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Abstract Background Delivering an intervention to a group of patients to improve health outcomes is increasingly popular in public health and primary care, yet "group" is an umbrella term which encompasses a complex range of aims, theories, implementation processes and evaluation methods. We propose a framework for the design and process evaluation of health improvement interventions occurring in a group setting, which will assist practitioners, researchers and policy makers. Methods We reviewed the wider literature on health improvement interventions delivered to patient groups and identified a gap in the literature for designing, evaluating and reporting these interventions. We drew on our experiences conducting systematic reviews, intervention, mixed method and ethnographic studies of groups for breastfeeding and weight management. A framework for health improvement group design and delivery evolved through an iterative process of primary research, reference to the literature and research team discussion. Results Although there is an extensive literature on group processes in education, work, politics and psychological therapies, far less is known about groups where the aim is health improvement. Theories of behaviour change which are validated for individual use are often assumed to be generalisable to group settings, without being rigorously tested. Health improvement or behaviour change interventions delivered in a group setting are complex adaptive social processes with interactions between the group leader, participants, and the wider community and environment. Ecological models of health improvement, which embrace the complex relationship between behaviour, systems and the environment may be more relevant than an individual approach to behaviour change. Conclusion The evidence for effectiveness and cost-effectiveness of group compared with one-to-one interventions for many areas of health improvement in public health and primary care is weak or unknown. Our proposed framework is the first step towards advocating a more systematic approach to designing, evaluating and reporting interventions in group settings, which is necessary to improve this currently weak evidence base. This framework will enable policy makers and practitioners to be better informed about what works, how it works and in which contexts when aiming to improve health in a group setting.

Abstract Background The UNICEF Baby Friendly Initiative includes a community component to help women who want to breastfeed. This study aimed to document the health visitor role in promoting and supporting breastfeeding in Glasgow during 2000 and the effect it had on breastfeeding rates. Methods Glasgow, UK, has a population of 906,000, with approximately 10,000 births per year. Glasgow has high levels of material deprivation and traditionally low breastfeeding rates. This was a cross-sectional study in January 2000 which used a postal questionnaire to document individual health visitors' interventions, activities and attitude towards breastfeeding. Infant's breastfeeding data collected routinely by the Child Health Surveillance programme from 1 August 1998 to 28 February 1999 was directly matched with interventions, activities and attitudes reported by their own health visitor. Results 146/216 (68%) health visitors completed and returned the questionnaire. 5401 child health records were eligible and 3,294 (58.2%) could be matched with health visitors who returned questionnaires. 2145 infants had the first visit from 8 to 20 days of age and the second 3 to 7 weeks later. At the first postnatal visit 835 of 2145 (39%) infants were breastfed (median age of 13 days) and 646 (30%) continued to breastfeed at the second visit (median age 35 days). Infants being breastfed at the first visit were significantly more likely to be fed infant formula at the second visit if their health visitors had had no breastfeeding training in the previous two years (OR1.74 95%CI 1.13, 2.68). Conclusion It is essential that Health Visitors are specially trained to support breastfeeding postnatally.