What was the research about?
Type 2 diabetes is a long-term health problem that causes blood sugar levels to rise. It is common among people from the Marshall Islands. Keeping blood sugar levels normal can help prevent damage to the heart, brain, eyes, limbs, and kidneys. Patients can manage diabetes by eating healthy foods, exercising, and checking blood sugar levels regularly.
In this study, the research team worked with Marshallese people living in Arkansas to adapt a diabetes education program. The new program included personal stories and analogies common in Marshallese culture. Patients with type 2 diabetes could invite family members to take part in the education sessions. Patients and family members worked together to set health goals.
The research team compared patients in the new program with those in a standard diabetes education program. The team looked at patients’
- Blood sugar levels
- Cholesterol levels
- Body mass index, or BMI, which measures body fat based on height and weight
- Diabetes self-care tasks, such as checking blood sugar levels and seeing a doctor
What were the results?
After one year, compared with patients in the standard program, patients in the new program
- Had lower blood sugar levels
- Were more likely to check their blood sugar levels regularly
Patients in the two programs didn’t differ in cholesterol levels, BMI, or other diabetes self-care tasks after one year.
Who was in the study?
The study included 221 Marshallese adults with type 2 diabetes living in Arkansas. The average age was 52, and 59 percent were women.
What did the research team do?
The research team worked with Marshallese adults to create the new program. Then the team assigned patients by chance to the new or the standard program. Both programs included 10 hours of diabetes education on topics like healthy eating, exercise, checking blood sugar, and setting health goals.
In the new program, a trained community health worker led eight weekly 75-minute sessions in patients’ homes in the Marshallese language. Community health workers are trained to teach people about health and link people in their community with health and social services. In the standard program, patients went to six weekly 100-minute sessions at a local community center without their family members. A trained diabetes educator gave sessions in English with help from an interpreter.
People from the Marshallese community and healthcare providers were members of the research team.
What were the limits of the study?
The study included Marshallese adults in Arkansas. Results may differ in other places or for people of other backgrounds. The two programs differed in many ways; the research team can’t be sure which parts of the program led to the results.
Future research could test how the new program works for other groups of Pacific Islanders.
How can people use the results?
Health centers that serve Marshallese patients can use these results when considering diabetes education programs.
To compare the effectiveness of a culturally adapted, family-centered diabetes self-management education (DSME) program versus standard diabetes education on lowering hemoglobin A1c (HbA1c) levels in Marshallese patients with type 2 diabetes living in Arkansas
|Design||Randomized controlled trial|
|Population||221 Marshallese adults with type 2 diabetes living in Arkansas|
Primary: HbA1c levels
Secondary: BMI, total cholesterol, HDL level, diabetes self-care behaviors (glucose monitoring, annual doctor visits, annual foot exam, annual eye exam, maintaining a healthy weight, physical activity)
|Timeframe||1-year follow-up for primary outcome|
This randomized controlled trial compared the effectiveness of a culturally adapted, family-centered diabetes self-management education program, called adapted DSME, with standard diabetes education, or standard DSME, on lowering HbA1c levels in US Marshallese patients, a population with high type 2 diabetes prevalence.
Researchers randomly assigned patients to either the adapted DSME or standard DSME program. Both programs included 10 hours of diabetes education on topics such as healthy lifestyle habits, blood glucose management, and goal setting. In the adapted program, a trained community health worker delivered eight weekly 75-minute education sessions in patients’ homes in Marshallese. Patients invited one or more adult family members to participate in the sessions with them. Researchers worked with the Marshallese community to create culturally appropriate content for the adapted DSME program. Content included collective goal setting and the use of personal testimonies and analogies common in Pacific Islander culture. In the standard DSME program, patients attended six weekly 100-minute diabetes education sessions at a local community organization without their family members. A certified diabetes educator offered sessions in English with the help of an interpreter.
The study included 221 Marshallese adults with type 2 diabetes living in Arkansas. The average age was 52, and 59% were female.
To measure HbA1c levels, researchers used a rapid A1c test kit. To assess diabetes self-care behaviors, researchers surveyed patients about their glucose monitoring, physical exams, and physical activity. Researchers measured patients’ height and weight to calculate body mass index (BMI), and they used a commercial lipid panel kit to measure total cholesterol and high-density lipoprotein (HDL) levels. Researchers assessed all outcomes at baseline, immediately after the intervention, and again 6 and 12 months after the intervention.
The Marshallese community, healthcare providers, and researchers used a community-based participatory research approach to design the study and collect data.
After one year, compared with patients in the standard DSME program, patients in the adapted DSME program had greater declines in HbA1c levels (p=0.013).
Patients in the adapted DSME program were also more likely to check their blood glucose levels regularly compared with those in the standard DSME program (p<0.05).
Patients in the two programs did not differ in BMI, total cholesterol, HDL, or other diabetes self-care behaviors after one year.
The study included Marshallese patients in Arkansas. Findings may not be generalizable to other geographic regions or populations, including Marshallese patients living outside of Arkansas. The adapted DSME program differed from the standard DSME program in several ways; researchers cannot be sure which aspects of the adapted DSME program affected which outcomes.
Conclusions and Relevance
In this study, a culturally adapted education program offered in patients’ homes and involving family members improved blood glucose levels for Marshallese patients with type 2 diabetes.
Future Research Needs
Future research could test whether the adapted DSME program is effective among other groups of Pacific Islanders.
Final Research Report
View this project's final research report.
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Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers asked whether the researchers based their hypothesis on the limitations of previous research in this population, or on evidence that a family-based approach to diabetes care was successful in other communities. The researchers added this discussion to the report, stating that they developed their hypothesis and intervention based on their own pilot work, the limitations of other studies, input from stakeholders, and success of other family-care models.
- Reviewers noted that the two interventions tested differed in several ways that included but were not limited to the family component. They also stated that the trial did not allow for the possibility of attributing any observed differences in results to any particular component of each intervention. The researchers agreed that the original name of one of the two diabetes self-management education (DSME) interventions “Family DSME,” did not fully capture the extent of the differences that the intervention offered compared to Standard DSME. They changed the name of Family DSME to Adapted DSME in response to this concern.
- Reviewers asked that the report describe the clinical importance of any observed differences in results and not overinterpret small differences. The researchers edited the report to soften the language and offer more context in describing differences observed between the two study arms.
Conflict of Interest Disclosures
Study Registration Information
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