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Introduction: The Republic of the Marshall Islands (RMI) is an independent nation and a member of the United States (US) Affiliated Pacific Islands through a Compact of Free Association. Health disparities in the RMI are striking, with high rates of type 2 diabetes mellitus (T2DM). The International Diabetes Federation has documented age-adjusted prevalence of T2DM at 23.0 %, compared to the US (13.2 %) and globally (9.8 %). T2DM has a devastating impact on patients and their families., Methods: The purpose of this article is to present the study protocol for the fully powered two-arm cluster randomized controlled trial using a wait-list control to evaluate the effectiveness of a Family Diabetes Self-Management Education and Support (Family DSMES) program when delivered in a group setting by community health workers (CHWs) in faith-based organizations (FBOs) in the RMI. The study used a community engaged approach, and the study protocol includes adaptations based on the results of our one-arm pilot study., Summary: This study will provide new and innovative information on the effectiveness of Family DSMES delivered in a group setting by CHWs in FBOs in the RMI. The knowledge gained from this research will inform DSMES interventions conducted with Marshallese and other Pacific Islander communities, as well as DSMES interventions conducted in other low-resource countries., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Rural populations experience a higher prevalence of both food insecurity and type 2 diabetes mellitus (T2DM) than metropolitan populations and face many challenges in accessing resources essential to optimal T2DM self-management. This study aims to address these challenges by delivering a T2DM-appropriate food box and recipes directly to rural participants' homes., Methods: This is a comparative effectiveness randomized controlled trial including 400 English- or Spanish-speaking rural adult participants with T2DM (HbA1c ≥6.5%) experiencing food insecurity. Participants are randomly assigned to a 3-month Healthy Food Delivery Intervention (HFDI) plus one 60-min virtual consultation with a diabetes educator or consultation only. The HFDI includes a weekly food box delivery with recipes. Data are collected at pre-intervention, 3-months (post-intervention), 9-months, and 15-months. The primary outcome is change in HbA1c, with secondary measures including diet quality (Healthy Eating Index-2015, calculated from one 24-h dietary recall at each data collection time point), cardio-metabolic risk factors (i.e., blood pressure, lipids, body mass index, glucose), and patient-centered outcomes (e.g., T2DM self-efficacy, T2DM-related distress). Process evaluation data (e.g., successful food box deliveries, diabetes educator consultation attendance, intervention satisfaction) are collected during and post-intervention (3-months). A cost-effectiveness analysis based on traditional cost per quality-adjusted life year gain thresholds will be conducted to estimate the incremental cost-effectiveness between HFDI plus consultation and consultation alone., Conclusion: Findings from this study will provide evidence regarding the effectiveness of an intervention that promotes participant adherence and improves access to healthy food., Clinical Trial Registration: NCT04876053., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Physical activity can delay functional decline in people with type 2 diabetes (T2D), but these associations have not been studied within a sample of Native Hawaiian or Pacific Islander adults with T2D. Using data from a randomized control trial in which 218 Marshallese adults with T2D participated in a 10-week diabetes self-management education intervention, this study tested our hypothesis that physical activity would predict physical function when controlling for time and other variables. Levels of physical activity were positively associated with levels of physical function, even after controlling for time and other covariates. These findings provide a more robust understanding of the relationship between physical activity and physical function in a sample of minority adults with T2D. Future studies should further explore levels of physical activity needed to maintain and improve physical function so that culturally appropriate physical activity interventions can be developed., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: The aim of this study is to assess and document engagement in type 2 diabetes mellitus (T2DM) self-care behaviors and self-reported diabetes knowledge among Marshallese adults living in the Republic of the Marshall Islands (RMI)., Methods: The study uses data from a T2DM health screening study completed in the RMI; survey and biometric data were captured as part of the health screenings. Study objectives were examined using descriptive statistics to describe the characteristics of the participants, their diabetes self-care behaviors, and their levels of self-reported diabetes knowledge., Results: Results indicate many Marshallese diagnosed with T2DM did not engage in adequate self-care behaviors, including blood sugar checks and foot examinations. Participants reported having forgone needed medical care and medication due to issues with cost and/or access, and participants reported low levels of diabetes knowledge., Conclusions: The results demonstrate the need for further work in improving engagement in diabetes self-care by Marshallese living in the RMI. Increased engagement in self-care and diabetes education programs may help Marshallese with T2DM to improve control of their glucose and avoid long-term health complications, as well as reduce costs to the healthcare system., Competing Interests: Declaration of Competing Interest The authors declared no competing interests., (Copyright © 2023 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Introduction: Diabetes self-management education and support (DSMES) is effective for reducing health complications among people with type 2 diabetes (PWD). However, standard DSMES interventions have not been effective for Marshallese Pacific Islanders., Methods: A culturally adapted Family-DSMES intervention for Marshallese PWD was implemented in churches in Hawaii and Washington state and delivered by Marshal-lese community health workers. We assessed changes in hemoglobin A1c (HbA1c), body mass index (BMI), and blood pressure from pre-to post-intervention (12 weeks)., Results: One hundred eighty-five (185) participants-99 PWD and 86 family members-completed classes and had valid pre-and post-intervention HbA1c data. For PWD, there were significant decreases in HbA1c (-0.69%; p=.0000) and BMI (-0.38; p=.008)., Discussion: The clinically and statistically significant reduction in HbA1c among PWD adds evidence for the effectiveness of family models of DSMES. Results will be used to inform future interventions and research studies with Marshallese and other Pacific Islander communities.

Introduction: Striking health disparities exist in the Republic of the Marshall Islands (RMI). The RMI has one of the highest age-adjusted type 2 diabetes mellitus (T2DM) rates in the world (23.0%) compared to global (9.3%) and United States (US; 13.3%) rates. We conducted health screenings including clinical indicators of T2DM and hypertension among Marshallese in the RMI., Methods: Screenings were conducted at 20 churches on Majuro Atoll. Participants completed questionnaires and biometric data collection assessing glycated hemoglobin (HbA1c), blood pressure, and body mass index., Results: Screenings included 528 participants and showed a high prevalence of T2DM, obesity, and hypertension. One-third of participants were referred to the non-communicable disease clinic. The percent of adults in this study with T2DM-indicative HbA1c (48.5%) is higher than observed at the national level (23.0%)., Discussion: Results highlight the need for non-communicable disease-related programs in the RMI., Competing Interests: PM-K was employed by Iakwe Home Health LLC. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Andersen, Rowland, O'Connor, Bing, Riklon, Mendoza-Kabua and McElfish.)

This study compared the effectiveness of two Diabetes Prevention Program (DPP) interventions on weight loss among overweight and obese Marshallese adults. The study was a two-arm cluster randomized controlled trial conducted in 30 churches in Arkansas and Oklahoma. Marshallese adults with a body mass index ≥25 kg/m 2 were eligible for the study. The study sample included 380 participants. Participants received either a faith-based adaptation of the DPP or a family-focused adaptation of the DPP, each delivered over 24 weeks. The primary outcome was weight change from baseline. Secondary outcomes included changes in Hemoglobin A 1c , blood pressure, dietary intake, family support for healthy behaviors, and physical activity. Outcomes were examined longitudinally using general linear mixed effects regression models, adjusting for baseline outcomes, sociodemographic covariates, and clustering of participants within churches. Reductions in weight were small for both groups. Overall, only 7.1% of all participants lost 5% or more of their baseline body weight. There were no significant differences in weight loss between the 2 arms at 6 months ( P  = .3599) or at 12 months ( P  = .3207). Significant differences in systolic and diastolic blood pressure were found between the 2 arms at 6 months ( P  = .0293; P  = .0068, respectively). Significant within-arm changes were found for sugar-sweetened beverage consumption and family support for both arms at both follow-ups. Both interventions achieved a modest weight loss. While even modest weight loss can be clinically significant, future research is needed to identify chronic disease prevention interventions that can successfully reduce weight for this at-risk population.

There is a high prevalence of type 2 diabetes mellitus (T2DM) among the Marshallese in the Republic of the Marshall Islands (RMI). However, no prior literature has examined self-reported health indicators, self-management activities, barriers to care, diabetes knowledge, and family support for diabetes management. This study examined health indicators among participants with T2DM (n=41). Clinical measures included glycated hemoglobin (HbA1c) and fasting glucose level, blood pressure, pulse pressure, and cholesterol levels. Survey items included participants' self-reported health indicators, self-management activities, barriers to care, diabetes knowledge, and family support for diabetes management. Clinical health indicators demonstrate the poor health status of the participants, including uncontrolled fasting glucose levels and HbA1c levels (61.9% had an HbA1c ≥9.0%), high blood pressure, elevated pulse pressure (65.9% had pulse pressure >40 mmHg), and high total cholesterol. Participants report limited knowledge and participation in diabetes self-management behaviors, limited family support, and faced numerous barriers to medical care, medications, and supplies. This study provides insight into the T2DM disparities experienced by Marshallese in the RMI. This study is the first to document the self-reported health indicators, self-management activities, barriers to care, diabetes knowledge, and family support for diabetes management. The results highlight the need for T2DM management interventions and will be used to refine a culturally adapted intervention for delivery in the RMI., (©Copyright 2021 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Objective: To document sleep duration and sleep quality among a sample of Marshallese adults and to examine if sleep duration and quality are associated with type 2 diabetes, body mass index (BMI), and self-reported health in the Marshallese population., Design: Cross-sectional analysis of a staff-administered survey., Setting: Thirty Marshallese churches in Arkansas and Oklahoma., Participants: The study includes 378 Marshallese participants, 56.6% female, with a mean age of 42.4 years (±11.6). Recruitment was limited to participants who were considered overweight, with a BMI >25 kg/m 2 ., Measures: Staff-administered surveys were used to collect data on sleep duration, sleep quality, and self-reported health. Clinical measures were collected by trained research personnel using standard tools and protocols. Kruskal-Wallis tests, Spearman's correlations, and nonparametric tests of trends were used to evaluate differences in HbA1c, BMIc, and self-reported health by sleep duration and quality. Multivariable analyses were used to test the associations, controlling for sociodemographic factors., Results: Fifty-four percent of the participants reported something other than normal sleep duration and 52.4% reported at least 1 night of difficult or interrupted sleep in the previous 2-week period. Longer sleep duration was associated with lower HbA1c and poorer sleep quality was associated with higher HbA1c. Poor sleep quality was associated with lower self-reported health. However, neither sleep duration nor quality was associated with BMI. The associations were found independent of sociodemographic factors., Conclusion: This is the first study to document sleep duration and sleep quality, as well as the first study to examine the relationship between sleep and HbA1c, BMI, and self-reported health in Marshallese adults with a BMI >25 kg/m 2 . This research will be used to help develop sleep interventions to address type 2 diabetes health disparities in the Marshallese community., (Copyright © 2021. Published by Elsevier Inc.)

Hypertension and type 2 diabetes (T2D) are major public health issues that disproportionately affect minority communities, including Native Hawaiians and Pacific Islanders (NHPI). Minority communities are also more likely to have undiagnosed hypertension and T2D. Marshallese Pacific Islanders have been shown to have high proportions of diagnosed and undiagnosed hypertension and T2D. Using survey and biometric data collected from 378 overweight/obese Marshallese Pacific Islander adults, this study documents the prevalence of hypertension and T2D, as well as the prevalence of undiagnosed hypertension and T2D. The study also examines associations between undiagnosed hypertension and undiagnosed T2D and age group, sex, health care access (defined by foregone care due to cost and health insurance status), and body mass index (BMI). Among participants with blood pressure readings indicative of hypertension, 68.4% were undiagnosed, and among participants with HbA1c indicative of T2D, 31.6% were undiagnosed. A quarter of participants (24.5%) had blood pressure and HbA1c measures indicative of both undiagnosed hypertension and undiagnosed T2D. Undiagnosed hypertension was significantly associated with age group ( p's <0.0001) and sex ( p =0.028). Undiagnosed T2D was significantly associated with age group ( p's <0.05), forgone care due to cost ( p =0.018), health insurance status ( p =0.035), and BMI ( p =0.001). Participants in this study had high proportions of undiagnosed hypertension and undiagnosed T2D. These findings will be immediately useful for those working to address hypertension and T2D disparities among Marshallese and other NHPI populations., (Copyright ©2021, Yale Journal of Biology and Medicine.)

Aims: A randomized control trial (RCT) of diabetes self-management education (DSME), undertaken by a community-based participatory research (CBPR) partnership between the University of Arkansas for Medical Sciences (UAMS) and the Marshallese community in Arkansas. The RCT examined the effect of hours of intervention exposure, with the hypothesis that increased exposure is one reason the Adapted-Family DSME was found to be more effective than the Standard DSME., Methods: Some 221 Marshallese with type 2 diabetes were randomized to an Adapted-Family DSME group (in-home setting) (n = 110) or a Standard DMSE group (community setting) (n = 111). The Adapted-Family DSME included 10 h of education that covered the core self-care elements recommended by the American Diabetes Association (ADA) and American Association of Diabetes Educators' (AADE) recommendations. The Standard DSME included 10 h of intervention with all ADA and AADE core elements., Results: The number of hours of intervention exposure in the Adapted-Family DSME arm (mean = 8.0; median = 10.0) was significantly higher than the number of hours of intervention received in the Standard DSME arm (mean = 1.5; median = 0.0). As hypothesized, higher exposure was associated with a significant reduction in HbA 1c in a model including only study arm and exposure (P = 0.01), and in a model including study arm, exposure, and all demographic variables (P = 0.046)., Conclusions: This finding is consistent with previous reviews that showed increased exposure to DSME produced improved glycaemic control and ≥ 10 h of DSME produces clinically meaningful reductions in HbA 1c ., (© 2019 Diabetes UK.)

The purpose of this study was to (a) describe the development of a culturally appropriate glucose monitoring video using a community-based participatory research approach and (b) assess the cultural appropriateness and effectiveness of the video. The topic of the video-using a glucometer and the importance of performing blood glucose checks-was chosen by Marshallese community stakeholders. The video was produced in Marshallese with English subtitles and disseminated through YouTube. Participants were recruited from August 16, 2016 to September 12, 2016 in a diabetes clinic that serves Marshallese patients in northwest Arkansas. Fifty participants completed a survey at pre- and postintervention, with questions capturing demographic information and questions on glucose monitoring self-efficacy using an adapted version of the Stanford Patient Education Research Center's Diabetes Self-Efficacy Scale. Twenty of those participants who completed the survey also completed semistructured interviews that assessed cultural appropriateness and effectiveness of the video. Participants reported significant increases in self-efficacy related to glucometer use and the importance of performing blood glucose checks ( p  < .001) and a 1.45% reduction in A1C between preintervention and 12 weeks postintervention ( p  = .006). Qualitative results indicated the video was both culturally appropriate and effective. The findings of this study were consistent with evidence in the literature, which shows health education videos can be effective at improving health behaviors. Using a community-based participatory research approach to prioritize video topics, and including members of the community in the creation and dissemination of the videos, could aid in ensuring the videos are effective and culturally appropriate.

Objective: Marshallese adults experience high rates of type 2 diabetes. Previous diabetes self-management education (DSME) interventions among Marshallese were unsuccessful. This study compared the extent to which two DSME interventions improved glycemic control, measured on the basis of change in glycated hemoglobin (HbA 1c )., Research Design and Methods: A two-arm randomized controlled trial compared a standard-model DSME (standard DSME) with a culturally adapted family-model DSME (adapted DSME). Marshallese adults with type 2 diabetes ( n = 221) received either standard DSME in a community setting ( n = 111) or adapted DSME in a home setting ( n = 110). Outcome measures were assessed at baseline, immediately after the intervention, and at 6 and 12 months after the intervention and were examined with adjusted linear mixed-effects regression models., Results: Participants in the adapted DSME arm showed significantly greater declines in mean HbA 1c immediately (-0.61% [95% CI -1.19, -0.03]; P = 0.038) and 12 months (-0.77% [95% CI -1.38, -0.17]; P = 0.013) after the intervention than those in the standard DSME arm. Within the adapted DSME arm, participants had significant reductions in mean HbA 1c from baseline to immediately after the intervention (-1.18% [95% CI -1.55, -0.81]), to 6 months (-0.67% [95% CI -1.06, -0.28]), and to 12 months (-0.87% [95% CI -1.28, -0.46]) ( P < 0.001 for all). Participants in the standard DSME arm had significant reductions in mean HbA 1c from baseline to immediately after the intervention (-0.55% [95% CI -0.93, -0.17]; P = 0.005)., Conclusions: Participants receiving the adapted DSME showed significantly greater reductions in mean HbA 1c immediately after and 12 months after the intervention than the reductions among those receiving standard DSME. This study adds to the body of research that shows the potential effectiveness of culturally adapted DSME that includes participants' family members., (© 2019 by the American Diabetes Association.)

Marshallese experience high rates of type 2 diabetes. Proper management of diabetes requires multiple self-care behaviors, yet little is known about Marshallese's diabetes-related self-care behaviors. Survey data from 111 Marshallese adults with diabetes were used to examine relationships between self-care behaviors and socio-demographic characteristics. The most common self-care behavior was attending annual doctor visits, while the least common was maintaining a normal weight. Age group, education level, and having a regular doctor were significantly associated with engaging in self-care behaviors. Having a regular doctor had the most effect on performing self-care behaviors (p = 0.006); although, only 38.7% reported having a regular doctor. To minimize diabetes-related complications, efforts to improve self-care behaviors among the Marshallese should be developed. Alternatives to traditional healthcare providers, such as community health workers, may be a viable strategy with this population given only one-third reported having a regular doctor.

Objective: We sought to improve understanding of diabetes-related health beliefs and physical activity behaviors of Marshallese adults with and without type 2 diabetes (T2D)., Methods: We used tests of comparison and regression analyses to examine data from 376 Marshallese adults collected at church-based events., Results: One in 5 (20.2%) respondents had received a T2D diagnosis. About one-fourth of the respondents fell into one of 4 physical activity levels: zero times per week (28.7%), one time per week (19.4%), 2-3 times per week (24.7%) and ≥4 times per week (26.9%). Using logistic regression, we found T2D diagnosis status was not statistically associated with level of physical activity. However, having time to be physically active was significantly associated with being physically active ≥4 times per week. Being obese, having less than a high school education, not having time, and not having a comfortable place to exercise were significantly associated with never being physically active., Conclusions: These findings help fill gaps in Pacific Islander health literature and will inform public health interventions to improve rates of physical activity among the Marshallese and other Pacific Islander communities.