Abstract
Background
Effective treatments are available to address the rising prevalence of childhood obesity in the U.S. Families in rural communities face unique barriers to accessing and engaging in these programs. This study evaluated interests and considerations for behavioral health programming to treat child obesity in rural southern U.S.
Methods
Rural counties with high prevalence of adult obesity (> 40%) were selected for recruitment following interviews with community partners and agents, in accordance with the Hexagon Tool framework. Researchers collaborated with extension agents and communities to recruit parents (n = 33) and children (n = 15) for cross-sectional focus groups and parent surveys (n = 295). The survey was adapted from questions on The Knowledge, Attitudes and Practices Scale, The Behavioral Information Preference Scale, and The Health Information National Trends Survey. Parent focus group data was analyzed using inductive reasoning, and content analysis was used for child focus group data. Descriptive statistics were used to interpret survey results.
Results
Parent surveys (18–54 years, 50% male) indicated concern for childhood overweight and obesity (129/295 responses), as well as great interest in health education (153/295). Responses indicated high acceptability of digital (184–193/295) and group-class (192/295) formats for programming and accessing information. During focus groups, parents (≥ 18 years, 94% female) identified structural barriers including lack of resources as limitations for participation. Children (M = 10.5 ± 1.3 years, 60% boys) identified improving overall health and athleticism as desired outcomes.
Conclusions
Families living in rural settings desire programming for childhood obesity treatment. Researchers and community leaders can build capacity and utilize existing resources to implement programs.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-025-23381-0.
Keywords: Rural, Community health, Family weight management, Lifestyle treatment, Pediatrics
Introduction
Child and adolescent obesity prevalence in the U.S. continues to rise, with 1 in 5 youth meeting the classification for having obesity (BMI percentile ≥ 95th ), contributing to increased prevalence of related negative physical and mental health outcomes [1]. Evidence-based obesity treatment for youth includes intensive health and lifestyle behavior treatment (IHBLT) [2]- family-based programming that provide counseling on modifying social and environmental structures to improve dietary quality, increase physical activity, and establish/maintain healthy behaviors through collaborative goal setting and self-monitoring [2]. These programs are effective in decreasing child weight [3, 4] and increasing mental and physical health outcomes such as improving psychological wellbeing [5] and reducing disordered eating patterns [6]. Unfortunately, families have limited access to the programs due poor accessibility outside of specialty clinics and exclusion of treatment coverage in health plans, among others [7, 8]. Rural communities are at greater risk for increased weight and related chronic disease and are limited even further by these geographical and economical barriers [9]. There is limited evidence to suggest these programs are effective in rural settings [10], but more programmatic development and evaluation is needed to enhance access, provider uptake, and family engagement and retention [11]. Engaging with rural communities to understand their unique needs and facilitating their participation in the design and implementation of health programming may contribute to the dissipation of health disparities [12, 13]. The purpose of this study was to evaluate interests and considerations for behavioral health programming to treat child obesity among families in rural communities. The specific outcomes to be identified are: 1a) identify behavioral health outcomes that are important to parents and children; 1b) identify barriers to participating in behavioral health programming that are unique to rural communities; 2a) identify the relative importance of behavioral health programming; 2b) identify modes of interest for communicating health information; and, 2c) identify formats of interest for programming.
Methods
Rural counties in a U.S. southern state were identified for eligibility by the Centers for Disease Control and Prevention’s (CDC) High Obesity Program (HOP), in which universities and Cooperative Extension agents work with communities with disproportionate prevalence of adult obesity (> 40% of the population) [14]. The program is designed to implement evidence-based obesity prevention strategies in the specified counties (CDC 1809# [cooperative agreement number 58DP006570], PI: Holston). Two HOP counties were selected for the present study based on a series of interviews of community partners and agents, following the framework of the Hexagon Tool [15] to determine community interest, priorities, and readiness for IHBLT. The Hexagon Tool is used during the exploration process for identifying the fit and feasibility of potential programs and practices for use in community settings. It is comprised of three program indicators (supports [expert assistance, external resources for implementation], evidence [outcome, fidelity and cost effectiveness, strength of evidence for whom and in what conditions], and usability [adaptations for context, well-defined program]) and three implementing site indicators (need [focus population and subpopulations, multiple data sources to understand needs and assets, community perceptions], capacity [costs, resources needed and available], and fit [community values, impact on other initiatives, and alignment with other priorities of implementing site]) [15]. For the present study, agents affiliated with the research institution and community leaders were pivotal in recruitment and creating community connections between the researchers and participants.
Parents ages 18 + y who resided in the pre-specified counties with children under 18 y currently enrolled in school were considered eligible to participate in a 60-minute focus group and/or anonymous online survey during July 2023. Children were considered eligible to participate in the 45-minute interactive child focus group if they were between the ages of 9 and 12 y, if they resided in one of the pre-specified counties, and if they were currently enrolled in school. Exclusion criteria for the focus groups included cognitive impairments that would interfere with participation in group discussion. These focus groups collected information about behavioral health outcomes important to families and barriers to participating in these programming unique to their rural communities (outcomes 1a and 1b).
An online parent survey was advertised through social media (private Facebook group page, privately administrated by local extension agents) to parents throughout the two counties of interest. The survey gathered quantitative data about attitudes concerning pediatric obesity, acceptance of and interests for an IHBLT, as well as interest in digital health as a potential intervention modality (outcomes 2a, 2b, and 2c). Participants completed the survey using the online REDCap platform [16, 17]. Questions were adapted from validated measures, including The Knowledge, Attitudes, and Practices Scale [18] to measure parent’s perspectives of childhood obesity and reveal misconceptions that may represent barriers to participating in a family-based IHBLT. The Behavioral Information Preference Scale [19] was adapted to understand parent’s interests in the ways they would like to receive health information. The Health Information National Trends Survey [20] was adapted to measure families’ access, usage, and interest in digital health as an intervention modality. Survey results were described by reporting the proportion converted to percentage for each item response.
Focus groups took place in July 2023 in local community colleges and churches. These locations were available for public use and accessible to participants. All study procedures were approved by the Institutional Review Board at Pennington Biomedical Research Center (FWA#00006218), and informed adult consent, informed consent to participate obtained from parents or legal guardians of a child under the age of 16, and child assent were collected. Parent focus group participants received $40, and survey participants were entered to win 1-of-3 $100 gift cards. Child focus group participants received $25. Focus group co-leads were trained by experienced research staff in procedures to reduce potential bias (e.g., avoid leading questions, encourage discussion from all members). However, the sample may not be completely representative of the larger population given the relatively small size.
Qualitative data were obtained during four parent focus groups (n = 33) and three child focus groups (n = 15). The purpose of the parent focus groups was to collect information about perceived barriers to implementing and engaging in healthy lifestyle programming, available resources in the community to make programming accessible, and desired content and formatting for programming to reduce child and family obesity. One attendee was present for the first focus group, leading the research team to increase social media outreach via Facebook advertisements in targeted areas/groups privately administrated by extension agents. Focus group facilitation remained consistent across all focus groups with one co-lead facilitating the semi-structured interview discussion (Appendix A) and the other co-lead supporting by taking notes, keeping time, and being available to address any arising needs that may interrupt discussion.
The purpose of the child focus groups was to collect information about desired outcomes of IHBLT programming. Child participants were first shown a short video cartoon created to introduce the study and provide examples of intervention programs aimed at improving healthy lifestyle behaviors. A vignette approach was used so that children could think about healthy lifestyle programs in terms of the children in the cartoon. Children were then asked to brainstorm outcomes they think are important to measure in a healthy lifestyle program by writing these ideas on an easel-sized notepad. Subsequently, the children decided on the importance of each of these outcomes using a traffic light system, where a red sticky note for each written outcome indicated a score of 3 (not important), yellow indicated a score of 2 (somewhat important), and green indicated a score of 1 (very important). The colored sticky notes were placed on the notepad to indicate their level of agreement (red, yellow, green) with the importance of the item and these sticky notes were tallied as scores (3, 2, or 1, respectively). An in-depth description of the focus group design and administration is in review (Altenburg et al., in review). Focus groups were facilitated by two trained moderators.
Survey responses were maintained on the HIPAA-compliant REDCap website. Data downloaded for analysis was stored on a password protected computer. Descriptive statistics were calculated using SPSS version 28.0 [21] to describe proportions in the form of percentages. Data management occurred within the qualitative coding software Dedoose [22], which is a secure password-protected qualitative data analysis platform. Any files containing interview transcripts were stored internally on password-protected Louisiana State University AgCenter and Pennington Biomedical computers. Participant names were not collected during the actual interview process, and any identifying names were removed from the focus group transcripts prior to qualitative analysis. Parent focus group discussions were transcribed verbatim and imported into Dedoose between August and September 2023. Data analysis proceeded in an inductive manner to allow meaning to emerge from participant voices. Structural coding was used to segment transcripts into sections based on relevant research questions. Initial and in-vivo coding was then used to summarize participant responses in their own words. Coding was conducted by three independent coders (co-authors JF, KS, and MG) and discrepancies in coding were resolved through consensus. Interrater reliability (100%) was ensured through the inductive coding process by using codes derived from the research questions. The three independent coders met following independent coding to discuss any discrepancies and ensure consensus on code meanings and application. Finally, codes were grouped into overarching themes to describe major needs and desires of components of IBHLT.
For the child focus groups, content analysis was used, including qualitative concepts, themes, and quotes about specific elements, development, and implementation of a family-focused IHBLT program. The analysis was based on notes taken by the facilitator. The evaluation processes included: (1) generation of key words, phrases, and quotes coded as variable themes agreed upon by at least one other participant in the group; (2) grouping of variables based on unifying concepts and themes; and (3) review of the variable groupings to ensure consistency and relevance of proposed unifying concepts.
Results
A total of 295 parents completed demographic survey information (ages 18–54 y, 38% identified as White, 16% as Native Hawaiian or Pacific Islander, and 15% as Black or African American; 54% as Non-Hispanic/Latino(a)), and n = 206 completed all survey items (Table 1). Online survey responses were removed from the analytic sample if participating parents indicated their child was not in the specified age range, the response was not completed in English, responses indicated they did not reside in or their child did not attend a school in the state where the study occurred, and if there was evidence of duplicate entries (61 excluded for these reasons). Common interests for IHBLT topics (outcome 1a, identify behavioral health outcomes important to parents and children; Behavioral Preference Scale) included learning to self-monitor nutrition and activity (56%), learning how to build good social support (58%), learning how to overcome barriers to a healthy lifestyle (63%), and learning about healthy eating plans for the whole family (62%). When considering potential barriers to participating in a program (outcome 2b, identify barriers to participating in behavioral programming unique to rural communities), many identified a lack of time (47%), while few reported low motivation (20%). Parent attitudes concerning pediatric obesity (outcome 2a: identify relative importance of behavioral health programming), as measured by the Knowledge, Attitudes, and Practices Scale, revealed concern for the impacts of overweight and obesity on children (61%). Some respondents (39%) agreed with the misconception that overweight, and obesity are only health concerns for adults. Respondents generally accepted healthy lifestyle/weight management programming to be potentially beneficial to their family (73%). When responding to the Behavioral Information Preference Scale to inform outcomes 2b and 2c (identify modes of interest for communicating health information, identify formats of interest for programming), parents reported preferring to access health information via social media messaging and videos (90%), mobile apps (89%), and attending classes with other families (89%), among other modalities. Many had interest for programming to occur in a convenient place in the community (64%). To facilitate potential remotely-delivered programming, the majority of parents reported owning one or more electronic device and having access to the internet, with 41% using their smartphone for access. Participants were largely willing to use their devices to communicate with program facilitators (58%; Health Information National Trends Survey). See Supplemental Tables 1–3 for a complete list of survey responses.
Table 1.
Sociodemographics of parent survey respondents
| N = 295 | ||
|---|---|---|
| Demographics | N | % |
| Parent age | ||
| 18–24 | 38 | 13 |
| 25–34 | 88 | 30 |
| 35–44 | 107 | 36 |
| 45–54 | 43 | 15 |
| Did not respond | 19 | 6 |
| Household income | ||
| Less than $10,000 | 5 | 2 |
| $10,000-$29,999 | 27 | 9 |
| $30,000-$49,999 | 61 | 21 |
| $50,000-$69,999 | 65 | 22 |
| $70,000 - $89,999 | 68 | 23 |
| $90,000 - $109,000 | 32 | 11 |
| $110,000 - $139,000 | 23 | 8 |
| $140,000 and above | 10 | 3 |
| Prefer not to say | 4 | 1 |
| Parent gender | ||
| Female | 137 | 46 |
| Male | 147 | 50 |
| Other | 1 | 1 |
| Prefer not to say | 10 | 3 |
| Parent race | ||
| American Indian or Alaskan Native | 24 | 8 |
| Asian | 27 | 9 |
| Black or African American | 45 | 15 |
| Multiracial | 35 | 12 |
| Native Hawaiian or Pacific Islander | 48 | 16 |
| White | 112 | 38 |
| Prefer not to say | 4 | 1 |
| Parent ethnicity | ||
| Hispanic/Latino (a) | 112 | 38 |
| Non-Hispanic/Latino (a) | 158 | 54 |
| Prefer not to say | 25 | 9 |
After the four focus groups, facilitators (research staff) determined that there was thematic saturation at the conclusion of the four parent and three child focus groups to address the study outcomes, thus not warranting additional groups. Parents in the focus groups (N = 33, 93.9% self-reported identifying as female) recognized the value and importance of participating in an IHBLT program (outcome 1a). Their suggestions for IHBLT development included program delivery by a trusted community member with expertise in health services, such as a nurse:
“You were asking about credentials; I’m going to be very honest. I don’t think it really matters. I think the person that heads the program up could be a neighborhood Granny, somebody everybody knows, our parents, everybody trusts, literally. Now, when you want to talk about childhood diabetes absolutely you bring in a nurse from [local hospital] and they will speak. So, you’re going to have different speakers coming in with different criteria and you want to talk about this, you have a person that’s an expert in that area. But as to running it you need local people. Because I’m going to tell you. We don’t trust everybody out here. And your credentials don’t mean that much to us.”
“The only profession I know that is trusted is nurses. Nurses have a higher trust rate than doctors and priests…nurses have always had a stellar reputation for being trustworthy.”
Parents preferred for the program to include information regarding handling picky eaters, cooking demonstrations, meal planning, gardening, and safe, enjoyable, and accessible physical activity opportunities:
“[I would like to hear] How to expand the diet in a healthy way for a child with sensory issues who is going to be focused on chicken nuggets and french fries. One of my students - chicken nuggets, fries, goldfish - that’s it. So how can we expand a healthy diet? Get them to try new things…"
“Well, bringing up the picky eater thing of different ways to cook healthy foods that would be more appetizing towards picky eaters.”
Parents also described barriers (outcome 1b) to participating in an IHBLT, including: lack of transport to spaces where sessions may be held, scheduling difficulties, and time commitment:
A lot of people in here with 2, 3, or 4 kids and some families are larger, you know. So, when you’re trying to carpool, when you’ve got two moms or two dads, grandma here and aunt there and seven children… Yeah, we don’t mind cramming them in, but it’s not legal….
Parents also discussed structural barriers to implementing components of an IHBLT, including lack of financial resources to make healthier eating choices and safe and accessible physical activity opportunities:
"So having them get access to information, I could see it being difficult for them, because also not everybody in my community has a computer at home. Pretty much everyone has a smartphone…so, if these families are on…do they have access to what a good diet is? Can they afford it? Can they afford fresh fruits and vegetables? Probably not. Can they afford to go to a farmers’ market? No. Can they buy whole grains? No. It’s strictly about money. Do they have the information? Maybe they do, maybe they understand. But do they have the funds for that? For healthy foods? And the answer is probably no.”
“[I’d like to hear about] physical activity because that’s another thing. Yes, there is a small gym available here, but they’re just like in my situation I know it’s 24 hours, but as far as like classes like exercise classes, there’s nothing of that nature.”
“They don’t get to go in the park because you’re scared. You’re scared for them to go. You don’t know who’s in the park.”
To overcome these barriers in the adoption and engagement in IHBLT programming, participants considered resources already available to the community. Suggestions included program delivery either at schools or community centers in multiple locations throughout the county:
“I am trying to think of places that people go to regularly. Churches. Quite frankly if I’m sitting at church and the guy starts talking about what I eat- uh, off topic you know - get back onto your topic okay? Do people access libraries? Yes. Everybody? No. But everybody goes to school.”
Additionally, parents provided suggestions like utilizing Council on Aging transportation that is already available or employing school buses to both address transportation needs and to provide economic opportunities for drivers in the community. One participant stated:
“There are Council on Aging transportation vehicles…school buses…maybe that’s a way for our school bus drivers to get supplemental income is they possibly volunteer but be compensated for their time. To run the buses or the people that drive for the Council on Aging and they be reimbursed for the use of their vehicles, but it’d be awesome, I mean even if they just had a generalized pickup area like at the post office.”
Children were 10.5 ± 1.3 y and primarily boys (60%). Children identified several outcomes they desire in an IHBLT program (Table 2; outcome 1a). Outcomes of the greatest importance across all three child focus groups included eating more healthy foods, becoming healthy/strong, becoming more athletic and/or better at sports, having access to a variety of good foods, participating in more sports, and having safe places to play after school and on the weekends.
Table 2.
Aggregated child focus group desired outcomes for rural behavioral health programming
| Desired Outcomes for Improvement and/or Intervention Components | Level of Importance | Importance Indicator1 (Vote Frequency) |
|---|---|---|
| Eating healthy foods | Very important | 1 (8) |
| Being healthy/strong | Very important | 1 (7), 2 (1) |
| Being more athletic | Very important | 1 (6), 2 (2) |
| Being better at sports | Very important | 1 (8) |
| Access to a variety of good foods | Very important | 1 (2) |
| Sports clubs participation | Very important | 1 (2) |
| Obstacle course participation | Very important | 1 (2) |
| Safe places to play after school/weekends | Very important | 1 (2) |
| Participating in more sports | Very important | 1 (6) |
| Riding or racing bikes performance | Somewhat important | 1 (3), 2 (5), 3(1) |
| Learning about health habits | Somewhat important | 1 (5), 2 (3) |
| Active learning | Somewhat important | 1 (1), 2 (1) |
| More cheerleading | Somewhat important | 1 (3), 3 (3) |
| More running | Somewhat important | 1 (3), 2 (2), 3 (1) |
| Cardio and strength training | Somewhat important | 1 (4), 2 (2) |
| More sports in PE | Somewhat important | 1 (2), 2 (2), 3 (2) |
| Going outside more | Somewhat important | 1 (4), 2 (1), 3 (1) |
| Gardening | Somewhat important | 1 (4), 3 (2) |
| Arts and crafts | Somewhat important | 1 (3), 3 (3) |
| Running club or running performance | Somewhat important | 1 (4), 2(6), 2(2) |
| Receiving playground equipment | Somewhat important | 2 (2) |
| Track and field performance | Not important | 3 (6) |
11 (very important), 2 (somewhat important), 3 (not important)
Discussion
Our findings revealed perceived supports and barriers to implementing IHBLT programs within rural communities. Children and parents were interested in participating in programming to improve health and identified programming outcomes that were of value to them. Several solutions were offered for implementing this type of program in ways that would be accessible and relevant to rural communities.
Others have conducted focus groups in rural communities to identify potential barriers and facilitators of childhood obesity treatment [11, 13]. These studies report similar barriers as identified in the current report, including limited resources [13] and a desire for information delivery across multimedia platforms [11], but fail to include the child perspective and are limited in the facilitators identified throughout the parent and extension agent focus groups. The child experience and preferences are critical components to consider when designing a family-based behavioral program as complex family contexts can impede or support a healthy environment [8].
The findings from this study will inform the modification of IHBLT for rural populations. Parent and child perceptions and desired outcomes provided in this mixed methods study will be incorporated into the design and evaluation of an obesity treatment trial. Next steps include partnering with local health care providers and educators to build capacity for IHBLT implementation. A limitation of this study includes the remaining rural and underserved counties that the research team were unable to connect with via providers and community leaders (e.g., participants without Facebook may not have been able to participate). It is possible that the perceptions and opinions of these communities are missing and may represent a population with greater needs based on social determinants of health. Novel approaches to connect and engage with these communities are needed.
Families living in rural areas have a desire for health programming within their communities and are motivated to learn about improving nutritional intake, increasing physical activity, and achieving overall well-being. They desire programming to be led by a trusted local facilitator, cover the topics of importance to the families like self-monitoring nutrition and activity and overcoming picky eating, as well as potentially being delivered digitally to improve accessibility. There are structural barriers unique to rural settings that limit access and engagement that must be considered in the design and implementation of IHBLT programming.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Thank you to the children and parents/caregivers for their involvement and contributions to this work, as well as Sydney Vidrine, for research and community outreach support.
Author contributions
AB: methodology, project administration, supervision, writing- original draft, writing- review and editing, formal analysis; DH: funding acquisition, conceptualization, data curation, resources, investigation, methodology, writing- review and editing; JF: project administration, supervision, writing-review and editing; KS: formal analysis, project administration, writing-review and editing; MG: formal analysis, writing-review and editing; EB: project administration, writing- review and editing; DH: methodology, writing- review and editing; PM: project administration, data curation, writing-review and editing; AS: conceptualization, data curation, resources, investigation, methodology, supervision, writing- original draft, writing- review and editing. All authors reviewed the manuscript.
Funding
This publication was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government. This publication was supported in part by U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Data are located in controlled access data storage at Pennington Biomedical Research Center.
Declarations
Ethics approval and consent to participate
All procedures in this study were approved by the Pennington Biomedical Research Center Institutional Review Board (FWA#00006218) in accordance with the declaration of Helsinki. Informed adult consent, informed consent obtained from the parents or legal guardians of any participating child under the age of 16, and child assent were collected.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Data are located in controlled access data storage at Pennington Biomedical Research Center.