Evaluation of the effectiveness of Ajjmuurur Baamḷe DSMES in the RMI

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ABSTRACT Health disparities in the Republic of the Marshall Islands (RMI) are striking with extremely high rates of diabetes and other cardiometabolic diseases. Documented rates of type 2 diabetes mellitus (T2DM) in the RMI range from 20%-50%. This is significantly higher than global (8.5%) and US (11%) rates. The extreme disparities in the RMI are exacerbated by a lack of research, lack of funding, a lack of services, and a lack of culturally-appropriate interventions. Residents of the RMI experience unique barriers to self-management of T2DM, as well as possess unique cultural assets that can be leveraged to help mitigate these barriers. The research team worked with the Marshallese community in Arkansas to develop and evaluate a culturally- adapted family model of DSMES (Ājjmuurur Baamḷe DSMES). Ājjmuurur Baamḷe DSMES is based on a collectivist approach, incorporates Marshallese cultural practices, and uses “talk story” as a conversational, rhythmic, and culturally preferred way of sharing knowledge. Ājjmuurur Baamḷe DSMES includes family members as participants and focuses on family motivational interviewing, family goal setting, and family behavioral change with specific focus on education about supportive and nonsupportive family behaviors. The curriculum is assets based and it works to overcome barriers facing Marshallese patients by leveraging culturally specific facilitators of healthy behavior change. Our central hypothesis is that persons who receive the Family Model DSMES "Ājjmuurur Baamḷe" will have improved HbA1c (primary outcome), blood pressure, lipids, BMI, increased knowledge, self-efficacy, empowerment, and quality of life, along with decreased diabetes-related complications and diabetes-related distress. This study's objective is to conduct a cluster RCT using a wait-list control to evaluate the effectiveness of Ājjmuurur Baamḷe DSMES when delivered in faith- based organizations (FBOs) by Community Health Workers (CHWs). Our specific aims are: 1. Test the effectiveness of Ājjmuurur Baamḷe DSMES to improve diabetes-related outcomes among Marshallese patients; 2. Evaluate the effect of Ājjmuurur Baamḷe DSMES on family members; and 3. Conduct an indigenous evaluation to understand the extent to which the intervention adheres to Pacific Islander cultural values and evaluate the cultural appropriateness of the research. Data will be collected from patients (Aim 1) and their family members (Aim 2) at baseline, immediately post-intervention (12 weeks), at four months and twelve months post-intervention. An indigenous evaluation (Aim 3) will be conducted at six months and each year thereafter to document and inform process improvement efforts in study implementation. While the Marshallese are a small population, this population is underrepresented in research, and they are experiencing a health crisis that must be addressed. The proposed study offers a promising intervention that has the potential to affect substantially health disparities experienced by Marshallese and other Pacific Islanders in the USAPI.