Six focus groups were conducted in 3 separate communities in rural Kansas between September, 2006 and December, 2006. There were 31 women overall, with focus group sizes being on average between 4 and 9 women. The pre-focus group 17-item survey identified that 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 one obesity-related comorbidity. Hypertension was most commonly self-reported (62%). Their mean ± SD SF-12 Physical Component Summary (PCS) score was 44 ± 12, and their mean ± SD SF-12 Mental Component Summary (MCS) score was 52 ± 9. PCS and MCS scores are standardized and normed with a mean of 50 and a SD of 10 using US population estimates.
There were five broad themes that emerged from these focus groups: 1) lack of support from primary care providers, 2) primary care offices as community resources, 3) lack of resources for promoting dietary change but adequate resources for physical activity, 4) the importance of group support and inclusiveness, and 5) a need for more intensive interventions for weight control. Each of these themes is described further below.
Lack of support from primary care providers
Participants reported wanting more encouragement and directive support on weight control from their primary care providers (PCP). One woman said, “The only time he’s (i.e., PCP) ever said anything to me about my weight is he came in one day and he said, “Do you really weigh that much?” I said, “Yeah.” He said, “Oh. You might want to lose some weight.” And that was it.” Participants stated that their primary care providers do not typically address weight until it is accompanied by comorbid medical conditions. One woman stated, “It’s maybe on your way out after you changed your medicine or checked your blood pressure and everything which I take blood pressure medicine, that he may say, “Well, it may come down a little if you lose 10 pounds.” That’s the only thing I’ve gotten out of him.” Furthermore, these participants felt strongly that their PCP should raise the issue of weight control more often, and should help them set specific weight control goals. One woman shared, “I’ve often thought that if he (i.e., PCP) would say to me, “Before you come in again, I would like to see three pounds.” I mean I need to set a goal. But if he (i.e., PCP) sets a goal, I think I might be more apt to strive for that because I wouldn’t want to let him down.” Another woman said, “That’s what my perception is, and they should really just say, “You’re overweight” and don’t be bashful about it.” Overall, participants recognized that time pressures and the complexity of chronic disease care are barriers to diagnosing and treating obesity in primary care. These women felt that while obesity care could be effectively delivered by other professionals at the primary care office, their PCP needs to be involved regularly in weight control treatment.
Primary care offices as community resources
Participants felt that primary care offices are critical community locations where weight control initiatives should be located. This was especially emphasized in our two frontier rural locations, although this theme was woven throughout the groups. Participants stated that they were looking for low cost or free weight control programs involving group support, accountability with weight assessments, and exercise opportunities located at the primary care office or local hospital. One woman said, “I think if the doctor’s office had a place with their patients where you can get together like this as a group, and we had to weigh in and [we got] a little reward like a tennis shoe or something. Kind of like a Weight Watcher’s that is free.” Another woman said that they are “looking to the health centers as an important leader in the community around information exchange and places where people can gather to support each other and link to the community.” Another woman shared, “I would like to see the hospital exercise room opened up to employees. I think if they would offer it to say certain departments or maybe even outside people during different times.” Participants saw the primary care office as more than a place to visit with their PCP, but also as a community resource that should be more open to providing group weight loss programs.
Lack of community resources for promoting dietary change but adequate resources for physical activity
Overall, participants felt that community resources for dietary change were largely lacking, whereas resources for encouraging physical activity were more available. Physical activity resources included school, church, and hospital exercise programs, community centers, senior centers, and safe walking areas. Resources for dietary guidance were lacking, and distance to commercial weight control programs was a significant barrier for participants living in the frontier rural communities. For two communities, the nearest commercial weight control programs were 30 to 50 miles away. In one town, several women formed a self-directed weight control group and boasted significant collective weight loss, however, they did express regret that they did not have specific guidance from weight control professionals. As one woman noted, “Some people just don’t have the [nutrition] knowledge of, this is what’s good for you, this is what’s bad, how much is good for you, and how much isn’t.” Participants expressed a desire for more help with weight loss from resources like the county health departments. Participants also noted that healthy options at restaurants were lacking in their communities. As one women stated, “Some of the restaurants could change their menus. Like how when we came out here, how everything just gets gravy. We’re not used to biscuits and gravy in the morning. And you just can’t go in, well there’s really no [other] restaurants around.”
Importance of group support
Participants identified group support and inclusiveness as critical to the success of weight control initiatives. One woman said, “You’re working with people that are in your group of weight loss, so you’re constantly saying, we can’t eat that.” Another woman said, “I decided to take matters into my own hands, and went back to the office. I said, Gals, is anybody interested in losing weight and we’ll all get together and we’ll do this together? They all said yes.” Another participant shared, “Everybody looked forward to all these people getting together…if there was a place that you could always go to and there would always be other people, I think more people would do it.”
Several women felt that there were weight control challenges that were unique to women in rural communities, and that group support could help deal with these challenges. Participants spoke about their roles as caregiver, home manager, and cook even though many were working outside of the home. Several women felt that sharing these experiences in groups might be very helpful in facilitating weight control success. One woman said, “Well, it’s the whole support system. Like with me, I don’t have a lot of friends. I’m a busy person. I’m busy with my kids. I’m busy with whatever. So I don’t have a huge support system. Groups are good to me because then you do know that, ‘Hey, you know what? I am having a really bad day, and I want to eat like a full package of candy bars right now’…I could call somebody.”
Another unique aspect of small rural communities is the difficulty with usual care control arms, largely due to the importance of inclusiveness. These women shared that they wanted to know who else was participating in weight control projects so that they could develop support networks. Although maintaining confidential recruitment was important due to the stigmatizing nature of obesity, several participants expressed that they valued inclusiveness more than confidentiality, in part because personal relationships with medical providers and patients are typical in rural communities.
Need for more intensive interventions
Participants universally stated that they needed more intensive weight control interventions that provided regular support, encouragement, expertise, and accountability. One woman said, “That’s a big thing to me. Accountability to somebody, and you ought to have some of that to yourself I know. But when I have to go and weigh in, it’s easier.” Another woman said, “I think one of my ideas was to form small groups.…being accountable to each other, weighing in front of each other, committing to each other, helping, encouraging, all that.” One woman shared, “Nobody ever said to me, “Why don’t you get on a program,” except my husband. It wasn’t until I was diagnosed with diabetes that I went into shock, and ate broccoli for a week or something like that.” Finally, one woman stated it concisely when she said, “I felt like I needed more to motivate me.”