Pediatric Obesity Management in Rural Clinics in California and the Role of Telehealth in Distance Education

The prevalence of obesity has doubled among children aged 2 to 5 years, and it has tripled among children aged 6-11 years, over the past 30 years.1 Obesity is now considered a public health “epidemic” in the United States affecting 17% of children, with an additional 15% of children qualifying as overweight.2 Childhood obesity has been identified as a risk factor for the development of multiple health problems, including type 2 diabetes, hypertension, hypercholesterolemia, obstructive sleep apnea, anxiety, depression,3-8 and adult obesity and its complications.9,10 Childhood obesity is a particularly challenging problem in rural areas. Parents of obese rural children report that lack of local weight loss resources, lack of exercise facilities, and lack of access to healthy foods are barriers to weight loss.11 Rural residents have lower access to pediatric and specialty care, greater travel time to health care providers, less availability of health insurance, lower likelihood of exercising, and higher rates of obesity, heart disease and diabetes compared to their urban counterparts.12-15 Since approximately 90% of children have a source of ongoing health care, clinicians have recurring opportunities to contribute to the management of pediatric obesity.12,13 However, unique challenges faced by rural clinicians include professional isolation, reduced access to medical information and continuing education, and limited communication with sub-specialists and ancillary support services.16,17 Telehealth is defined as the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and health care professional education, and public health.18 Telehealth has been successfully used in dermatology, psychiatry, pulmonary medicine, obesity, and cardiology,19-23 and it has reduced the cost of health care and time related to travel.24-26 Few studies have assessed rural health care providers’ challenges related to pediatric obesity and their interest in telehealth applications to address these challenges. Our goals were to determine: (1) self-efficacy and perceived effectiveness of health care providers in rural California in managing child and adolescent obesity; (2) perceived barriers in the treatment of overweight rural children and adolescents; (3) clinical resources that may enhance the effectiveness of obesity management in rural areas, and (4) potential strategies to improve obesity management and rural health care provider training through telehealth. In addition, we assessed whether there were differences in attitudes, barriers, and need for clinical resources based on professional group, years of practice and duration of practice in rural settings. The Chronic Care Model offers a framework to identify factors influencing the management of pediatric obesity and guided the design of the questionnaire used in our study.27 The Model has been used to improve the quality of disease management for other chronic illnesses in a variety of settings and populations. The 6 key areas identified within the Chronic Care Model are (1) self-management support, (2) decision support, (3) delivery system design, (4) clinical information system, (5) organization of the health care system, and (6) community resources.