Addressing Marshallese Immigrant Barriers to Diabetes Self-Management through Family DSMES

摘要 马绍尔人是太平洋岛民中的一个亚群，他们的健康状况存在很大差异， 2型糖尿病（T2 DM）的发病率是世界上最高的。1 -6 T2 DM的估计 马绍尔人的范围为20%至50%，而美国人口为8.3%。1 -6试点数据（n = 401） 记录了阿肯色州的马绍尔移民有极高的T2 DM发病率（38.4%）， 糖尿病患者（32.6%），仅有10%的人有自我管理行为。马绍尔移民人口 在美国（US）增长迅速。马绍尔移民经历独特的障碍，自我- T2 DM的管理，以及可以用来帮助缓解这些障碍的独特文化资产。 研究小组与马绍尔社区合作，开发了一种适应文化的家庭模式， DSMES（家庭DSMES）。干预使用基于资产的方法， 集体主义文化，并利用家庭的影响力，帮助马绍尔移民从事自我， 管理行为。对一个家庭进行了家庭-DSMES的初步实施和评估 在病人家里。虽然家庭DSMES在改善患者结局方面取得了成功，但 在家庭环境中一次向一个家庭提供干预的挑战和费用 不可持续拟议的研究将测试对信仰组织（FBO）的干预（而不是 到患者家中）与家庭组（而不是一次一个家庭）。随着这些重要的 变化，我们假设家庭DSME将是有效的和可持续的。我们的具体目标是：1） 测试家庭DSMES改善马绍尔群岛患者糖尿病相关结局的有效性; 2)评估家庭-DSMES对家庭成员的影响;以及3）进行成本效益分析， 了解干预成本与结果的关系。我们将进行一项全功率集群RCT， 包括288名马绍尔T2 DM患者及其288名家庭成员。一个等待名单控制臂， 包括患者和家庭成员将在研究期间作为未经治疗的对照组。的RCT 将在24个马绍尔群岛FBO进行，并将由马绍尔群岛社区卫生工作者教授。 将在基线时从研究两组的患者及其家庭成员中收集数据， 干预后即刻、干预后6个月和12个月。我们还将获得医疗 记录发布以提取参与者在干预后18个月和24个月的生物测定结果。此外 在我们的初步分析中，我们将考察感知社会（家庭）支持对 患者的结果。我们还将根据性别、出生地， 和文化适应的程度。虽然马绍尔人人口不多，但这个移民社区 他们在研究中的代表性不足，他们正在经历一场必须解决的健康危机。测试组 在FBO的交付是扩大家庭DSMES的覆盖面和长期可持续性的必要条件。

ABSTRACT Marshallese are a subpopulation of Pacific Islanders that are experiencing significant health disparities, with some of the highest documented rates of type 2 diabetes mellitus (T2DM) in the world.1-6 Estimates of T2DM in the Marshallese range from 20% to 50%, compared to 8.3% for the US population.1-6 Pilot data (n = 401) documented that Marshallese immigrants in Arkansas have extremely high rates of T2DM (38.4%), and pre- diabetes (32.6%), and only 10% engage in self-management behaviors. The Marshallese immigrant population has increased rapidly in United States (US). Marshallese immigrants experience unique barriers to self- management of T2DM, as well as unique cultural assets that can be leveraged to help mitigate these barriers. The research team worked with the Marshallese community to develop a culturally-adapted family model of DSMES (Family-DSMES). The intervention uses an asset-based approach predicated upon Marshallese’s collectivist culture and leverages the influence of family to help Marshallese immigrants engage in self- management behaviors. The initial implementation and evaluation of Family-DSMES was taught to one family at a time in patients’ homes. While the Family-DSMES was successful at improving patient outcomes, there are challenges and expenses for delivery in a home setting to one family at a time that make the intervention unsustainable. The proposed study will test the intervention in faith-based organizations (FBOs) (as opposed to patients’ homes) with groups of families (as opposed to one family at a time). With these significant changes, we hypothesize that the Family-DSME will be effective and sustainable. Our specific aims are: 1) Test the effectiveness of Family-DSMES to improve diabetes-related outcomes among Marshallese patients; 2) Evaluate the effect of Family-DSMES on family members; and 3) Conduct a cost-effectiveness analysis to understand intervention costs in relationship to outcomes. We will conduct a fully-powered cluster RCT that includes 288 Marshallese patients with T2DM and 288 of their family members. A wait-list control arm that includes patients and family members will serve as an untreated comparison group during the study. The RCT will be conducted at 24 Marshallese FBOs, and it will be taught by Marshallese community health workers. Data will be collected from patients and their family members in both arms of the study at baseline, immediately post-intervention, six months, and 12 months post-intervention. We will also obtain a medical records release to abstract participants’ biometric outcomes at 18 and 24 months post-intervention. In addition to our primary analyses, we will examine the potential mediation effect perceived social (family) support has on patients’ outcomes. We will also evaluate potential heterogeneity of treatment effects according to sex, nativity, and level of acculturation. While the Marshallese are a small population, this immigrant community is underrepresented in research, and they are experiencing a health crisis that must be addressed. Testing group delivery in FBOs is imperative to expanding the reach and long-term sustainability of the Family-DSMES.