Graduation Date

Summer 8-14-2020

Document Type


Degree Name

Doctor of Philosophy (PhD)


Health Promotion and Disease Prevention Research

First Advisor

Paul Estabrooks

Second Advisor

David Dzewaltowski

Third Advisor

Jennie Hill

Fourth Advisor

Robert Schwab


Rural adults are at heightened risk for obesity, yet evidence‐based interventions lack consistent translation into clinical practice. This multi-phase study addresses this gap. First, a systematic review and meta-analysis of rural adult weight loss interventions were conducted to assess overall impact. Though few studies reported participant representativeness, meta‐analyses revealed a significant weight reduction among interventions. Second, 10 focus groups were conducted with primary care (PC) staff to determine the feasibility of implementing a weight-management program through PC. Differences in responses among rural, micropolitan, and metropolitan was also assessed. Thematic analyses revealed rural PC currently lacks the capacity to manage patient weight at a population level. A program to which physicians could refer patients was preferred. These results informed the selection of a digitally-delivered, evidence-based weight loss program to implement through PC while concurrently examining different physician referral and engagement processes for improving program reach. Five PC physicians were randomly assigned a sequence of 4 referral strategies: point of care referral (POC) with/without active telephone follow-up (ATF); electronic health record registry-derived letter with/without ATF. Of 996 potential referrals, 571 were made over 16 weeks; 97 patients enrolled in the program (55% female). Patients receiving ATF were more likely to be screened (49%vs7%; pppF(3,51)=1.93, p=.14) or between participants that did and did not receive ATF (F(1,53)=1.52, p=.22). Cost per participant was $372. Letter referral with ATF appears to be best for enrolling a larger number of patients in a weight-management program, but resource costs may make POC with ATF more attractive to rural clinics.