Our goal was to assess rural health care providers’ self-efficacy and perceived effectiveness with respect to the treatment of pediatric obesity, challenges and solutions to providing care in rural areas, and the potential utility of telehealth in addressing these challenges. Health care providers who responded to this survey were, in general, not very confident in their own ability to treat obesity in children but believed that obesity treatment in children can be effective. Several barriers, such as lack of local weight management programs, low patient motivation, and inadequate family involvement, may interfere with treatment efforts. Overall, providers expressed high interest in participating in additional training employing telehealth technologies.
Multiple challenges related to the care of obese children and adolescents currently exist in rural primary care. Continuing education for rural health care providers is additionally a challenge given their geographic isolation. However, telehealth technologies provide an opportunity to overcome this barrier. Resources that can potentially be delivered using existing telehealth technologies include (1) access to weight management programs, dieticians and psychologists31
; (2) distance education in pediatric obesity treatment, motivational interviewing, brief-focused counseling, and strategies to maximize third-party reimbursement; (3) clinician and office staff training and support in office systems improvement; (4) access to web-based patient educational materials; (5) access to a web-based directory of local and regional resources that support healthy weight management; and (6) access to web-based clinical algorithms to guide treatment.
Surveys of health care providers in urban areas show similar results.32
Poor reimbursement for time-intensive visits for obesity treatment exists even in specialized obesity referral clinics, regardless of the severity of obesity.33
A national needs assessment, which did not specifically examine geographic location, demonstrated that the 2 most frequent barriers to obesity treatment reported by clinicians were lack of parent involvement and lack of patient motivation.34
Clinicians’ self-reported confidence in their ability to help motivate patients to change behaviors has been reported as a barrier in other studies.35
Many health care providers have not been trained in motivational interviewing and other counseling techniques to enhance adherence to behavioral change.36
Motivational interviewing and brief negotiation have been adapted for use in busy and time-limited clinical visits, and gaining proficiency in these techniques may be an effective approach in rural health care settings.37-39
Strengths of our study are the high response rate as well as the fact that we included a variety of health care professionals involved in the delivery of care in rural California (family physicians, pediatricians, nurse practitioners, and physician assistants). Although we have identified important issues related to the delivery of health care for pediatric obesity in rural underserved areas, our study relied primarily on self-report and did not include direct measures of health care provider knowledge or clinical practice. Additionally, it is possible that responding health care providers may have had greater interest in the management of pediatric obesity than non-respondents.
Although our survey provides valuable data to plan targeted interventions in California, similar surveys of rural clinics in other states would help determine whether health care providers in other geographic locations face the same challenges to pediatric obesity management. Once targeted interventions have been designed, further research on the feasibility, acceptability and effectiveness of such interventions to enhance obesity care in rural areas needs to be conducted. Since our study relied primarily on self-report, other measures of health care provider knowledge or clinical outcomes may provide further information regarding challenges to obesity management in rural areas.
Information obtained from this study will guide the development of tailored interventions delivered by telehealth to rural health care providers to enhance the clinical care of obese children and adolescents. For example, nurse practitioners may be a suitable target group for interventions using Internet case-conferencing, given their high interest in this medium of communication and lower reported time constraints. For rural clinics to provide effective care for chronic diseases such as obesity, it is additionally necessary to put into place efficient practice systems that facilitate implementation of clinical recommendations.