Kileti Mejbon came to the United States seeking a better life for his children. Now, they are taking care of him. The 63 year old, who hails from the Marshall Islands, retired from his job in Northwest Arkansas because of symptoms from type 2 diabetes. Doctors diagnosed him with the disease in 2010.
Before that time, he had never heard of diabetes nor did he know the symptoms. But he learned that the tingling he sometimes felt in his hands and feet was a symptom of diabetes.
So, when University of Arkansas for Medical Sciences offered type 2 diabetes education programs as part of a PCORI-funded study on improving the condition in the Marshallese community, he eagerly became a participant.
“Before the classes, when I tried walking around my house, my body was shaking, and I didn’t feel comfortable. But now, by following all the exercise and eating all the food I learned that I need to have every day, I feel better,” Mejbon said via his interpreter.
The study he participated in compared the effectiveness of a culturally adapted family-model diabetes self-management education (DSME) intervention to standard DSME in improving blood sugar control, measured by the change in hemoglobin A1c (HbA1c)—a person’s average blood sugar level over the past three months. HbA1c is commonly used in diagnosing and monitoring diabetes.
In the May 2019 issue of Diabetes Care, the research team reported that compared to standard DSME, participants in the culturally adapted family-model DSME showed significantly greater reductions in HbA1c immediately after the program and one year later.
A Growing Health Disparity
Type 2 diabetes has become a well-known part of daily life for the Marshallese community.
In Northwest Arkansas—home to the second-largest Marshallese population in the continental United States—health screenings found 38.4 percent of Marshallese people had HbA1c levels indicating diabetes. Of the 401 community members participating in one screening event, 32.6 percent had levels on par with prediabetes.
By comparison, in the state of Arkansas, about 11 percent of adults have diabetes.
Many people like Mejbon moved to the United States as part of the Compact of Free Association—an agreement allowing Marshallese people to legally live, travel, or study here on a passport and the US military to conduct activities in the Republic of the Marshall Islands.
|Culturally Adapted Training on Type 2 Diabetes Management
The research team at the University of Arkansas created culturally sensitive educational materials for use in their study. These types of materials incorporate knowledge of patients’ backgrounds, cultures, ethnicities, and belief systems to increase their understanding of health topics. Below are two examples of allegories that the team used in its study.
|Drawn from the Family-Centered Diabetes Self-Management Education Curriculum, University of Arkansas for Medical Sciences. Staff animation by Rob Treadway.|
From 1946 to 1958, the US military tested nuclear weapons in the Republic of the Marshall Islands, detonating the equivalent of 7,200 Hiroshima-sized bombs. The tests contaminated local food sources—predominantly fish and plants—that the Marshallese relied upon, according to the book, Bravo for the Marshallese: Regaining Control in a Post-Nuclear, Post-Colonial World.
As a result, most food became imported, and the Marshallese adopted an unhealthy diet of convenience foods, high in fat and simple carbohydrates.
The change in lifestyle has come with soaring rates of type 2 diabetes among other health disparities that originated from the Marshallese people’s experience with earlier radiation exposure.
“The historical trauma that happened with nuclear testing created lots of distrust in research and perpetuated health disparities,” said Pearl McElfish, PhD, MBA, co-lead on the PCORI-funded study. “It made our use of a more participatory method of research not just a good method but really an essential method.”
The translatability of our work was incredibly important to us. We wanted to test things that didn’t just advance knowledge, but really advanced practice.Pearl McElfish, PhD, MBA Co-lead, PCORI-funded study
Letting the Community Lead
Diabetes Education Programs Studied
Culturally Adapted Family-Model DSME
- Delivered in patients’ homes by community health workers speaking Marshallese with support from a certified diabetes educator
- Eight weekly 75-minute sessions
- Family members participated
- Delivered at nearby community centers by a certified diabetes educator with assistance from a bilingual interpreter
- Six weekly 100-minute sessions
- Patients were in groups and the program did not include family members
In fact, McElfish, her co-lead Peter Kohler, MD, and their team took their primary cue for the study’s focus from the Marshallese community’s participation in previous needs assessments. In them, the group identified diabetes as their major health concern.
The community continued to drive the study in many ways, including the research team’s hiring of many Marshallese staff members.
Their presence built trust between the community and researchers. Also, the community’s knowledge was key in creating a diabetes education program tailored to Marshallese culture, including the use of personal stories, references to religion, and commonly used analogies.
Researchers randomly assigned 221 Marshallese adults with type 2 diabetes living in Arkansas to either the culturally adapted diabetes education program or the standard one. They compared the programs’ effectiveness in terms of patients’ blood sugar and cholesterol levels; body mass index, which measures body fat based on height and weight; and diabetes self-care, such as checking blood sugar levels.
“We wanted to design a study that used measures that were as close to those that would typically be implemented. The translatability of our work was incredibly important to us,” McElfish said. “We wanted to test things that didn’t just advance knowledge, but really advanced practice.”
In addition to the degree of community engagement, the study was unique in its inclusion of family members.
“Even though they now live in this country, most of the Marshallese eat together as a family, and eat whatever is fixed for them,” said Kohler, who is an endocrinologist by training.“ I think the logic of including the food preparers of the household in the education program and having people on our staff who are Marshallese themselves describe it to them, provides a more effective way to transmit the information.”
Mejbon agrees. For him and his six family members who participated, the lessons they learned continue to benefit him.
This included lessons on how to maintain a healthy diet and to buy food and prepare meals. Also, Mejbon still exercises 30 minutes daily, after learning how important daily exercise is for our lives.
“As a father, I didn’t really know about being a diabetic. I wanted my other family members, especially my children to join, so they can protect themselves from getting diabetes and they can help their kids and grandkids in the future,” Mejbon said.
A Mark of Success
At its conclusion, the study published its findings in a peer-reviewed journal for health practitioners, documenting its successful implementation of DSME in Marshallese individuals, the first of its kind.
Compared to patients in the standard DSME, researchers found that patients who participated in the culturally adapted family-model DSME showed significantly greater reductions in HbA1c and were more likely to check their blood glucose levels regularly a year later.
However, the programs didn’t differ in terms of patients’ body mass index, total cholesterol, or other diabetes self-care behaviors after one year.
“As someone who primarily does policy systems and environmental research, I think part of our study’s success is the result of us helping change the family environment,” McElfish said. “You’re not just teaching the patient, but you’re teaching the person who’s preparing the food and who’s doing the grocery shopping.”
Expanding Their Reach
View Senate Resolution 9: Arkansas State Senate Commends Research Team, University of Arkansas
While spreading the word through journal articles and presentations is important, that’s just the beginning of dissemination, she added.
After the study, the team provided participants with infographics containing the study’s results and their personalized results. They also host biannual town hall meetings where they provide study updates to the Marshallese community.
McElfish, Kohler, and their team are also working to share the study’s results with other large Marshallese populations in the United States and to reach diabetes educators.
In 2017, the Arkansas State Senate commended the team and the University of Arkansas for Medical Sciences for addressing healthcare disparities in diabetes among the Marshallese population.
Working with Marshallese individuals in this study informed the creation of a subsequent project looking at diabetes before it starts. The ongoing study, with support from a PCORI award, focuses on preventing Marshallese adults with prediabetes from progressing to full-fledged diabetes mellitus.
COVID-19-Related Project Enhancement and the Marshallese community
In July 2020, the research team received additional PCORI funding to its ongoing study in diabetes prevention. The award will support studying COVID-19 and the Pacific Islander community in Arkansas—a group that has tested positive for the virus at a rate at least 300 percent higher than that of the general population.
More Details About the Photos
- Left: Karra Sparks, RD, (right) a University of Arkansas for Medical Sciences certified diabetes educator, provides training on blood sugar monitoring to Morda Netwon in the culturally adapted family-model DSME program.
- Middle: Staff from the Marshallese Educational Initiative and the University of Arkansas for Medical Sciences met in early March 2020 to work on programs for the Marshallese in Northwest Arkansas.
- Right: Kileti Mejbon enjoying a healthy lunch. He credits the lessons he learned in the project’s culturally adapted DSME program for teaching him how to make healthy food choices to help control his blood sugar.
Photos courtesy of Lisa Smith, Pearl McElfish, the Marshallese Educational Initiative, Kejjo Clarence, and Kileti Mejbon.
By Melissa Schenkman, Writer and Editor
Posted: September 28, 2020
What's Happening at PCORI?
The Patient-Centered Outcomes Research Institute sends weekly emails about opportunities to apply for funding, newly funded research studies and engagement projects, results of our funded research, webinars, and other new information posted on our site.