetable consumption (Wang et al., 2014). An adequate intake of fruit and vegetables reduces the risk of cardiovascular diseases, stomach cancer and colorectal cancer (Bazzano et al., 2003; Riboli and Norat, 2003). The consumption of high energy processed foods, high in fats and sugar, increase the risk of obesity compared to low energy dense foods such as fruit and vegetables (Swinburn et al., 2004).

The amount of salt consumed is an important determinant of blood pressure levels and overall cardiovascular risk (Brown et al., 2009). It is estimated that reducing dietary salt intake from the current 9–12 g per day to the globally recommended 5 g for adults would have a significant impact on reducing blood pressure and cardiovascular disease (He and MacGregor, 2009).

Besides the amount of fat in the diet being important, so is the type with the replacement of saturated fats with unsaturated fats considered for many years to be beneficial in reducing risk of coronary heart disease (Hu et al., 1997). A Mediterranean style diet, where the fat is mainly unsaturated, is perceived as being a diet we should aspire to.

Many people have a diet that is too high in free sugars, which can lead to weight gain and poor dental health (SACN, 2015). The main sources of free sugars in our diet include soft drinks, table sugar, confectionery, fruit juices, biscuits, cakes, pastries, puddings and breakfast cereals all of which can be replaced by alternatives with a lower sugar content. The alternatives are also likely to have a healthier overall nutrient profile. Free sugars provide no other important nutrients other than being an energy source. The important relationship between healthy teeth and gums and being able to consume a healthy, varied diet is often overlooked.

Whilst the amount of free sugars in most people’s diet is too high, the average intake of dietary fibre is too low in developed countries. Dietary fibre is important for colorectal health and alongside a healthy fluid intake and sufficient physical activity, can help to reduce the prevalence of constipation. In the UK the recommended daily amounts for adults have increased from 18 g/day to 30 g/day (SACN, 2015).

Having an adequate intake of micronutrients is also an important aspect of a healthy balanced diet. Micronutrient deficiencies, for example iron, calcium, iodine and vitamin D, are still common, particularly among vulnerable populations. The European Food and Nutrition Action Plan (2015–2020) aims to reduce the prevalence of anaemia in non‐pregnant women of reproductive age by 50%. Group education which ensures that naturally iron rich foods are chosen in the diet will be important to ensure that this target can be achieved in such a large group of women.

People and families with lower incomes (in developed countries), generally have a less healthy diet with a lower intake of fruit and vegetables and a higher intake of processed high energy dense junk foods (McLaren, 2007). Whilst many people may be aware of what a healthy balanced diet includes, there is a need to make this diet more accessible and affordable and attractive as well as to support people to develop the skills and confidence needed to prepare healthier foods.

Insufficient physical activity

Insufficient physical activity is the fourth leading risk factor for mortality (WHO, 2009). People who are insufficiently physically active have a 20–30% increased risk of all‐cause mortality compared to those who engage in at least 30 minutes of moderate intensity activity on most days of the week (WHO, 2010). The estimated risk of ischaemic heart disease is reduced by 30%, the risk of T2DM by 27% and the risk of breast and colon cancer by 21–25% through participation in 150 minutes of moderate physical activity each week (WHO, 2010). Additionally, physical activity reduces the risk of stroke, hypertension and depression and, given its key role in energy expenditure, is fundamental to energy balance and thus weight management. In 2010, 23% of adults aged over 18 years were insufficiently active, having less than 150 minutes of moderate intensity physical activity or the equivalent per week (WHO, 2014). The prevalence of insufficient physical activity actually rises according to the level of country income with higher income countries having more than double the prevalence compared to lower income countries for both men and women. Almost 50% of women in high income countries do not get sufficient physical activity (WHO, 2009).


In 2015 the latest data suggests that the harmful use of alcohol, hazardous and harmful drinking, was responsible for 3.3 million (5.9%) deaths per year worldwide (WHO, 2015). More than half of the deaths occurred as a result of NCDs, including cancers, cardiovascular disease and liver cirrhosis with both morbidity and mortality occurring relatively early in life. In the 20–39‐year age‐group approximately a quarter of total deaths are alcohol related with more men than women affected. An estimated 5.1% of the global burden of disease, as measured by disability‐adjusted life years, is caused by the harmful use of alcohol. Beyond the direct health consequences, the harmful use of alcohol leads to significant social and economic losses to both individuals and the wider society.

The relationship between the risk of these diseases and alcohol is dependent on both the amount and also the pattern of alcohol consumption (Rehm et al., 2010). Low risk patterns of alcohol consumption might actually be beneficial for some population groups.

Besides there being a lack of knowledge about what constitutes a unit of alcohol the additional risks of binge drinking are poorly understood. Similarly, people are generally unaware of the energy contribution that alcohol can make to the diet and this can significantly contribute to obesity levels (Gatineau and Mathrani, 2012).

These lifestyle behaviours lead in turn to five key metabolic/physiological changes:

raised blood pressure (hypertension)





Raised blood pressure

Globally, raised blood pressure is estimated to cause 12.8% of the total number of deaths and 3.7% of the total disability‐adjusted life years. It is a major risk factor for coronary heart disease and ischaemic and haemorrhagic stroke (Lim et al., 2007). In some age‐groups, the risk of cardiovascular disease doubles for each incremental increase of 20/10 mmHg of blood pressure (Whitworth, 2003). Besides coronary heart disease and stroke, other complications attributable to a raised blood pressure include heart failure, peripheral vascular disease, renal impairment, retinal haemorrhage and visual impairment (Williams et al., 2004). The global prevalence of raised blood pressure in adults aged over 25 years was approximately 40% (WHO, 2009) and achieving a 25% relative reduction in the prevalence of raised blood pressure remains a WHO target to help prevent and manage NCDs (WHO, 2014). Some ethnic groups are more prone to hypertension at a younger age than others.

Overweight and obesity

Over the past 30 years, obesity has increasingly become one of the greatest public health concerns reaching epidemic proportions. It has a significant impact on both physical and mental health and well‐being with an estimated 93.6 million of global disability‐adjusted life years caused by being overweight or obese in 2010 (Lim et al., 2012). Nearly three million people die each year as a result of being overweight or obese but this is likely to be a gross underestimate due to its link with a number of other chronic diseases and the complications resulting from the metabolic disturbances. Mortality rates increase with increasing levels of obesity (PSC, 2009). In many countries, approximately two‐thirds of the adult population are either overweight or obese and around a quarter are obese. The prevalence of a high body mass index (BMI) increases with income level of a country, but within countries health inequalities are seen, particularly for women. In a high income country, women from the lowest socioeconomic group have twice as high a prevalence of obesity compared to those in the highest socioeconomic group (WHO Global Database, 2014).

For optimal health, the median BMI for adults should be 21–23 kg/m2 and the target for individuals should be to maintain a BMI between 18.5 and 24.9 kg/m2 (WHO, 2014). Again some ethnic minority groups, notably people of South Asian origin, benefit from a lower BMI in the healthy range. People of South Asian and black origin will be more likely to experience metabolic complications such as hypertension and type 2 diabetes once their BMI exceeds 23 kg/m2 (NICE, 2013).

There are direct links between obesity prevalence and the development of T2DM as outlined next. Similarly links have been observed between obesity and cardiovascular disease risk. A raised BMI increases the risk of cancers of the breast, colon/rectum, endometrium, kidney, oesophagus and pancreas (WCRF/AICR, 2007). Overweight and obesity are also associated with impaired mental health well‐being and low self‐esteem, infertility, poor pregnancy outcomes, sleep apnoea, osteoarthritis and general mobility problems. Given limited mobility, obese people are less likely to engage in physical activity of moderate to high intensity, which exacerbates the health problems they face.

The prevalence of overweight and obesity in children has also increased since the 1990s. T2DM is now being seen in children as a consequence of this increase and the metabolic changes associated with obesity. Early onset of T2DM is associated with an increased risk of morbidity and mortality during the most productive years of life. Microvascular complications can be present at time of diagnosis. Adolescents with T2DM are also prone to secondary obesity‐related complications, including hypertension, non‐alcoholic fatty liver disease and metabolic syndrome, all of which are associated with increased cardiovascular risk. The earlier that a person develops T2DM, the earlier and more likely they are to be affected by the associated macro‐ and microvascular complications. This has a significant impact on the quality of their life (Pinhas‐Hamiel and Zeitler, 2007). As with adults, being overweight or obese not only affects the physical health of children but also their psychological health. Children may be bullied because of their weight and the underlying weight stigma present in society can mean that they are less likely to achieve their academic and employment potential (Puhl and Brownell, 2003).

Latest figures suggest that the global prevalence of overweight and obesity in children aged under 5 years has increased from around 5% in 2000 to 6.3% in 2013 (WHO Global Database, 2014). With easy access to energy‐dense fast foods and a greater number of indoor based leisure activities that lead to sedentary lifestyles, prevalence levels continue to increase with age. This is causing concern to many government health departments. Again, health inequalities are seen, with children of less educated parents being most affected.

The WHO European Region Health Plan for 2020 promotes a life‐course approach to help achieve universal access to affordable, balanced and healthy food for all. Organizations such as Public Health England are committed to supporting the development and implementation of a national childhood obesity strategy (PHE, 2015). This life‐course approach will include the importance of good maternal nutrition. There will be more focus on antenatal lifestyle advice given the clear associations between growth in utero and early infancy and subsequent health, including risk of childhood obesity and adult cardiovascular risk (Barker, 1995). The health benefits of breastfeeding still need to be promoted with more mothers encouraged to both initiate breastfeeding and also to breastfeed for a longer period so that both the mother and infant can get the full benefits. In developed countries we see differences in breastfeeding rates across different socioeconomic groups and efforts to increase breastfeeding rates need to be targeted to more socially deprived communities where the level of maternal education is lower. Establishing good breastfeeding practice is important alongside the introduction of appropriate solid foods, given that good eating habits are acquired at an early age.

Children, up until a certain age and apart from in a school setting, are dependent on their parents with respect to both access to a healthy diet and opportunities to be physically active. Hence any attempt to promote lifestyle change in children should include parents and, for some cultures, grandparents and the extended family also, as the main agent of change. Generally, a family approach works best.


These metabolic abnormalities are characteristic precursors of both T2DM and cardiovascular disease. The transition from prediabetes to T2DM in adults is usually a gradual progression that occurs over a period of 5–10 years (Weiss et al., 2005). Fundamental to the development of T2DM is a level of insulin resistance. When the muscle and liver become resistant to the action of insulin, as is often the case in overweight and obese individuals, the pancreas tries to compensate by producing more insulin to maintain normal blood glucose levels and this is characterized by hyperinsulinaemia. When pancreatic function is not able to maintain this level of activity, blood glucose levels gradually rise and in the early stage of declining function this would be associated with impaired glucose tolerance. Whilst obesity is probably the most important cause of insulin resistance, it is not the degree of obesity itself but the distribution of body fat that has the greatest effect. Increased visceral fat and decreased subcutaneous fat deposition are more closely linked to insulin resistance. People with an ‘apple‐shaped’ figure and greater abdominal obesity are more likely to develop metabolic abnormalities compared to those with a more ‘pear‐shaped’ figure. Some ethnic groups are genetically more sensitive to abdominal adiposity and these metabolic changes are seen at a lower BMI and it is recommended that different BMI ‘cut off’ values are used with different ethnic groups (NICE, 2013).

Insulin resistance and hyperinsulinaemia also impair lipid metabolism and are associated with higher circulating triglyceride and free fatty acid levels and lower levels of circulating HDL‐cholesterol, the latter being beneficial in reducing the risks of raised cholesterol levels.

Hence it is appropriate that many government health departments are screening for prediabetes in order to offer public health interventions that prevent or delay the progression to T2DM. These interventions are likely to focus on weight management to reduce both insulin resistance and hyperinsulinaemia and prevent the associated abnormalities seen in lipid metabolism. Approximately one quarter of some adult population groups may be found to have prediabetes, according to the WHO guidelines, on screening (Abraham and Fox, 2013).

Summarizing the need for lifestyle change

As indicated previously, a large proportion of NCDs are both preventable and better managed through the reduction of the four modifiable behavioural risk factors. Healthcare systems should deliver interventions for individuals who either already have NCDs or who are at risk of developing them. Further, the long‐term nature of many NCDs requires a comprehensive approach that is not dependent on the time of diagnosis or stage of the condition.

Still the main focus of healthcare for NCDs in many countries remains hospital‐based acute clinical care based on a medical model. People with NCDs present at hospitals when cardiovascular disease, cancer, diabetes and chronic respiratory disease have reached the stage of being an acute event or with long‐term complications already established. This is a very expensive approach that will not contribute to a significant reduction in the burden of NCDs. It also denies people the health and social benefits of taking care of their condition at an early stage. The prevention and management of NCDs needs to be integrated both into primary healthcare and the acute setting. Gaps in the provision of support for people with NCDs can lead to heart attacks, strokes, renal disease, blindness, peripheral vascular disease, amputations and the late presentation of cancer. It can deny people who have been successfully medically treated to make a full recovery and prevent secondary reoccurrence.

Whilst cardiovascular diseases, cancers, diabetes, chronic respiratory disease and, increasingly, liver disease have been listed as the main NCDs contributing to global ill‐health, other chronic conditions such as poor mobility, lower back pain, osteoporosis, functional bowel disorders, dementia and poor mental health are of increasing importance. These chronic conditions all contribute to the individual and societal burden and are likely to further increase in prevalence given the aging population. The same four modifiable behavioural risk factors may also contribute either directly or indirectly to the severity of these conditions and may also be used to improve patient outcomes.

Other long‐term conditions where group education may play an important role in helping the individual to better manage their health include type 1 diabetes, coeliac disease, physical disabilities including arthritis and chronic kidney disease.

1.3 Why group education?

The 30% of the UK’s population with a long‐term condition, including non‐communicable disease, accounts for 70% of the current NHS spending. Reducing people’s dependence on healthcare professionals and increasing their sense of control and well‐being is a more intelligent and effective way of working (de Silva, 2011).

Self‐care is defined by the WHO as including ‘activities that individuals, families and communities undertake with the intention of enhancing health, preventing disease, limiting illness and restoring health’ (WHO, 2002). Self‐management support through the provision of group education that focusses on behaviour change can help to improve self‐efficacy, which in turn can have a positive impact on people’s clinical symptoms, attitudes and behaviours, quality of life and patterns of healthcare resource use (Chih et al., 2010; King et al., 2010; Weng et al., 2010; Sol et al., 2011).

Self‐efficacy refers to an individual’s belief in their ability to successfully change a certain behaviour and to be able to maintain this behaviour change. Those with high levels of self‐efficacy feel confident in their own ability to be able to achieve certain goals.

Group education and peer support programmes aim to help people learn how to manage their own care more effectively, including when to use different healthcare services and resources. Many group education sessions take place in a healthcare setting or in the community but there are also some examples that have been delivered in the workplace, children’s centres and schools. This book provides examples of different settings in which group education can be delivered.

Information provision alone is unlikely to be sufficient to motivate sustainable behaviour change and improve clinical outcomes.

General components that have been proven to support self‐management include:

involving people in decision making

emphasizing problem solving

promoting healthy lifestyles and educating people about their conditions and how to self‐manage

motivating people to self‐manage using targeted approaches and structured information and support

helping people to monitor their symptoms and know when to take appropriate action

helping people to manage the social, emotional and physical impacts of their conditions

providing opportunities to share and learn from other service users with the same condition (de Silva, 2011).

Whilst all of these components can be more efficiently delivered through group delivery, it is the benefits of the wider support in the group setting that allow for the opportunities to share and learn from peers. Groups offer a forum for people, and their family or carers, with any long‐term condition to gather and learn together.

A group can be defined as a gathering or an assembly of people with a common interest, such as diabetes self‐management (Mensing and Norris, 2003). The number of people in a group can vary dependent on a number of factors including the topic, the delivery method, the size of the venue, the facilitators preference and ensuring viability. However, a minimum number of group participants is usually required to maximize the full benefits of group support.

Group attendees and educators have an opportunity to use creative approaches to learning.

1.4 What is the evidence for group education?

Putting aside cost‐effectiveness, published literature demonstrates that group education for self‐care can provide benefits in terms of knowledge, self‐efficacy and health outcomes. Much of the literature has studied the benefits of group education for people with diabetes (Mensing and Norris, 2003). Since the 1970s, supporting people with diabetes in groups to help improve their glycaemic control has been seen as an effective intervention. Today, lifestyle interventions are recommended for preventing T2DM in people at high risk with up to a 58% reduction in risk cited as achievable (NICE, 2012). For those people with diabetes, the use of trained lay educators to facilitate the group is being explored with positive findings (Mandalia et al., 2014).

A number of NCDs, other long‐term conditions and innovative evidence‐based programmes that have been designed to promote lifestyle change in different population groups and that have measured efficacy, are presented as examples to encourage change in practice:

The ROMEO study for people with type 2 diabetes

Italian people (n = 815), with non‐insulin treated diabetes and who had been diagnosed with diabetes for at least 1 year were randomized to either a group or to individual care.

Seven 1‐hour group sessions with around 10 participants were held over 2 years with the group education including group work, hands‐on activities, problem solving, real‐life simulations and role playing.

After 4 years, those attending the group sessions had much better diabetes and cardiovascular management, despite being on similar medications. Equally, their health behaviours, quality of life and knowledge of diabetes were all significantly better (Trento et al., 2010).


Group facilitators receive training, support with materials and regular supervision.

There is more about role play in Chapter 5.

A peer support diabetes prevention programme

A peer support diabetes prevention programme demonstrated effectiveness of a culturally sensitive programme delivered by trained peers in Turkish‐ and Arabic‐ speaking communities in Australia. Ten bilingual peer leaders were recruited via a media release from existing health and social networks (leaders included ethnic workers, interpreters, health promotion workers, teachers), and were trained by diabetes educators over a 2‐day period. Each leader recruited 10 participants who attended two lots of 2 hour sessions 1 week apart, with support telephone calls as follow up. Leaders were paid for their training time, recruitment of participants and delivering the sessions. The small group intervention was based on a modified, culturally sensitive training manual and delivered using interactive strategies using culturally sensitive foods. Pedometers were given out as an incentive to increase activity levels.

Three months after the programme the participants mean body weight and waist circumference were both significantly reduced, diabetes knowledge enhanced and lifestyle behaviours significantly improved (Sulaiman et al., 2013).


Culturally appropriate health education is defined as ‘education’ that is tailored to the cultural or religious beliefs and linguistic skills of the community being approached, taking into account likely literacy skills (Overland, 1993). It could include adapting established ‘health education’ to innovative delivery methods, such as using community based health advocates, delivering the information to same gender groups or adapting dietary advice to fit the likely diet of the population group (Hawthorne et al., 2008).

In a 2014 Cochrane review and meta‐analysis (Attridge et al.