Group versus individual phone-based obesity treatment for rural women

Abstract

Rural women have among the highest rates of obesity and sedentary lifestyle, yet few studies have examined strategies for delivering state-of-the-art obesity treatment to hard-to-reach rural areas. The purpose of this pilot trial was to examine the impact and cost-effectiveness of a 6-month behavioral weight loss program delivered to rural women by phone either one-on-one with a counselor or to a group via conference call. Thirty-four rural women (mean BMI = 34.4, SD = 4.6) were randomized to group phone-based treatment or individual phone-based treatment. Completers analysis showed that weight loss was greater in the group condition (mean = 14.9 kg = , SD = 4.4) compared to the individual condition (mean = 9.5 kg, SD = 5.2; p = .03). Among the total sample, 62% of participants in the group condition achieved the 10% weight loss goal compared to 50% in the individual condition, and group treatment was found to be more cost-effective. Future research is warranted to examine the benefits of group phone-based treatment for long-term management of obesity among rural populations.

Introduction

Rural populations suffer from health disparities as evidenced by higher premature mortality rates, poorer access to healthcare, and poorer lifestyle behaviors, including higher rates of obesity and physical inactivity compared with their non-rural counterparts (Eberhardt and Pamuk, 2004, National Center for Health Statistics, 2001). In addition, rural women in particular suffer from higher rates of stress and depressive symptoms (Hauenstein & Boyd, 1994) which are established risk factors for weight regain (Byrne, 2002, Elfhag and Rossner, 2005). As a result, women of the most rural counties have the highest prevalence of obesity, with rates 1.6 times greater than suburban women (Sobal, Troiano, & Frongillo, 1996).

State-of-the-art behavioral obesity interventions are limited in rural areas. On-site obesity programs have been delivered in rural primary care clinics (Ely et al., 2008) schools (Davis, James, Curtis, Felts, & Daley, 2008), and Cooperative Extension Offices (regional offices affiliated with land-grant universities with the mission to “extend” their resources through non-credit programs; Janicke et al., 2008, Perri et al., 2008). However, these in-person treatment delivery approaches present a barrier for many rural residents who may have long transportation distances to clinic sites, especially in frontier areas, and where availability of trained health counselors may be limited. In response to a need for alternatives to face-to-face meetings, web- and telephone-based weight control interventions have been examined. Of these, phone-based treatment appears to have the greatest reach for rural populations of whom only 53% have home internet access, the majority of which is dial-up connection with variable download time (Pew Internet and American Life Project, 2006).

Phone-based interventions are typically delivered one-on-one between a patient and provider. Group phone-based treatment is an alternative approach that holds great promise because it capitalizes on the same mechanisms of face-to-face group treatment by allowing participants to interact with each other in real time while still providing the reduced participant and provider burden with the phone treatment modality. The benefits of group treatment have been written about extensively in the psychotherapy literature and include factors such as interpersonal learning, imparting information to others, and developing optimism and hope for change (Yalom, 1995). In behavioral obesity treatment, aspects of group counseling such as support, accountability to one another, and group problem-solving are believed to be important for sustaining difficult lifestyle changes (Donnelly et al., 2007, Perri et al., 2001). Renjilian et al. found that obese women randomized to face-to-face group treatment lost significantly greater weight than those randomized to face-to-face individual treatment, regardless of their expressed preference for individual or group counseling (Renjilian et al., 2001). However, it is unknown whether or not group treatment is more effective than individual treatment when delivered by phone. Treatment processes such as the counseling relationship and effective problem-solving may differ when interaction is limited to phone contact.

The purpose of this pilot study was to examine the effects of a behavioral weight loss program delivered to rural women in two formats: individual phone counseling and group phone counseling. It was hypothesized that group treatment would result in greater weight loss and improvements in diet and physical activity behaviors compared to individual treatment. We also explored psychosocial treatment process variables that may influence the effectiveness of group and individual phone-based treatment (i.e., development of problem-solving skills, working relationship between counselor and participant, and match or mismatch with participants' stated baseline preference for individual or group treatment) as well as the cost-effectiveness of the two approaches.