Results Summary
What was the research about?
Type 2 diabetes is a long-term health problem that causes blood sugar levels to rise. The rate of diabetes among the Marshallese, a Pacific Islander population living in the United States, is four times higher than that of the general population.
In this study, the research team worked with Marshallese people living in Arkansas and Oklahoma to adapt the Diabetes Prevention Program, or DPP, for Marshallese adults with obesity or overweight. DPP is a program shown to reduce risk factors for diabetes, such as having obesity. It promotes exercise and healthy eating. The team adapted and compared two six-month programs:
- Wholeness, Oneness, Righteousness, Deliverance, or WORD DPP. This version focused on using faith to help people make healthy lifestyle changes. It had 16 group sessions. Community educators used pictures and analogies in sessions about faith and health.
- Partnership for Improving Lifestyle Intervention, or PILI DPP. This version focused on Pacific Island culture, using social networks to help people make healthy lifestyle changes. It had 14 group sessions with topics such as how families can be active together or how to share health goals with family and friends. Community educators encouraged participants to keep a daily log of their weight, exercise, and diet.
The research team looked at weight loss and other health outcomes.
What were the results?
Six months after the programs ended, few people in each program lost weight. In both programs, only 7 percent of people lost at least 5 percent of their body weight. People in the two programs didn’t differ in:
- Weight loss
- Blood sugar levels or blood pressure
- Exercise or healthy eating
- Confidence in managing their health
- Social support
Who was in the study?
The study included 380 Marshallese adults with overweight or obesity. Of these, 27 percent had pre-diabetes and 48 percent had type 2 diabetes. The average age was 42, and 57 percent were women. All lived in Arkansas and Oklahoma.
What did the research team do?
The research team assigned 31 churches by chance to offer WORD DPP or PILI DPP. People took part in the program assigned to their church. For both programs, a trained community educator led the 90-minute group sessions in Marshallese and English over 6 months.
At the start of the study, right after the programs ended, and six months later, the research team measured patients’ weight, blood sugar levels, and blood pressure. Patients also completed surveys.
People from the Marshallese community and healthcare providers were members of the research team.
What were the limits of the study?
COVID-19 made it hard for patients to attend in-person sessions and stay in the study, which may have affected study results. The study included Marshallese adults in two states. Results may differ in other places or for people from other backgrounds.
Future research could look at other ways to help Marshallese adults lose weight and prevent diabetes.
How can people use the results?
Health centers that serve Marshallese patients can use these results when considering ways to support weight management.
Professional Abstract
Objective
To compare the effectiveness of two lifestyle interventions, adapted from the Diabetes Prevention Program (DPP), in improving weight management among Marshallese adults who have overweight or obesity
Study Design
| Design Element | Description |
|---|---|
| Design | Cluster randomized controlled trial |
| Population | 380 Marshallese adults ages 18 and older with a body mass index ≥25 living in Arkansas and Oklahoma |
| Interventions/ Comparators |
|
| Outcomes |
Primary: change in body weight Secondary: blood glucose levels, blood pressure, physical activity, dietary intake, self-efficacy, social/family support |
| Timeframe | 6-month post-intervention follow-up for primary outcome |
This cluster randomized controlled trial compared the effectiveness of two lifestyle interventions, adapted from the DPP, in improving weight loss among Marshallese adults. The rate of diabetes among Marshallese persons living in the United States is four times higher than the rate among the general population. DPP is a lifestyle intervention shown to improve risk factors for type 2 diabetes, including obesity, for multiracial populations.
Researchers worked with Marshallese adults in Arkansas and Oklahoma to identify, adapt, and compare two six-month interventions:
- Wholeness, Oneness, Righteousness, Deliverance (WORD) DPP. This intervention helped participants leverage their faith to make healthy lifestyle changes. Community educators offered 16 sessions about faith and health, using pictures and analogies.
- Partnership for Improving Lifestyle Intervention (PILI) DPP. This intervention, an adaptation of the DPP for Pacific Island culture, used social and family networks to support healthy lifestyle changes. It included 14 sessions on topics such as how families can be active together and how to share health goals with family and friends. Community educators encouraged participants to keep a daily log of their weight, physical activity, and nutrition.
Researchers randomly assigned 31 Marshallese churches in Arkansas and Oklahoma to receive one of the two interventions. Participants received the intervention assigned to their church. For both interventions, a community educator led the 90-minute group sessions in Marshallese and English over 6 months.
The study included 380 Marshallese adults with overweight or obesity. The average age was 42, and 57% were female. At baseline, 27% of participants had pre-diabetes and 48% had type 2 diabetes based on their hemoglobin A1c level. At baseline, immediately post-intervention, and six months post-intervention, researchers measured patients’ body weight, blood glucose levels, and blood pressure. Patients also completed surveys about other study outcomes.
The Marshallese community, healthcare providers, and researchers used a community-based participatory research approach to design and conduct the study.
Results
At six months post-intervention, participants in the two interventions did not differ significantly in any study outcomes. Neither the WORD DPP nor the PILI DPP resulted in significant weight loss. Only 7% of participants across both interventions lost at least 5% of their body weight.
Limitations
COVID-19 affected session attendance and participant retention, which may have affected study results. The study included Marshallese adults in Arkansas and Oklahoma. Findings may not be generalizable to other populations or Marshallese adults in other regions.
Conclusions and Relevance
The study found no differences in weight loss between the WORD DPP and PILI DPP.
Future Research Needs
Future research could examine other ways to improve weight management among Marshallese adults.
COVID-19-Related Study
Learning How COVID-19 Has Affected Marshallese Communities in the United States
Results Summary
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
What was this COVID-19 study about?
COVID-19 is a viral disease that can be mild or severe. Having diabetes or high blood pressure may increase the risk of severe illness. Because these health problems are common among people from the Republic of the Marshall Islands, Marshallese people are at risk for severe illness from COVID-19.
In this study, the research team wanted to learn how COVID-19 has affected Marshallese people living in the United States. The team did an online survey and held group discussions with Marshallese adults.
What were the results?
The survey found that most people tried to prevent COVID-19 by following public health advice. For example:
- 98 percent reported wearing a face mask
- 97 percent reported washing hands for at least 20 seconds
- 97 percent reported that they kept at least six feet between themselves and people who didn’t live with them
People often used drive-through testing sites for COVID-19. About 28 percent of those surveyed reported that they’d had a positive COVID-19 test; about 23 percent had never been tested for COVID-19.
When asked about willingness to get a COVID-19 vaccine, 57 percent said they would get one. But 28 percent didn’t know or were unsure. Older adults and people who had a higher income, lived in the United States longer, had health insurance, or had a primary care doctor were more likely to say they would get a vaccine.
The group discussions found:
- COVID-19-related cultural changes, such as less in-person social contact and less sharing of food than before the pandemic.
- Changes in diabetes self-care. For example, some people with diabetes ate too much or had sugary drinks, such as soda, to cope with stress. Others ate healthy to better manage diabetes.
- Varied willingness to get a COVID-19 vaccine. Some people wanted to get a vaccine due to the number of COVID-related deaths among Marshallese people. Others didn't want to get one due to concerns about safety or how it was developed.
What did the research team do?
The research team did the online survey with 120 Marshallese adults in 13 states. Of these, 36 percent didn’t have health insurance, and 44 percent didn’t have a primary care doctor. The average age was 35, and 65 percent were women. The survey asked about what people do to prevent COVID-19, where they prefer to get tested, and their views on the COVID-19 vaccine.
The nine virtual group discussions included 53 Marshallese adults. Of these, 68 percent were women. All lived in Arkansas, Hawaii, or Oklahoma. Groups were in English or in the Marshallese language based on people’s preferences. People discussed how COVID-19 affected their daily lives.
Marshallese community members gave input during the study.
What were the limits of the study?
Because study participants were not selected by chance, results may not apply to all Marshallese people.
How can people use the results?
Doctors and other healthcare professionals can use the results to support Marshallese communities during the COVID-19 pandemic.
Professional Abstract
In response to the COVID-19 public health crisis in 2020, PCORI launched an initiative to enhance existing research projects so that they could offer findings related to COVID-19. The initiative funded this study and others.
Background
The COVID-19 pandemic has disproportionately burdened racial and ethnic minority groups in the United States, including the Marshallese, a Pacific Islander population from the Republic of the Marshall Islands. In the Marshallese community, conditions that increase the risk of severe COVID-19 are prevalent, including obesity, diabetes, and hypertension.
Objective
(1) To learn how COVID-19 has affected Marshallese communities; (2) To document COVID-19 prevention practices and testing preferences among Marshallese people
Study Design
| Design Element | Description |
|---|---|
| Design | Online survey, virtual focus groups |
| Population |
Survey: 120 Marshallese adults living in 13 states Focus groups: 53 Marshallese adults living in Arkansas, Hawaii, or Oklahoma |
| Outcomes | Adherence to COVID-19 prevention practices, preferred COVID-19 testing locations, vaccine hesitancy, impacts of COVID-19 on the Marshallese community |
| Data Collection Timeframe |
Survey: July 2020–November 2020 Focus groups: September 2020–November 2020 |
This mixed-methods study examined how COVID-19 has affected Marshallese adults living in the United States. The research team conducted an online, self-administered survey and nine virtual focus groups that explored adherence to COVID-19 prevention practices, preferred COVID-19 testing locations, vaccine hesitancy, and the impact of COVID-19 on Marshallese adults.
The survey included 120 Marshallese adults in 13 states. Of these, 36% did not have health insurance, and 44% did not have a primary care provider. The average age was 35, and 64% were female.
The focus groups included 53 Marshallese adults and were in Marshallese or English based on participant preference. Of these adults, 68% were female, and all lived in Arkansas, Hawaii, or Oklahoma.
Community advisory boards with Marshallese community members provided input throughout the study.
Results
Survey results. Most respondents reported adhering to COVID-19 prevention practices. For example, 98% reported wearing a face mask, 97% reported washing their hands for at least 20 seconds, and 97% reported practicing physical distancing.
Drive-through screening events were the most used testing locations. Among respondents, 77% reported having had a previous COVID-19 test; 28% of respondents reported having had a positive COVID-19 test.
When asked about their willingness to get a COVID-19 vaccine, 57% reported they would get one, and 28% did not know or were unsure whether they would. Respondents who were older (p<0.01) and had a higher income (p<0.05), longer residence in the United States (p<0.01), health insurance (p<0.01), and a primary care provider (p<0.05) were more likely to express willingness to get a COVID-19 vaccine.
Focus group results. Themes identified in the qualitative analysis included:
- Cultural disruptions related to COVID-19, including less in-person social contact and less sharing of food than before the pandemic.
- Varied experiences of diabetes self-care. For example, some people overate or drank sugar-sweetened beverages such as soda to cope with stress, and others ate healthy to better manage diabetes.
- Varied willingness to receive a COVID-19 vaccine. For example, some people were motivated to get a vaccine because of the number of COVID-related deaths among Marshallese people. Others were hesitant to be vaccinated due to concerns about safety or lack of information about vaccine development.
Limitations
Because the research team did not randomly select survey participants, results may not be generalizable to all Marshallese adults.
Conclusions and Relevance
This study identified ways that COVID-19 has affected Marshallese people living in the United States, including changes to social practices and diabetes self-care. The study also provided insight into respondents’ preferences for COVID-19 testing and vaccination.
Peer Review Summary
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. Those comments and responses included the following:
- This final report was focused on the COVID-19 enhancement to the main PCORI-funded study.
- The reviewers requested more information on how stakeholder engagement contributed to the scope and implementation of this study. The researchers explained that most of the engagement occurred as preparation for the main study; they added more information to the engagement section in this report.
- The reviewers questioned the sample size goal, which was stated as about 2,000 participants in the study protocol, given that only 248 individuals expressed interest in the study and were deemed eligible, and 128 of those individuals did not complete enough items on the study survey to be included in the analyses. The researchers acknowledged this recruitment shortfall in their study limitations and acknowledged they could not know how many of the survey respondents came from the main PCORI study or were recruited specifically for this enhancement project.
- The reviewers noted the important policy implications of this study given the unusually high rate of COVID-19 infections among the Marshallese population living in Arkansas and participating in the study. The researchers agreed that this was concerning and reported they had begun work with the Arkansas Department of Health to analyze COVID-19 infection rates in this population over a longer period.
Final Enhancement Report
View this COVID-19 study's final enhancement report.
DOI - Digital Object Identifier: 10.25302/05.2022.AD.160334602-C19
Final Research Report
View this project's final research report.
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Journal Citations
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Peer-Review Summary
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. Those comments and responses included the following:
- Some reviewers indicated that the lack of significant differences between the two weight-loss interventions and the high participant attrition rate were a result of inadequate engagement of community members in the study. The reviewers interpreted the report’s description of patient and stakeholder engagement to indicate that there was considerable disagreement and debate in the community regarding this study. The researchers disagreed with the reviewers, stating that healthy debate indicated strong community engagement and partnership and that changes made to the study protocol indicated a successful collaboration where both researchers and stakeholders listened to each other’s ideas and concerns.
- The researchers requested more discussion about the implications of the study results, particularly the lack of effect for the two weight-loss interventions based on the Diabetes Prevention Program in this population. The reviewers hypothesized that this lack of effect indicated problems with intervention delivery, low participant and community engagement, and high rates of missing data. The researchers expanded their discussion around potential reasons for the lack of significant findings in this study. They stated that the findings are most likely related to the well-known difficulties with losing weight, compounded by social, economic, and environmental barriers to weight loss in the Marshallese population.
- The reviewers asked for clarification on how the researchers accounted for cluster in these analyses, since participants were clustered within churches and each church was randomized to one intervention or the other. The reviewers hypothesized that the sample size did not provide enough power to detect differences between groups because cluster was not taken into account in the power analyses. The researchers assured reviewers that they did consider clustering in all of their longitudinal analyses and in their power calculations and that the observed differences in outcomes between the two groups were too small to be considered significant.
- The reviewers questioned the researchers’ approach to accounting for missing data because the reviewers did not believe missing data could be considered missing at random since they were connected to study attrition. In response the researchers ran additional analyses that demonstrated no differences in the results based on whether the data were thought to be missing at random.