A Qualitative Assessment of Weight Control among Rural Kansas Women

doi:10.1016/j.jneb.2008.04.355

Journal of Nutrition Education and Behavior

Volume 41, Issue 3, May–June 2009, Pages 207-211

https://doi.org/10.1016/j.jneb.2008.04.355 Get rights and content

Abstract

Objective

To explore weight control beliefs, attitudes, knowledge, and practices among rural Kansas women, and to characterize the relationship of these women with their primary-care providers around weight control.

Design

Qualitative research using focus groups.

Setting

Three separate communities of rural Kansas.

Participants

Six focus groups among 31 women during fall 2006.

Intervention

Two focus groups in each community, each of 2-hour duration. A focus group moderator's guide was used to explore the roles of individuals, primary-care practice teams, and communities around weight control.

Analysis

This study used a qualitative analysis with an iterative process and standard techniques. The analysis team summarized central findings, descriptive topic areas, and general themes.

Results

There were 5 broad themes that emerged from these focus groups. These themes are lack of support from primary-care providers; primary-care offices as community resources; lack of resources for promoting dietary change, but adequate resources for physical activity; the importance of group support and inclusiveness; and a need for more intensive interventions for weight control.

Conclusions and Implications

Rural populations have an above-average prevalence of obesity and related comorbidities. Rural communities need better approaches for addressing the obesity epidemic.

Introduction

Obesity is a leading preventable cause of death in the United States (US), second only to tobacco smoking.1, 2 Rural populations suffer disproportionately from obesity, physical inactivity, and obesity-related comorbidities compared to their urban counterparts,3, 4 which is felt to be a result in part of a “later adoption” of new technologies and treatment compared with their urban counterparts.⁵ Nonetheless, there are relatively few studies exploring weight control beliefs and practices among rural communities, rendering a thorough understanding of these rural-urban differences in obesity and obesity-related complications difficult.

In the general US population, women have a higher prevalence of obesity than men.⁶ This gender disparity in obesity risk has also been demonstrated in rural populations.⁷ Furthermore, gender-based differences in weight management and beliefs have been identified for rural populations.⁸ Compared with men, women are more likely to demonstrate weight-related concerns and to be involved in a weight control attempt at any given time.⁹ Women have a more extensive history of weight cycling and tend to engage in different weight control strategies than men.10, 11 Obese women are more likely to suffer social stigma related to weight compared to their male counterparts, and they have a greater psychological burden as a result.10, 12 This disparity is thought in part to be a result of societal discrimination against obese individuals, especially against women.¹² Nonetheless, gender differences in weight control experiences have been understudied among rural populations, which is important, given that over 20% of the US population resides in a rural community.¹³

This study used a qualitative approach to explore weight control beliefs, attitudes, and knowledge among rural Kansas women, with a special focus on characterizing the relationship of these women with their primary-care providers and practices around weight control. Improving the recognition and treatment of overweight and obesity in primary-care settings is a critical initiative.¹⁴ Lack of attention by clinicians has been identified as a contributing factor to the escalating obesity epidemic.¹⁵ Furthermore, because this project represented the developmental phase of a pilot trial for weight control in rural primary care, community and social activation around weight control were explored.

Section snippets

Description of Evaluation

This project completed 6 focus groups to explore weight control among women from 3 separate communities of rural Kansas during the fall of 2006. Two focus groups in each community were held to ensure adequate representation from each community and to have some scheduling flexibility for recruitment purposes. Patients were recruited from 3 primary-care practices in 3 separate rural Kansas counties.

Two study sites were in frontier rural counties in western Kansas, with overall populations of 1534

Lessons Learned

Six focus groups were conducted in 3 separate communities in rural Kansas between September and December 2006. There were 31 women overall, with focus group sizes containing on average from 4 to 9 women. The pre–focus-group 17-item survey identified participant mean ± SD age was 60 ± 14 years, and their mean ± SD body mass index was 33 ± 5. All of the women were white, and most reported at least 1 obesity-related comorbidity. Hypertension was most commonly self-reported (62%). Their mean ± SD

Implications for Research and Practice

This study used focus groups to explore weight control beliefs, attitudes, and experiences among a group of women from 3 rural Kansas primary-care practices. These women had long experience with weight control attempts and had specific thoughts and ideas about how to improve weight control in rural communities. Similar to nonrural environments, these women felt a lack of support for weight control from primary-care providers. The women shared that accountability and guidance from their

Acknowledgments

This work was funded by a Building Interdisciplinary Research Careers in Women's Health (BIRCWH) K12 grant to Dr. Ely (University of Kansas Medical Center, PI Drs. Soares and Thomas) and a National Heart, Lung, and Blood Institute K23 grant to Dr. Ely (PI, 1 K23HL085125-01A1). We gratefully acknowledge the physicians and staff at the 3 collaborating rural primary-care practices of this project. This research would not have been possible without their eager participation and supportive efforts.

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Despite research showing substantial weight disparities along the rural–urban continuum, little work has attempted to identify differences in prepregnancy weight status or gestational weight gain (GWG) outcomes between rural and urban birthing people. As such, the goals of this research were to 1) document the prevalence of prepregnancy overweight and obesity and excessive GWG in rural and urban birthing people and 2) examine changes in rural and urban prepregnancy overweight or obesity and excessive GWG over time.
Birth certificate data provided sociodemographic variables, prepregnancy body mass index, GWG, and rurality status on 465,709 respondents who gave birth in Minnesota from 2012 to 2019. A series of regression models estimated risk differences in 1) prepregnancy weight status and 2) excessive GWG between rural and urban respondents over time, controlling for relevant covariates.
Rural individuals had a 4.9 percentage-point (95% confidence interval, 4.5–5.3) higher risk of having prepregnancy overweight or obesity compared with urban individuals, and a 2.6 percentage-point (95% confidence interval, 1.9–3.3) higher risk of gaining excessive gestational weight. The disparities in prepregnancy overweight or obesity and excessive gestational weight between rural and urban individuals widened over time.
These findings contribute to accumulating evidence documenting notable health disparities between rural and urban individuals during the perinatal period and support the need to develop prevention and treatment efforts focused on improving the weight-related health of individuals living in rural communities.
Protocol for the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) Trial: Comparing three obesity treatment models in rural primary care
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Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N = 1440) age 20 to 75 with a BMI 30–45 kg/m². In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care.
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Our study is one of few studies targeting weight control in underserved populations of breast cancer survivors with other trials targeting African Americans [83]. Barriers faced by rural women include limited access to fitness facilities and lower-cost large chain grocery stores, sociocultural dietary norms such as high fat and potluck meals, norms against exercising during leisure time, and in the Midwest plains weather constraints for outdoor exercise with extreme temperatures, high winds, and little shelter [84,85]. These barriers are in addition to barriers common to lower socioeconomic groups such as job- and family-related stress, lower education and literacy, and poorer access to healthcare [86].
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However, research also shows that putting this knowledge into practice in everyday eating and food choices is problematic. First, health advice and nutrition guidelines may be challenging to reconcile with everyday life with its social and work-related commitments, time constraints, food traditions and taste preferences (Ely, Befort, Banitt, Gibson, & Sullivan, 2009; Holm, 2003a). As Ristovski-Slijepcevic, Chapman, and Beagan (2008) have suggested, people’s ideas of healthy eating draw on various kinds of cultural and traditional, nutritional as well as ethical discourses.
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: This work was funded by a Building Interdisciplinary Research Careers in Women's Health (BIRCWH) K12 grant to Dr. Ely (University of Kansas Medical Center, PI Drs. Soares and Thomas) and a National Heart, Lung, and Blood Institute K23 grant to Dr. Ely (PI, 1 K23HL085125-01A1).

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Research BriefA Qualitative Assessment of Weight Control among Rural Kansas Women

Abstract

Objective

Design

Setting

Participants

Intervention

Analysis

Results

Conclusions and Implications

Introduction

Section snippets

Description of Evaluation

Lessons Learned

Implications for Research and Practice

Acknowledgments

J Nutr Educ Behav

Addict Behav

Prev Med

Excess deaths associated with underweight, overweight, and obesity

JAMA

Actual causes of death in the United States, 2000

JAMA

A national study of obesity prevalence and trends by type of rural county

J Rural Health

Obesity and physical inactivity in rural America

J Rural Health

Rural epidemiology: insights from a rural population laboratory

Am J Epidemiol

Prevalence and trends in obesity among US adults, 1999-2000

JAMA

Gender-specific disparities in obesity

J Community Health

Prevalence of attempting weight loss and strategies for controlling weight

JAMA

Research Brief
A Qualitative Assessment of Weight Control among Rural Kansas Women