Groups for change

What Makes a Good Physical Activity Group for People with Long-Term Conditions?

Using the MAGI framework to understand what happens within groups and how instructors can make a difference.

Two group exercise instructors can deliver very similar physical activity programmes, with comparable exercises, equipment and facilities, yet create quite different experiences for their participants. In one group, people arrive, complete their exercises and leave. In another, participants gradually get to know one another. They exchange advice, encourage each other, notice when someone is missing and begin to look forward to the social experience as much as the exercise itself.

What makes these experiences different? And how much influence does the instructor have?

These questions are particularly relevant to physical activity programmes supporting people living with long-term health conditions, where developing confidence, sustaining participation and overcoming barriers to activity can be just as important as completing an individual exercise session.

One useful way to explore these questions is through the Mechanisms of Action in Group-based Interventions (MAGI) framework, developed by Borek and colleagues (2019).

Looking beyond the exercise programme

Physical activity and exercise referral instructors working with people who have long-term conditions already consider a wide range of factors. An individual might have cardiovascular disease, diabetes, persistent pain, respiratory disease or several coexisting conditions. Their symptoms, functional capabilities, confidence, experience of physical activity and reasons for attending may vary considerably.

Good exercise prescription and appropriate individualisation remain essential. But delivering physical activity in groups introduces another dimension to professional practice: the interactions and relationships between the people taking part. A participant might gain reassurance from meeting someone who has experienced similar difficulties. Another might develop confidence after observing someone with comparable limitations successfully completing an activity. Someone else may attend more consistently because they enjoy seeing familiar faces.

These experiences are not necessarily created through exercise prescription. They emerge through the social processes taking place within the group. Understanding these processes can help instructors think more carefully about how their groups operate.

What is the MAGI framework?

The MAGI framework was developed by Borek and colleagues (2019) to identify and organise the processes through which group-based health behaviour-change interventions may influence participants. The researchers drew together evidence from group dynamics, behaviour-change research, qualitative studies and observations of group-based interventions. Weight-management groups were used as an important source of empirical material during its development.

Their work identified six overarching categories that provide a way of understanding what happens within group-based interventions.

Although MAGI was not developed specifically for physical activity referral programmes, its categories provide a useful framework for reflecting on group exercise delivery, particularly when supporting people with long-term conditions.

Six ways to understand a physical activity group

1. Group intervention design: How is the group organised?

The way a programme is designed influences the experiences participants can have. Consider a physical activity referral programme attended by people with different health conditions and levels of physical capability. Group size, session frequency, venue accessibility, participant composition and the structure of activities can all influence how comfortable participants feel and how easily they interact.

For example, a programme organised around individual exercise stations may provide excellent opportunities for tailored exercise but relatively few opportunities for participants to communicate. 

An instructor might therefore consider how the session structure could also create appropriate opportunities for interaction, without compromising individual exercise needs.

2. Facilitation techniques: What does the instructor do?

Group facilitation involves more than explaining exercises and supervising technique. Instructors make numerous small decisions that shape how a group works. They introduce people, encourage participation, manage conversations, respond to different personalities and help establish expectations about how members treat one another.

Consider an instructor who notices that a participant with persistent pain is reluctant to join an activity. Rather than focusing solely on reassurance from the instructor, they might create an appropriate opportunity for participants to discuss their experiences of adapting activities.

This requires professional judgement. Peer experiences can be valuable, but advice about managing health conditions must remain within appropriate clinical and professional boundaries.

The important point is that instructors can influence how participants interact, rather than being the sole source of information and encouragement.

3. Group dynamics and development: How does the group begin to work together?

Groups develop their own atmosphere, relationships, expectations and patterns of behaviour. A newly formed group may consist of unfamiliar individuals who are primarily focused on their own activities. Over time, members may begin greeting one another, sharing experiences, developing routines and feeling that they belong. For people who have previously felt excluded from exercise environments, this developing sense of group membership may be particularly meaningful.

However, positive group dynamics cannot be assumed. Groups may also develop unhelpful comparisons, dominant personalities or expectations that discourage some participants. 

Instructors can pay attention to these emerging patterns and consider how their facilitation influences them.

4. Interpersonal change processes: What happens between participants?

This is perhaps one of the most immediately recognisable aspects of group-based physical activity. Participants can influence one another through social learning, encouragement, comparison, practical support, shared problem-solving and other forms of interaction. Imagine a participant who is anxious about becoming breathless during exercise. Hearing another participant describe their own experience of gradually developing confidence may provide reassurance. Alternatively, seeing others performing at a much higher level could leave someone feeling inadequate or discouraged.

Group interactions can support change, but they can also create barriers.

Recognising both possibilities helps instructors move beyond simply encouraging more social interaction towards considering the quality and consequences of those interactions.

5. Intrapersonal change processes: What changes within individuals?

Group experiences can influence what individuals think, feel and believe about themselves. This might include changes in confidence, motivation, understanding, self-efficacy, habits or identity. A participant who initially describes themselves as someone who cannot exercise because of their health condition might gradually begin to see themselves as someone who is capable of being physically active.

That change may involve improvements in physical capability, but it could also be influenced by social experiences, encouragement and seeing others manage similar challenges.

For instructors, this creates an opportunity to consider outcomes beyond physical performance alone.

How are participants talking about themselves? Are they becoming more confident? Are they beginning to see physical activity as something they can maintain?

6. Contextual influences: What else affects the group?

No physical activity group operates in isolation. Participants bring different experiences, circumstances and challenges. For people living with long-term conditions, these may include fluctuating symptoms, fatigue, treatment schedules, accessibility difficulties, transport problems, financial pressures and experiences of healthcare or physical activity services.

Instructors also work within organisational and practical constraints. A participant's limited attendance, for example, may have little to do with motivation or the quality of the session.

MAGI reminds us that understanding how groups work requires attention to these wider influences, not simply what happens during the exercise class itself.

Using MAGI to reflect on professional practice

One of the most useful applications of MAGI is as a structured guide for reflecting on existing programmes.

Rather than trying to apply every element of the framework at once, an instructor might review a familiar group through six questions:

1. Design: Does the way this programme is organised help participants feel comfortable, included and able to participate?

2. Facilitation: What am I doing to encourage helpful interactions between participants?

3. Group dynamics: What sort of atmosphere and shared expectations are developing?

4. Interpersonal processes: How are participants influencing and supporting one another?

5. Individual change: What changes in confidence, motivation or identity might be taking place?

6. Context: What wider circumstances are influencing participants' experiences?

The framework doesn't provide a simple formula for creating a successful group. Nor does it suggest that every process will be equally important for every participant. Instead, it provides a broader perspective on the possible influences operating within a group, helping instructors recognise strengths, identify missed opportunities and consider new approaches.

The group itself is part of the intervention

When physical activity is delivered to people with long-term conditions, considerable professional attention rightly goes towards safety, exercise prescription, individualisation and progression. But the group itself also deserves attention.

The relationships people develop, the experiences they share, the expectations that emerge and the ways instructors facilitate participation can all influence what participants gain from a programme. The MAGI framework provides an evidence-informed way of thinking about these processes.

For instructors, the challenge is not to become experts in every theory of group behaviour. It is to develop a greater awareness of what happens between people, and a broader repertoire of approaches for supporting positive group experiences.

Good group leadership involves considering not only what exercise participants undertake, but also what being part of the group makes possible.

Further reading

Original research

Borek, A. J., Abraham, C., Greaves, C. J., Gillison, F., Tarrant, M., Morgan-Trimmer, S., McCabe, R., & Smith, J. R. (2019). Identifying change processes in group-based health behaviour-change interventions: Development of the mechanisms of action in group-based interventions (MAGI) framework. Health Psychology Review, 13(3), 227–247. https://doi.org/10.1080/17437199.2019.1625282 Download PDF

Detailed MAGI framework

The authors also published a comprehensive supplementary coding schema describing the framework categories and their component processes in greater detail.

Read Supplementary Document 6: MAGI Coding Schema (PDF) Download PDF