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Creating psychological connections between intervention recipients: Development and focus group evaluation of a group singing session for people with aphasia



Objectives The study sought to identify key design features that could be used to create a new framework for group-based health interventions. We designed and tested the first session of a group intervention for stroke survivors with aphasia which was aimed at nurturing new psychological connections between group members. Setting The intervention session, a participant focus group and interviews with intervention facilitators were held in a local community music centre in the South West of England. Participants A convenience sample of 10 community-dwelling people with poststroke aphasia participated in the session. Severity of aphasia was not considered for inclusion. Intervention Participants took part in a 90-min group singing session which involved singing songs from a specially prepared song book. Musical accompaniment was provided by the facilitators. Primary and secondary outcome measures Participants and group facilitators reported their experiences of participating in the session, with a focus on activities within the session related to the intervention aims. Researcher observations of the session were also made. Results Two themes emerged from the analysis, concerning experiences of the session (‘developing a sense of group belonging’) and perceptions of its design and delivery (‘creating the conditions for engagement’). Participants described an emerging sense of shared social identity as a member of the intervention group and identified fixed (eg, group size, session breaks) and flexible (eg, facilitator responsiveness) features of the session which contributed to this emergence. Facilitator interviews and researcher observations corroborated and expanded participant reports. Conclusions Engagement with health intervention content may be enhanced in group settings when intervention participants begin to establish positive and meaningful psychological connections with other group members. Understanding and actively nurturing these connections should be a core feature of a general framework for the design and delivery of group interventions.
Creating psychological connections
between intervention recipients:
development and focus group
evaluation of a group singing session
for people with aphasia
Mark Tarrant,
Krystal Warmoth,
Chris Code,
Sarah Dean,
Victoria A Goodwin,
Ken Stein,
Thavapriya Sugavanam
To cite: Tarrant M,
Warmoth K, Code C, et al.
Creating psychological
connections between
intervention recipients:
development and focus group
evaluation of a group singing
session for people with
aphasia. BMJ Open 2016;6:
e009652. doi:10.1136/
Prepublication history for
this paper is available online.
To view these files please
visit the journal online
Received 7 August 2015
Revised 4 December 2015
Accepted 7 December 2015
For numbered affiliations see
end of article.
Correspondence to
Dr Mark Tarrant;
Objectives: The study sought to identify key design
features that could be used to create a new framework
for group-based health interventions. We designed and
tested the first session of a group intervention for
stroke survivors with aphasia which was aimed at
nurturing new psychological connections between
group members.
Setting: The intervention session, a participant focus
group and interviews with intervention facilitators were
held in a local community music centre in the South
West of England.
Participants: A convenience sample of 10
community-dwelling people with poststroke aphasia
participated in the session. Severity of aphasia was not
considered for inclusion.
Intervention: Participants took part in a 90-min group
singing session which involved singing songs from a
specially prepared song book. Musical accompaniment
was provided by the facilitators.
Primary and secondary outcome measures:
Participants and group facilitators reported their
experiences of participating in the session, with a
focus on activities within the session related to the
intervention aims. Researcher observations of the
session were also made.
Results: Two themes emerged from the analysis,
concerning experiences of the session (developing a
sense of group belonging) and perceptions of its
design and delivery (creating the conditions for
engagement). Participants described an emerging
sense of shared social identity as a member of the
intervention group and identified fixed (eg, group size,
session breaks) and flexible (eg, facilitator
responsiveness) features of the session which
contributed to this emergence. Facilitator interviews
and researcher observations corroborated and
expanded participant reports.
Conclusions: Engagement with health intervention
content may be enhanced in group settings when
intervention participants begin to establish positive and
meaningful psychological connections with other group
members. Understanding and actively nurturing these
connections should be a core feature of a general
framework for the design and delivery of group
Groups are employed to deliver health-
related interventions in a variety of domains,
including rehabilitation,
health promotion
and the management of long-term condi-
tions such as multiple sclerosis
Groups are often assumed to be
cost-effective, relative to individual interven-
although there is a recognised lack of
data in this regard.
Moreover, the observed
heterogeneity in their design and delivery
Strengths and limitations of this study
The study addressed a recognised gap in knowl-
edge about how new group-based health inter-
ventions can be designed and delivered.
The study adopts an evidence-based approach to
assembling new groups for the delivery of health
interventions and identifies and defines a set of
core (group) intervention features.
The study provides triangulation of findings,
drawing on data from three sources (a focus
group, interview with group facilitators and
research observations of the intervention
While the findings resonate with previously
reported general processes of group formation,
the conclusions are drawn from data from a
single session of group singing for people with
one health condition.
Participants were clear about the potential health
and well-being benefits of participating in group
interventions like the one studied here, but it is
not possible to conclude definitively that this
participation actually affected health. Additional
research, employing other research designs, is
needed to address this question.
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 1
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highlights a need for greater detail in the reporting of
group interventions, particularly given the increasing
frequency with which they are being employed.
The current research aimed to inform a guidance
framework for the development and delivery of new
group interventions for long-term health conditions, in
accordance with the Medical Research Councils model-
ling phase of complex intervention development and
We designed, delivered and evaluated an
introductory session of a group intervention for stroke
survivors with aphasia. Besides impaired language func-
tion, people with aphasia experience a range of health
problems that negatively affect psychosocial functioning,
including social isolation and distress, which are not typ-
ically addressed in speech and language rehabilitation
12 13
Group-based interventions may be a
way of addressing psychosocial functioning needs of
people with long-term conditions such as aphasia, by
providing valuable opportunities for social interaction
and fostering the rebuilding of core skills (eg, social par-
ticipation, condence).
In support of this idea, obser-
vational, experimental and qualitative studies have
suggested that psychosocial problems may be addressed
in some group contexts.
Our study drew on principles of social identity
which holds that the psychological connections
members of a social group establish with each other
structure their attitudes, cognitions and behaviours,
including those related to health.
Belonging to a social
group, and valuing that membership, is an important
basis for psychological well-being.
16 1820
Although the
benets of group membership have been demonstrated
across a range of health conditions, including long-term
conditions such as multiple sclerosis,
much less is
known about how social identity can be actively nurtured
in new group settings. Social identity is unlikely to
emerge spontaneously as a result of merely bringing
people together in a new group
and, we suggest, needs
to be carefully nurtured through the actions of the
group facilitator(s).
Because of the inevitable variabil-
ity between people in medical (eg, physical function-
ing), psychological (eg, symptom perceptions) and
wider sociological (eg, socio-economic status) factors,
fostering the development of a common frame of refer-
ence and shared social identity in participants seems
necessary to prevent the factions and schism that may
otherwise occur in novel group settings.
Our study sought to identify key features that could be
used to design a framework for creating social identity in
new group interventions. Because feeling psychologically
connected to a group is strongly associated with group
commitment, or loyalty,
nurturing an early and positive
sense of social identity is likely to motivate participant
attendance at subsequent sessions of an intervention
programme and encourage more ready engagement
with intervention material and participant interaction.
Establishing social identity could be a key variable inu-
encing the progression of group interventions. For this
reason, we focused on the introductory session of an
The intervention we focused on was organised around
a programme of group singing for people with aphasia.
Numerous examples exist of community-based singing
groups for people with such long-term conditions, and
there is a growing research interest in the potential ben-
ets of group singing on well-being and quality of life,
both for healthy populations and those with long-term
conditions such as aphasia.
Some uncontrolled and
qualitative studies have suggested that singing groups
may help address the psychosocial needs of people with
long-term conditions such as aphasia,
there is a lack of rigorous data concerning both the
health benets of participation in such group interven-
tions and their design and delivery.
Objectives/aims. The aim of this study was to deliver an
introductory session of a new group intervention and
explore participantsexperiences of it. Specically, the
study examined participantsexperiences of taking part
in the session in terms of (A) its capacity to nurture psy-
chological connections between participants (shared
social identity) and (B) barriers and facilitators of parti-
cipantsengagement with it.
A qualitative approach was selected on the basis of a
constructionist epistemology. We utilised the construc-
tionist assumption that the truthhas multiple mean-
ings and is subject to individual interpretation and the
context of the current situation
29 30
but retained a theor-
etically underpinned approach grounded in principles
of social identity theory because this combination of
approaches was in line with our exploratory aims. Our
approach combined non-participant observation of the
introductory session of the group singing intervention, a
focus group with session participants and individual
interviews with music facilitators.
A convenience sample of stroke survivors with aphasia
(n=10) was recruited through a local network for people
with aphasia. Severity of aphasia was not considered for
inclusion. Potential participants were initially contacted
with the assistance of a local co-ordinator of an aphasia
network who was also a stroke survivor with aphasia.
Those interested in taking part in the study were pro-
vided with an information sheet explaining that they
would be asked to attend the singing session and con-
tribute to a focus group; written consent was obtained
from each participant. Participants were told that they
were free to withdraw from the study at any time (none
did). A local charity-funded music organisation supplied
the music facilitators and provided space for the singing
session and focus group/interviews. Participants were
reimbursed for their travel expenses.
2Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652
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Development of the group singing session
The singing session was designed with input from stroke
survivors with aphasia, music facilitators, a speech and
language therapist, health researchers and psychologists,
following principles of participatory design.
31 32
design meetings were held. The rst meeting produced
the outline of the singing session, with a focus on
describing group activities designed to encourage the
emergence of a social identity, as members of the singing
group, among the participants. Specically, the outline
described structural (eg, seating arrangements, session
break), musical (eg, using familiar, upbeat songs to
maximise participant engagement) and facilitator-led
(acknowledging group progress and providing feedback)
initiatives to promote and reward interaction between
participants and create for them a shared perception of
commonality, and group commitment, consistent with
social identity theory principles.
17 24
The session outline
was rened in the second meeting, which additionally
focused on potential barriers to participant engagement
with the singing session (eg, lacking condence in lan-
guage) and identifying procedures to minimise these
(eg, avoiding group member introductions at the session
outset). CC and a speech and language therapist advised
on potential barriers to participant communication and
contributed to the topic schedule used to guide the
focus group.
Research context and data collection
The singing session was led by two experienced music
facilitators and was observed by four of the authors (TS,
KW, KS and MT) who made independent session notes.
The session lasted 1.5 h and began with a brief introduc-
tion to the session by the facilitators and a short physical
and vocal warm-up activity. Participants then took part in
two focused singing blocks, led by the music facilitators,
separated by a short refreshment break. Participants
were each provided with a songbook containing lyric
sheets. The rst singing block focused on singing songs
preselected by facilitators to take account of the antici-
pated musical preferences of participants on the basis of
their ages.
The second singing block continued in the
manner of the rst block but additionally involved some
repetition of songs and rehearsal of different song ele-
ments, including introducing harmonies.
After the singing session, TS led a 45-min focus group
with the participants. The music facilitators were then
interviewed (45 min) by TS using a semistructured inter-
view guide to explore their reections on the singing
session, focusing on activities within the session related
to the underlying theoretical aims. The interview guide
was reviewed and agreed by the authors prior to use.
The focus group and facilitator interviews were audio
Data analysis
Audio recordings were transcribed verbatim. The
Framework Approach,
a widely used approach in applied
qualitative research, guided the data analysis. NVivo10
qualitative data analysis software was used to support data
management. TS and KW independently read the tran-
scripts numerous times to become familiarised with the
data. Initial ideas were then identied and coded using
both inductive and deductive processes. A thematic frame-
work was developed with the codes as columns and data
researcher observations). Through comparison of codes
and emerging themes, the framework was further rened,
and thematic charts were created incorporating the coded
data. The resulting themes and subthemes were then inde-
pendently veried by SD and, through discussion, inter-
pretation arising from the analysis was nalised.
Ten stroke survivors with aphasia (ve males, ve
females) took part in the singing session and focus
group. A carer of one participant also attended the
session but did not participate in any activities.
Participantsmean age was 58.60 years (SD=6.93). Stroke
type included four participants who had had an ische-
mic stroke, one a haemorrhagic stroke and one a sub-
arachnoid haemorrhage (the remaining participants did
not know their type of stroke). Mean time since stroke
was 7.70 years (SD=8.40).
As is reected in the section below, some participants
appeared more willing (and able) to contribute to the
focus group discussion than other participants. However,
it was clear from other contributions (eg, non-verbal
communication) that these participants agreed with the
sentiments expressed in the focus group by more vocal
members. The researcher observations of the singing
session and the facilitator interviews corroborate this
interpretation: there was nothing to suggest that any of
the less vocal participants in the focus group experi-
enced the singing session differently from the more
vocal participants.
Two inter-related themes emerged from the analysis of
the focus group and facilitator interview data that con-
cerned participantsexperiences of the singing session
(Developing a sense of group belonging) and their perceptions
of the session design and delivery (Creating the conditions for
engagement). Within these two themes, eight key features
were identied that could be used to design a framework
for developing social identity in new group interventions
(gure 1). These features are described in detail below,
supported by quotes from participants and music facilita-
tors, and also the researchersobservation notes.
Participant and facilitator names below are pseudonyms.
Theme 1: Developing a sense of group belonging
This theme described how the singing session provided
the foundations for developing psychological connec-
tions between group members and a sense of belonging,
characterised by being comfortable in the group and
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 3
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interacting with others. Three key features that emerged
within this theme are as follows:
(i) Homogenous nature of the group: Sharing a
health condition (in this case, aphasia) with every other
member of the singing group was described by partici-
pants as critical to them feeling at ease, or comfortable,
with the group. Homogeneity of condition also pro-
moted a sense of common understanding between parti-
cipants and was seen as a starting point for forming
connections with one another.
because we all have had brain problems it connects
you all. [Megan]
I think it is a good thing because everybody here under-
stands whats going on in your head and you can talk to
people about it if I talk to Julie or Rob about it or
Ben, then they understand, dont you? Understand
whats happened to you and what the pitfalls are or the
obstacles are. [Jack]
(ii) Member familiarity: Each participant knew at least
one other group member in advance of attending the
singing session, and everyone knew the local aphasia
network co-ordinator, Julie. This was regarded as con-
tributing positively to participantsengagement with the
session and appeared to inuence the rapid emergence
of a positive group dynamic.
Because most of us know at least a few people here and
we talk to them, so it is not mainly a problem. [Ben]
they actually settled very quickly. There was a common
understanding perhaps between them. [Beth, music
Notably, presession member familiarity was described
by some participants as a factor which would determine
their decision to attend a group programme such as
If you have got a group who didnt know anybody, then I
dont think anyone would turn up. You would have to get
a certain type to get them to turn up initially. I came
because Julie asked me, not because of any other reason.
Julie really brought everybody here together, so she
knows everybody that solves it, it makes it fairly easy
really. [Ben]
(iii) Member interactions: There were numerous
instances of interpersonal interaction during the singing
session (including non-verbal interaction such as eye
contact and the expression of emotions). Beth, the
music facilitator, was of the view that they [the partici-
pants] had a lovely way of being with each other too.
There was a lot of support in there, just by little glances,
encouraging glances here and there from people or
laughter and quite spontaneous things that went on.
Interaction often occurred between participants previ-
ously unfamiliar with each other: Ben felt he had
spoken to people who I have not spoken to before.
Interaction also occurred between the group members
and the music facilitators. This interaction was experi-
enced positively by the participants and encouraged
further engagement with the singing session. Indeed,
memberfacilitator interactions were deemed essential
for participants to provide feedback, for facilitators to
adapt and make changes accordingly and, overall, to
motivate participation.
they were very responsive I was very aware at the
start, it was quite hard to get any eye contact with
anybody in the circle because everybody was so xated
on that song book So I initiated a conversation with
somebody about a song and the words and, So they
werent saying it is not something they want to do but
[it] brought our attention to the fact that reading the
lyrics and the singing was a bit of [a] thing which is why
we kind of adapted to try and suggest that they shut their
song books. Thats when we invited them to shut the
Figure 1 Key features reflecting
participant experiences of an
introductory session of a new
group singing intervention for
people with aphasia.
4Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652
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books and do some work off the song book and trying to
join in. [Susan, music facilitator]
By coming to feel more comfortable with the group,
participants felt able to relax and reported reduced
anxiety. Indeed, it was apparent that participants and
facilitators were initially anxious about the singing
group, and this anxiety was reected in individual
contributions to the session, especially at the beginning
of it.
I think it will be [like this] in the rst session I was a
little bit embarrassed singing but I did do it but it was
very quiet singing I think. I dont think we sang as we
should do because we were a little bit self-conscious.
We work a lot with people who are nonverbal in different
contexts and we have worked with people with aphasia
but not a group of people with aphasia, so it was a differ-
ent thing and we were worried, a little bit worried about
people feeling uncomfortable and how we might
avoid that happening. [Beth, Music facilitator]
Well, you know that [there is] always is going to a bit of
anxietyat the start of the session, may be as to know
what to expect and as to what is expected of them.
[Susan, Music facilitator]
However, the inhibitions that participants reported
largely dissipated as the session progressed. Participants
and facilitators referred to the positive interactions as
possible reason for this.
the body language has changed, they were moving
more, the feet were going up, a bit more wriggling about,
and lots of smiling, nice body movement along with the
poses and the music . [Beth, music facilitator]
we have got to be at ease in any group, in any situation,
but particularly a group that may be anxious, just maybe
that would help. It did feel that as soon we had that inter-
action, then it was different. [Beth, Music facilitator]
The three features of this theme (group homogeneity,
member familiarity and interaction) contributed to the
emerging sense of belonging and connection, or shared
social identity that participants experienced as a result of
taking part in the singing session. These features also
underpinned their beliefs about the potential longer-term
health impacts of the intervention. Participants were
unanimous in their belief that a programme of singing ses-
sions like the current one had the potential to positively
inuence quality of life. Some participants elaborated on
this belief by describing other health benets that may
arise from belonging to and participating in groups like
this, including improved condence and coping with daily
stressors. Expectations about health benets appeared to
inuence participantsengagement with the session.
I think in a small group like this, we are so involved when
we are singing and you got to put yourself up and I think
because of that you are you get more comfortable with
other people, because of that you get more condent
with people. [Jack]
Theme 2: Creating the conditions for group engagement
Theme 1 was concerned with how participants experi-
enced the singing session and identied factors that con-
tributed to an emerging sense of shared social identity.
Theme 2 reected participantsand facilitatorspercep-
tions of the session features that created the conditions
for establishing the psychological connections underpin-
ning this identity. There were two subthemes within this
theme, one reecting xed, or planned, features of the
singing session, and one reecting exible, or responsive,
features of it.
Fixed features
(i) Group size: Participants suggested that intervention
groups like this should involve a maximum of around 15
people. They felt that interventions with larger groups
than this would inhibit one-to-one interaction with the
facilitatorsinteraction that they regarded as contribut-
ing to the groups success.
Well, the more person you put in, you dont reach the
purpose of it because you cant talk, and if you [are]
trying to talk to the people here, you would want to talk
to everybody, wont you? And the facilitators would need
them and this meeting would not be the same because
some people would not be able to say what they wanted
to say. [Jack]
(ii) Mid-session break: The 1520-min mid-session
break presented an opportunity for further interaction.
The positive dynamic this created spilled over into the
second half of the singing session. Participants and facili-
tators valued highly the mid-session break.
you need that, have that to say hi, how are youand
that was good as well and then we came back, our
singing I think went up after [that]. [Julie]
we have a rapport built between participants and our-
selves, and also with each other there was a lot of discus-
sion and lot of hustle and bustle going on really in the
break time and it became more visible in the second part
that people were more joking and laughing with each
other across the room more so than in the rst half.
[Beth, music facilitator]
This narrative resonates with the researchersobserva-
tions of the singing session. Early in the session, several
participants were observed to be hesitant in contributing
to the group singing; however, after the break, it was
apparent that the group dynamic had shifted such that
those whose contributions were previously muted were
now fully participatory.
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Flexible features
(1) Session delivery: Although certain aspects of the
singing session, such as the break and the group size,
were planned in advance of the session, the facilitators
adopted a exible approach to the session delivery that
was based on their own judgement as to how the session
was progressing and in response to verbal and non-
verbal feedback from participants. For example, while
the mid-session break was initially scheduled for 10 min,
this was allowed to over-run because of the high level of
interaction that was occurring between participants.
The facilitators emphasised the necessity of this exi-
bility in order to respond to the needs of the group.
Every group is going to be different and dynamic and
you need to be able to respond to the groups as they are
[Susan, music facilitator]
It is important to have a kind of awareness of things that
might happen that might be an issue so that you can
plan for it. But aside from that, it is good to have that
opportunity, those windows to explore because then you
get that nice surprises of things, you just try that and
then you just might hit on something really really positive
and really powerful for somebody. [Beth, music
Participants valued this approach too, although at the
same time emphasised the importance of the interven-
tion meeting their expectations. Expectations that were
not met could negatively inuence participantsmotiv-
ation to attend subsequent group sessions.
Personally I would like to have some achievement by the
end of some sorts if that is a possibility and I dont know
something like a choir or with progress. [Rob]
I think what they [facilitators] did was very good but
yeah if you did that every week and not anything else,
then I wouldnt come as there would not be anything for
me. I think the rst couple of weeks would be alright but
after that you know. [Jack]
For Jack to continue in the programme, the intervention
would need to focus on speech development: he said he
would not attend if the intervention comprised only
sing alongsessions.
(2) Encouraging different forms of participation:
Relatedly, the exibility of the session allowed facilitators
to introduce new activities that enabled different forms
of participation. At one point in the session, facilitators
encouraged participants to use a kazoo. The session
observers noted participantsenjoyment of this non-
singing activity, a view also expressed in the focus group
and facilitator interviews.
anybody who is feeling a bit something else they
can concentrate on. [Cath]
It is an excellent breathing exercise I think. [Megan]
quite empowering for them, they were waiting for the
end of the song so that they could make that noise.
[Beth, music facilitator]
Use of instruments in this way was felt to create an
additional form of participation in the group beyond
singing, and this was seen as particularly valuable for
participants with more severe aphasia who are less able
to vocalise.
Yes everybody did really enjoy it [the kazoo]. They took
risks themselves and for the lady that had quite profound
aphasia, she and the gentleman next to her in the
end, for them it was very marked, because they were
making the big noise. They both really liked that I think.
They were really into it. [Susan, music facilitator]
(3) Empowering participants: Facilitators also sought
opportunities for providing participants with some
control over the session content, through collectively
choosing the songs that the group would sing.
Facilitators felt that this sense of participant control was
important and contributed to a feeling of collective own-
ership over the group and its direction.
We were probably also trying to promote some more choice
making, so that the participants would perhaps decide
we can introduce new material but choose the one [song]
they are most comfortable with and the ones they would
want to spend time on. [Beth, music facilitator]
Another way in which participants were empowered
within the session was by allowing singing/musical mis-
takes to happen and by encouraging participants to take
singing risks.
for the participants to be able to make mistakes and
think not to be a problem, nobody is judging them, so
its ok to kind of expose yourself to those kind of chal-
lenges [Susan, music facilitator]
In summary, the above ve features in combination
reected the perceived design and delivery elements of
the singing session which allowed for the emergence of
shared social identity between participants described in
Theme 1.
We designed and delivered an introductory session of a
new group intervention for people with aphasia. Data
from a focus group with intervention participants, an
interview with group facilitators and direct observations
of the session highlighted an emerging sense of group
belonging and social identity among participants. This
emerging social identity was underpinned by shared per-
ceptions of group homogeneity, member familiarity and
social interaction (gure 1). The ndings from this study
support previous research that has established social
identity as an important determinant of a range of health
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18 28
Our research extends that earlier work by
showing how social identity can be actively nurtured in
new group interventions. This contribution is important
given the increasing frequency with which new patient
groups are assembled for the purposes of delivering
health interventions. Understanding how new social iden-
tities emerge, and knowledge of the factors that can
inhibit or facilitate this emergence, is an important rst
step in developing a new guidance framework to
enhance group-based interventions for health.
Our study highlights some potential benets of estab-
lishing early psychological connections and a sense of
group belonging among intervention participants.
Principally, the study shows that actively shaping interven-
tion participantsexperiences of new groups can encour-
age engagement with an intervention, partly because it
can reduce the anxiety that participants experience in
new group settings; nurturing shared social identity can
provide the foundation for effective delivery of interven-
tion content. Accordingly, to the extent that participants
feel comfortable in engaging with an intervention group,
it is possible that the health potential of the given inter-
vention will be better realised. Participants in the current
study were clear about the potential health benets of
this intervention, namely increasing condence and
quality of lifeoutcomes especially pertinent to their
health condition (aphasia). These anticipated benets
were attributed to the reported ease with which partici-
pants interacted with other members.
While our study has focused on a bespoke group inter-
vention for a specic health condition, we suggest that the
basic principles needed to establish belonging and psycho-
logical connectionsshared social identitythat have
been documented here should be core features of a
general framework for group interventions, including
those targeting health outcomes beyond psychosocial
By way of an example, recent research with baria-
tric surgery candidates has highlighted the role of shared
social identity in motivating engagement with a group
dietary education programme and subsequent lifestyle
behaviour change (Tarrant et al, 2015: unpublished observa-
tions). Similar to the ndings from the current study, social
identity in that study was shown to be an emergent prop-
erty of facilitated interaction that was based on perceptions
of group member similarity and shared experience.
Participants and group facilitators in the current study
identied several features relating to the design of the
intervention session (gure 1) that highlight how the
above basic principles of establishing social identity can be
implemented in group interventions. In line with recent
Medical Research Council guidance on process evaluation
in complex interventions,
these features can be seen as
reecting delity issues (eg, delivery of group interven-
tions) and also mechanisms of impact (eg, how participant
engagement and group interaction are achieved). Some of
the design features participants identied were regarded as
xedfeatures, or what might be termed form issues,inthe
sense that they could be planned in advance of the session
(eg, group size, mid-session breaks). Of particular note is
the nding that involving a member of the target popula-
tion in the organisation of the session (eg, recruitment)
contributed to participant engagement with the interven-
tion. Employing a group championin this way may
encourage a more rapid settling inof participants and
promote early social interaction leading to feelings of
belonging. Other features related to the perceived critical
role of the group facilitatorsboth in terms of their provi-
sion of key content relative to the intended health out-
comes (in our case, leading musical activities) and their
exibledelivery of the session, for example, by managing
the expectations of group members and responding to
their needs in situ. This exibility (or function issues)was
strongly valued by participants and reects other research
that has considered the role of group facilitators in man-
aging groups
(Tarrant et al, 2015: unpublished observations).
It also highlights the importance of ensuring that those
who are responsible for delivering group interventions are
appropriately skilled in group leadership: facilitators may
require specic training to become entrepreneurs of identity.
A clear strength of the current study is its triangulation
of ndings, drawing on data from three sources (focus
group, interviews and researcher observations). While
the conclusions drawn here about how to nurture social
identity in group interventions are based on data from a
single session of an intervention for people with a spe-
cic long-term health condition, they accord with some
of the general processes pertaining to group formation
that have been discussed elsewhere.
Our ndings also
resonate with those from other research programmes
that have started to explore the role of social and psy-
chological connections between participants in interven-
tion groups,
and the potential of music to facilitate
these connections.
Nonetheless, future research
should seek to test our conclusions in other healthcare
contexts, particularly those where there are fewer pre-
existing similarities between group members or lower
levels of initial homogeneity. Relatedly, while participants
here were clear about the potential benets of partici-
pating in a group intervention that is underpinned by
shared social identity between group members, it is not
possible to conclude that this participation actually
impacted participantshealth. Finally, we have articu-
lated group processes conducive to the initial formation
of social identity in an intervention group. How these
processes evolve over time across the context of an inter-
vention is an important consideration and is likely to
depend both on the specic health condition and group
membersindividual experiences of the intervention
and interactions with others receiving it.
37 38
ongoing research is building on the work here to nalise
the intervention specication such that it can be the
subject of a randomised controlled trial with clear out-
comes of value to people with aphasia.
This study should therefore be seen as a starting point
for understanding the ways in which participants in new
group interventions form psychological connections with
Tarrant M, et al.BMJ Open 2016;6:e009652. doi:10.1136/bmjopen-2015-009652 7
Open Access on February 23, 2016 - Published by from
one another, and it provides a guide to how these con-
nections might be deliberately nurtured by creating the
conditions for early active participant engagement.
Facilitating the development of a positive and meaningful
shared social identity among intervention participants
may pave the way for the delivery of key intervention
content pertinent to the intended health outcomes.
Author affiliations
University of Exeter Medical School, University of Exeter, Exeter, UK
Peninsula Collaboration for Leadership in Applied Health Research and Care
(PenCLAHRC), South West Peninsula, UK
Department of Psychology, Centre for Clinical Neuropsychology Research,
University of Exeter, Exeter, UK
Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth
University, Plymouth, UK
Twitter Follow PenCLAHRC at @PenCLAHRC
Acknowledgements The authors thank Jane Adamson, Ian Parsons, Bev
Snowden, Rachel Thame and Anna Batson for their contributions to the
development of the intervention session plan, a local aphasia network
chairperson for assistance in participant recruitment and Plymouth Music
Zone for providing music facilitators and use of their facilities for the singing
session and focus group/interviews.
Contributors MT was a project lead; and involved in the study conception and
design; intervention development; data collection; interpretation of results;
manuscript write-up. KW was involved in the data collection; data analysis
and interpretation of results; manuscript write-up. CC was involved in the
intervention development; study design; interpretation of results; manuscript
write-up. SD was involved in the study design; data analysis; interpretation of
results; manuscript write-up. VAG was involved in the intervention
development; interpretation of results; manuscript write-up. KS was involved
in the study conception and design; data collection; interpretation of results;
manuscript write-up. TS was involved in the study design; data collection; led
focus group and interviews; transcription of interview/focus group data; data
analysis; interpretation of results; manuscript write-up.
Funding This research was funded by the National Institute for Health
Research (NIHR) Collaboration for Leadership in Applied Health Research and
Care South West Peninsula. The views expressed are those of the authors and
not necessarily those of the NHS, the NIHR or the Department of Health.
Competing interests None declared.
Ethics approval University of Exeter Psychology Ethics Committee, Ref:
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this work non-
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session for people with aphasia
focus group evaluation of a group singing
intervention recipients: development and
Creating psychological connections between
Goodwin, Ken Stein and Thavapriya Sugavanam
Mark Tarrant, Krystal Warmoth, Chris Code, Sarah Dean, Victoria A
doi: 10.1136/bmjopen-2015-009652
2016 6: BMJ Open
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... A major focus of research around participatory small group interventions has been on their internal dynamics [12,13,38]. Ideally, participatory interventions should be delivered to groups of similar people, who can understand and appreciate each other's circumstances [39][40][41]. Indeed, studies have highlighted how identifying with other members of a group can enhance group cohesion [39][40][41]. ...
... Ideally, participatory interventions should be delivered to groups of similar people, who can understand and appreciate each other's circumstances [39][40][41]. Indeed, studies have highlighted how identifying with other members of a group can enhance group cohesion [39][40][41]. Furthermore, group sessions are preferably facilitated by liked and trusted peers [36,42]. ...
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... The number of studies examining the possible beneficial effects of aphasia choir participation on the quality of life and on communication outcomes is growing. Fogg and Talmage (2011), Tamplin et al. (2013) and Tarrant et al. (2021) all reported unfolding social connections through new friendships between choir participants and an increased sense of belonging after regular choir sessions consisting more than 50% of song singing (Monroe et al., 2020;Tarrant et al., 2016). Moreover, increasing confidence and improvement in the participants' mood during and in-between choir sessions as well as an increased sense of purpose, and that they liked "the fact that as an individual you are not categorized" (Fogg & Talmage, 2011, p. 267) were themes that also emerged from interviews with choir participants who live with aphasia, and their caregivers (Fogg & Talmage, 2011;Tamplin et al., 2013). ...
... Moreover, increasing confidence and improvement in the participants' mood during and in-between choir sessions as well as an increased sense of purpose, and that they liked "the fact that as an individual you are not categorized" (Fogg & Talmage, 2011, p. 267) were themes that also emerged from interviews with choir participants who live with aphasia, and their caregivers (Fogg & Talmage, 2011;Tamplin et al., 2013). Tarrant et al. (2016) adds that an increasing sense of belonging can result in social identity renegotiation, which is a social quality that has a beneficial effect on several health outcomes. Mantie- Kozlowski et al. (2018) suggests that in aphasia choirs "a context where participant enjoyment is viewed as fundamental to social value and hence, ongoing involvement in the activity" (2018, p. 17) should be given a more emphatic role compared to other therapeutic considerations. ...
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Aphasia choirs have been gaining more and more attention for the last decade. The operation of these are based on two pillars: the therapeutic effect of singing with aphasia and decreasing the social isolation of clients with a verbal language disorder. The aim of this article is to draw attention to the international community of these choirs, with special focus on the Hungarian Aphasia Choir, and show their challenges resulting from the restrictions imposed by the SARS-CoV-2 pandemic. The Hungarian Aphasia Choir has had their therapeutic rehearsals online for seven months. The participants’ experiences and their coping methods regarding online and offline choir sessions were examined by an online survey of five questions completed by thirteen choir members living with aphasia as well as some of their caregivers. The responses clearly show the choir members’ general desire to carry on offline rehearsals, while the results also demonstrate that online rehearsals are effective in decreasing social isolation.
... The SPA intervention was informed by the social identity approach to health (Haslam et al., 2018) and the social identity model of behavior change (Tarrant et al., 2020), and was designed to encourage the formation of SSI among the recipients (Tarrant et al., 2018). Alongside singing and music-making, other activities were built in to the intervention to encourage this process, including group-level feedback and encouragement from facilitators, identification of similarities between group members (e.g., recognizing shared interests in music and singing), group goal setting, inclusive language, and also refreshment breaks to encourage member social interaction and personal disclosure (Tarrant et al., 2016). The trial process evaluation included an assessment of the group processes that were active during the intervention sessions-and specifically the extent to which group members exhibited a sense of SSI. ...
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Community groups are commonly used as a mode of delivery of interventions for promoting health and well-being. Research has demonstrated that developing a sense of shared social identity with other group members is a key mechanism through which the health benefits of group membership are realized. However, there is little understanding of how shared social identity emerges within these therapeutic settings. Understanding the emergence of shared social identity may help researchers optimize interventions and improve health outcomes. Group-based singing activities encourage coordination and a shared experience, and are a potential platform for the development of shared social identity. We use the “Singing for People with Aphasia” (SPA) group intervention to explore whether group cohesiveness, as a behavioral proxy for shared social identity, can be observed and tracked across the intervention. Video recordings of group sessions from three separate programmes were rated according to the degree of cohesiveness exhibited by the group. For all treatment groups, the final group session evidenced reliably higher levels of cohesiveness than the first session (t values ranged from 4.27 to 7.07; all p values < 0.003). As well as providing confidence in the design and fidelity of this group-based singing intervention in terms of its capacity to build shared social identity, this evaluation highlighted the value of observational methods for the analysis of shared social identity in the context of group-based singing interventions.
... Forum | Update on current concepts and evidence in interprofessionality in aphasia linking language in different modalities as well as cognitive and motor functions in group projects Rilling et al., 2010 psychologists, musician instructors/ therapists and speech and language therapists feeling part of a group with people who have the same difficulties, working on a music piece accompanied by professionals Tarrant et al. (2016) Tamplin et al. (2013 Regarding aphasia, further research in the specific field of aphasia and collaborative practice is claimed considering the ICF framework (Threats, 2010) as well as the development of valid and reliable assessment tools that can be conducted by different health care providers (Vallumrod et al., 2016). Attard et al. (2017Attard et al. ( , 2020 claim to support further research especially in order to determine what best supports the families. ...
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... In a carefully facilitated intervention, this may enable participants from other areas who are experiencing similar issues, which would help the participants to view issues as being malleable to change [35], thus facilitating critical thinking and reflection. Studies have suggested, however, that differences within groups may pose a challenge because transformative processes work best in groups where participants can relate to what their peers are saying [36][37][38]. Researchers and practitioners should consider a more purposive form of recruitment, where participants who are recruited online undergo a preliminary session geared towards finding and grouping people in a way that enables constructive discussions. This study has a number of limitations. ...
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There is increasing interest in the possibility of delivering violence prevention interventions online. This interest has been intensified by the ‘stay at home’ mandates brought about by COVID-19, which has pushed violence prevention practitioners to find innovative ways to deliver violence prevention interventions during the pandemic. Our study sought to understand the ways in which social contexts may enhance or impede participatory interventions for youth online. We conducted 20 in-depth interviews with researchers and practitioners based in various parts of the world. Data were analysed using thematic network analysis. Results indicated that online participatory violence prevention interventions may on the one hand be undermined by material factors such as access to devices, familiarity with technology, Internet infrastructure, and recruitment strategies. On the other hand, young people’s preference for online engagement, the ability to reach those less inclined to take part in in-person interventions, and the potential for continued engagement in cases of participants on the move were raised. Online group-based participatory violence interventions are crucial for situations when in-person meeting may not be possible. We present initial thoughts on how social contexts might impact the occurrence of these interventions online. More evidence is needed to help us understand how the social contexts can shape the outcomes of online participatory violence prevention interventions.
... Pearce et al. (2017) found that both singing groups and creative writing groups experienced increases in relational bonding -that is, personal connections with individuals in the group -but that only the singing condition yielded an increase in sense of connection to the group as an entity. This attachment to the group as a whole has been shown to improve health and wellbeing outcomes for adults living in a retirement community (Dingle et al., 2020), marginalized individuals (Haslam et al., 2016), people who care for a spouse with Parkinson's Disease (Forbes, 2020), and stroke survivors with aphasia (Tarrant et al., 2016), amongst others. Social identity theory is implicated in the sense of passion national sports team members display when their national anthem is played, and is connected to increased performance (Slater et al., 2018). ...
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Human musicality is a mystery. Theorists have proposed that it was evolutionarily adaptive through its ability to create a shared and positive emotional state, increase a sense of social cohesion, and encourage pro-social behaviours. This research found that group singing provides immediate socio-emotional wellbeing benefits but longer-term benefits are confined to emotional domains. These effects were not unique to group singing, but were similar across comparison groups. Wellbeing was facilitated by both group characteristics (music, movement, socialising) and individual mindset towards participation (motivation, flow), with greater benefits for exercise groups. Implications for social prescribing and similar interventions are discussed.
... For example, to satisfy the need for meaning, facilitators can have group members work toward a collective outcome, such as a performance, as being a part of something bigger than oneself may create a sense of meaning (E. . To satisfy participants' needs for belonging and relatedness, music group leaders could ensure that members are welcomed to each session, and that rehearsals include a break in the middle or after the rehearsal to promote social interactions among members (e.g., Tarrant et al., 2016;Dingle et al., 2019). ...
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Groups 4 Health is a group psychotherapy program that targets social group disconnection. An emerging evidence base supports its efficacy in reducing loneliness, depression, and social anxiety. However, to date there has been no formal analysis of its acceptability to clients and therapists, nor an investigation of its feasibility for wider implementation. This input from end-users is crucial to ensure the program’s wider suitability and to contribute to its improvement. This study drew data from three clinical trials, including 266 Groups 4 Health clients and 68 Groups 4 Health therapists. From the Phase III trial only, additional data were available from 90 clients in a dose-controlled CBT comparison group, and focus groups/interviews with 6 therapists and 13 clients. Client satisfaction was high, with all average ratings >7/10; significantly exceeding the CBT comparison group. Therapist satisfaction with each module was >5/7. Retention was >80%. Homework completion was high, with <10% of clients saying that they had not attempted the homework. Therapists and clients both emphasised the benefits arising from Groups 4 Health, and the contribution of the group context itself as a vehicle to achieve positive outcomes.
Purpose: There is increasing recognition of the contribution that group processes, particularly identification and cohesion, make to outcomes of group delivered health treatments. This study examined the role that these particular group processes play in the treatment of lower back pain, and a theorised mechanism of personal control through which group treatment might enhance outcomes. Methods: Participants (N = 85) elected to either receive NeuroHAB®, a defined functional movement therapy of 8 weeks duration, or continue with treatment-as-usual (TAU). Pain intensity and disability were assessed at baseline (T1) and post-intervention or 8 weeks later (T2), as well as at a 1-month follow-up (T3). Only the NeuroHAB® participants additionally completed weekly questionnaires that measured treatment group identification, cohesion, and personal control. Results: NeuroHAB® was significantly more effective than TAU in reducing pain intensity and disability at T2 and T3. Furthermore, among NeuroHAB® recipients, stronger treatment group identification and cohesion early in the program predicted better pain outcomes over time, and this relationship was fully mediated by perceptions of personal control. Conclusion: These data provide further support for the role of group identification and cohesion as a contributing mechanism of change in group-based treatments and extend this to the domain of pain management.Implications for RehabilitationA focus on defined functional movement therapy, as offered by the NeuroHAB® group program, was found to improve pain outcomes in patients with lower back pain.A key ingredient in the NeuroHAB® rehabilitation program was its group delivery.Group delivery supported treatment group identification and cohesion which, through enhancing the perception of personal control, reduced pain intensity and disability.
Arts and health initiatives can make a valuable contribution to the ongoing recovery of stroke survivors. This article focuses on a study of the ‘About Being’ project, which provides dance and movement sessions for stroke survivors in the Cumbrian city of Carlisle, United Kingdom. The study evaluated the model of practice applied to the community project and how the sessions supported the ongoing recovery of stroke survivors. The methodology involved observations of the sessions and qualitative interviews. A unique feature of this project is that it brings together the fields of education, arts and health by engaging practitioners, academics and student volunteers, along with the stroke survivors who participate in the sessions. It is proposed that the success of the ‘About Being’ project is attributed to its interdisciplinary and collaborative practice, person-centred approach and multidirectional learning environment, which is beneficial for all those involved.
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Background: Published descriptions of group-based behaviour-change interventions (GB-BCIs) often omit design and delivery features specific to the group setting. This impedes the ability to compare behaviour-change interventions, synthesise evidence on their effectiveness and replicate effective interventions. The aim of this study was to develop a checklist of elements that should be described to ensure adequate reporting of GB-BCIs. Methods: A range of characteristics needed to replicate GB-BCIs were extracted from the literature and precisely defined. An abbreviated checklist and a coder manual were developed, pilot tested and refined. The final checklist and coder manual were used to identify the presence or absence of specified reporting elements in 30 published descriptions of GB-BCIs by two independent coders. Reliability of coding was assessed. Results: The checklist comprises 26 essential reporting elements, covering intervention design, intervention content, participant characteristics, and facilitator characteristics. Inter-rater reliability for identification of reporting elements was high (95 % agreement, Mean AC1 = 0.89). Conclusion: The checklist is a practical tool that can be used, alongside other reporting guidelines, to ensure comprehensive description and to assess reporting quality of GB-BCIs. It can also be helpful for designing group-based health interventions.
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The low uptake of telecare and telehealth services by older people may be explained by the limited involvement of users in the design. If the ambition of 'care closer to home' is to be realised, then industry, health and social care providers must evolve ways to work with older people to co-produce useful and useable solutions. We conducted 10 co-design workshops with users of telehealth and telecare, their carers, service providers and technology suppliers. Using vignettes developed from in-depth ethnographic case studies, we explored participants' perspectives on the design features of technologies and services to enable and facilitate the co-production of new care solutions. Workshop discussions were audio recorded, transcribed and analysed thematically. Analysis revealed four main themes. First, there is a need to raise awareness and provide information to potential users of assisted living technologies (ALTs). Second, technologies must be highly customisable and adaptable to accommodate the multiple and changing needs of different users. Third, the service must align closely with the individual's wider social support network. Finally, the service must support a high degree of information sharing and coordination. The case vignettes within inclusive and democratic co-design workshops provided a powerful means for ALT users and their carers to contribute, along with other stakeholders, to technology and service design. The workshops identified a need to focus attention on supporting the social processes that facilitate the collective efforts of formal and informal care networks in ALT delivery and use.
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Attempts to tackle problems such as smoking and obesity increasingly use complex interventions. These are commonly defined as interventions that comprise multiple interacting components, although additional dimensions of complexity include the difficulty of their implementation and the number of organisational levels they target.1 Randomised controlled trials are regarded as the gold standard for establishing the effectiveness of interventions, when randomisation is feasible. However, effect sizes do not provide policy makers with information on how an intervention might be replicated in their specific context, or whether trial outcomes will be reproduced. Earlier MRC guidance for evaluating complex interventions focused on randomised trials, making no mention of process evaluation.2 Updated guidance recognised the value of process evaluation within trials, stating that it “can be used to assess fidelity and quality of implementation, clarify causal mechanisms and identify contextual factors associated with variation in outcomes.”3 However, it did not provide guidance for carrying out process evaluation
According to John Adair, the most important word in the leader's vocabulary is "we" and the least important word is "I". But if this is true, it raises one important question: why do psychological analyses of leadership always focus on the leader as an individual - as the great "I"? One answer is that theorists and practitioners have never properly understood the psychology of "we-ness". This book fills this gap by presenting a new psychology of leadership that is the result of two decades of research inspired by social identity and self-categorization theories. The book argues that to succeed, leaders need to create, champion, and embed a group identity in order to cultivate an understanding of 'us' of which they themselves are representative. It also shows how, by doing this, they can make a material difference to the groups, organizations, and societies that they lead. Written in an accessible and engaging style, the book examines a range of central theoretical and practical issues, including the nature of group identity, the basis of authority and legitimacy, the dynamics of justice and fairness, the determinants of followership and charisma, and the practice and politics of leadership. The book will appeal to academics, practitioners and students in social and organizational psychology, sociology, political science and anyone interested in leadership, influence and power.
Background: Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise capacity) attributable to the programmes. This review updates the review reported in 2006. Objectives: To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal exercise capacity in persons with COPD. Search methods: We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were current as of March 2014. Selection criteria: We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. We defined 'pulmonary rehabilitation' as exercise training for at least four weeks with or without education and/or psychological support. We defined 'usual care' as conventional care in which the control group was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered best practice at the start of the trial for all participants. Data collection and analysis: We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary study. We used standard methods as recommended by The Cochrane Collaboration. Main results: Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.We noted no significant demographic differences at baseline between members of the intervention group and those who received usual care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were community based (at community centres or in individual homes) and one study had both a hospital component and a community component. Most programmes were of 12 weeks' or eight weeks' duration with an overall range of four weeks to 52 weeks.The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition, it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by several studies, this impacted the overall risk of bias.We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies = 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19; low-quality evidence). Statistically significant improvements were noted in all domains of the St. George's Respiratory Questionnaire (SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15, 95% CI -7.95 to -2.36; N = 572; studies = 7).Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95% CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference. Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution. Authors' conclusions: Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.