Family Model of Diabetes Self-Management Education in the Marshallese Community

Background and Rationale

The Marshallese population suffers from a significant and disproportionate burden of type 2
diabetes. The rate of type 2 diabetes among the Marshallese is one of the highest of any
population group in the world—at least 400% higher than the general US population.1-7 Our
systematic review of local, national, and international data found estimates of diabetes in
the Marshallese (populations living both in the US and Marshall Islands) ranging from 30% to
50% compared to 8.3% for the US population and 4% worldwide.4-7 Causes for this disparity
have not been completely unraveled and are partially embedded in the history of the Marshall
Islands. Between 1946 and 1958, the US military tested nuclear weapons on several of the
Marshall Islands. People who inhabited the bombed islands and atolls were relocated, but
Marshallese living on nearby atolls that were not evacuated experienced nuclear fallout
during and after nuclear tests. Because of the nuclear testing, the Atomic Energy Commission
lists the Marshall Islands as one of the most contaminated places in the world, and several
studies demonstrate ongoing health effects from the nuclear testing.8 The nuclear
contamination resulted in significant and long-term changes in diet and lifestyle of the
Marshallese.9-12 These changes in diet and lifestyle have contributed to an increased rate of
type 2 diabetes.2-5,16-19 The Compact of Free Association between the Republic of the
Marshall Islands (RMI) and the US, signed in 1986, permits the US to conduct military
activities in the Marshall Islands and also allows Marshallese individuals to come to the US
without a visa. The Marshallese population living in the US tripled between 2000 and 2010,
with Arkansas having the largest population of Marshallese living outside of the RMI.

Diabetes self-management education (DSME) is an evidence-based model that has been shown to
improve glycemic control, reduce diabetic complications, and reduce the cost of managing
diabetes. Traditional implementation approaches of DSME have not been effective in
Marshallese populations, indicating that a unique approach tailored to this population is
needed.2-3 Because of the disproportionate burden of diabetes and related complications
experienced by this high-risk population, a novel adaptation of the evidence-based DSME model
and subsequent testing in a community-based setting are needed.

Using a Community Based Participatory Research (CBPR) approach, we have conducted four focus
groups and individual interviews with the Marshallese community to better understand how to
best address the well-established need for diabetes education. Through interviews and focus
groups, Marshallese participants pointed out that the delivery method and the concept of
self-management as an individual experience are problematic components. DSME was designed
with a very Western societal approach, which is highly individualistic. The Marshallese have
a highly collectivist culture and the idea of ―self‖ management is counter to their cultural
values. As stakeholders described, ―we eat together from one pot. For one person to refuse
the food from that one pot is not just inconvenient, it is shameful. It shames the person and
the person's family. It is not an acceptable option. We will not do it. The interviewees
stated that any changes must be a family change. Incorporating collectivist and family
concepts into the delivery mechanism is imperative. Through the interviews and focus groups,
the Marshallese community suggested that DSME be implemented within a family model with a
family group receiving DSME so that the entire family can benefit and the patient can be
supported in their effort to make lifestyle changes. Because ~30-50% of the Marshallese
community have type 2 diabetes, this approach could be even more beneficial.

Hypothesis and/or Specific Aims or Objectives

We hypothesize that a culturally adapted DSME implemented in a family model will result in
better diabetes management outcomes compared to traditional DSME for the Marshallese.

In the family delivery model, a participant is encouraged to invite his/her family members to
the diabetes educational sessions. As outlined by stakeholders, the model has several
potential benefits. First, patients are empowered to invite the people they define as family
and as appropriate for taking part in the sessions with them. Second, the education will
engage the patient-defined support unit. Third, given the high-rate of diabetes within the
community, it is highly probable that others within the group will have Type 2 diabetes or
pre-diabetes and may benefit from the intervention as well.

Our aim is to test a Family Model of DSME using a mixed-methods approach. Marshallese
participants with type 2 diabetes will be recruited. Those who are assigned to the family
model will be asked to invite one to ten adult members of their families to participate in
the DSME. Given that ~30-50% of adults in the Marshallese community have type 2 diabetes, and
the Marshallese typically have large families, recruitment for this nontraditional model is
plausible. Furthermore, the method was designed from input from our CBPR partnership with the
Marshallese.

This research is highly translational. It will help bridge the gap between knowledge of an
effective DSME intervention and actual implementation of the intervention among a Pacific
Islander population with especially high rates of type 2 diabetes and significant health
disparities.

Inclusion Criteria:

Primary Participant:

- Must be 18 years or older

- Self-reported Diabetes Mellitus Type 2 diagnosis by a health care provider

- Self-reported Marshallese ethnicity or descent

Secondary (Family) Participant:

- Must be 18 years or older

Exclusion Criteria:

- Younger than 18