Assessing the acceptability of a culturally adapted group-based pediatric intervention, Kokajjiriri, for Marshallese mothers and infants to improve nutrition and prevent childhood obesity.

BACKGROUND: Marshallese Pacific Islanders experience higher rates of obesity than other racial and/or ethnic communities. Despite the obesity rates experienced in this community, there are currently no childhood obesity prevention interventions designed for Marshallese Pacific Islanders in the United States. The purpose of this study is to assess the acceptability and feasibility of a culturally adapted group-based pediatric intervention, Kokajjiriri, with Marshallese mothers to improve nutrition and reduce childhood obesity. METHODS: A multi-methods design was used to culturally adapt the Kokajjiriri intervention for Marshallese mothers in Arkansas (n = 17). In phase one, we conducted 24-h dietary recalls with 20 Marshallese mothers to inform the cultural adaptation of the group-based pediatric intervention, and then in phase two, we culturally adapted and piloted three sessions of the intervention to determine the acceptability and feasibility of the intervention. RESULTS: Participants found the adapted intervention to be acceptable and feasible, found the location to be convenient and found the facilitator to be knowledgeable. Four themes emerged from the qualitative data: (1) Lactation Support; (2) Introducing Healthy Solids; (3) Rice Portion Control; and (4) Finding Resources. CONCLUSIONS: This is the first study to assess the acceptability and feasibility of a culturally adapted group-based pediatric intervention, Kokajjiriri, with Marshallese mothers to improve nutrition and reduce childhood obesity. The results from this culturally adapted group-based pediatric intervention, Kokajjiriri, will be used to inform future adaptations and implementation of the full intervention for Marshallese women and children.

Diabetes self-management education exposure and glycated haemoglobin levels among Marshallese participants in a randomized controlled study.

AIMS: A randomized control trial (RCT) of diabetes self-management education (DSME), undertaken by a community-based participatory research (CBPR) partnership between the University of Arkansas for Medical Sciences (UAMS) and the Marshallese community in Arkansas. The RCT examined the effect of hours of intervention exposure, with the hypothesis that increased exposure is one reason the Adapted-Family DSME was found to be more effective than the Standard DSME. METHODS: Some 221 Marshallese with type 2 diabetes were randomized to an Adapted-Family DSME group (in-home setting) (n = 110) or a Standard DMSE group (community setting) (n = 111). The Adapted-Family DSME included 10 h of education that covered the core self-care elements recommended by the American Diabetes Association (ADA) and American Association of Diabetes Educators' (AADE) recommendations. The Standard DSME included 10 h of intervention with all ADA and AADE core elements. RESULTS: The number of hours of intervention exposure in the Adapted-Family DSME arm (mean = 8.0; median = 10.0) was significantly higher than the number of hours of intervention received in the Standard DSME arm (mean = 1.5; median = 0.0). As hypothesized, higher exposure was associated with a significant reduction in HbA1c in a model including only study arm and exposure (P = 0.01), and in a model including study arm, exposure, and all demographic variables (P = 0.046). CONCLUSIONS: This finding is consistent with previous reviews that showed increased exposure to DSME produced improved glycaemic control and ≥ 10 h of DSME produces clinically meaningful reductions in HbA1c .

Eliciting culturally and medically informative family health histories from Marshallese patients living in the United States.

The United States (U.S.) resident Marshallese population is growing rapidly. Subsequent to this growth, Marshallese patients experience language and cultural barriers when attempting to access medical care in the U.S. This study: (a) documents how the Marshallese refer to biological and adopted family members; (b) identifies barriers encountered by Marshallese when seeking medical care; and (c) describes effective communication strategies for healthcare providers to use when treating Marshallese patients. Six key informant interviews were conducted in English with bicultural (U.S. and native Marshallese) informants, the majority of whom were women who worked in a healthcare setting. Participants were recruited through the Center for Pacific Islander Health in Arkansas and through personal contacts within the Marshallese community. Based on the study findings, examples of how providers can make genetic services more accessible and meaningful for Marshallese patients are also provided. This study is particularly relevant to genetic counselors as the number of Marshallese patients and families needing their services is growing.

'Just doing the best we can': health care providers' perceptions of barriers to providing care to Marshallese patients in Arkansas.

Introduction: Marshallese migrating to the United States encounter challenges in accessing health care. Previous literature has investigated Marshallese participants' perceptions of the barriers they face in accessing health care. For this study, health care providers managing the care of Marshallese patients were interviewed to understand the providers' perception of barriers that their Marshallese patients encounter. Methods: A qualitative research design was utilized to explore health care providers' perceptions of and experiences with the barriers faced by their Marshallese patients when accessing the US health care system. Results: The primary barriers identified were: (1) economic barriers; (2) communication challenges; (3) difficulty understanding and navigating the western health care system; and (4) structural and system barriers. Conclusion: This study provides insight on the barriers Marshallese patients face in accessing health care as well as the barriers providers face in delivering care to Marshallese patients. A better understanding of these barriers can help health care providers and educators to begin initiating improvements in the delivery of care to Marshallese patients.

Social and economic influences on infant and child feeding practices in a Marshallese community.

OBJECTIVE: The present study aimed to examine the key influences on infant and child feeding practices among a Marshallese community at each social ecological level. It is the first study to examine the key influences on infant and child feeding practices with Marshallese immigrant women in the USA and helps fill a gap in the previous literature that has included other immigrant women. DESIGN: Community-based participatory research design with twenty-seven participants taking part in four qualitative focus groups. SETTING: The study took place within the Marshallese community in Arkansas, USA.ParticipantsParticipants included Marshallese women with children aged 1-3 years and/or caregivers. Caregivers were defined as someone other than the parent who cares for children. Caregivers were often older women in the Marshallese community. RESULTS: There were five primary themes within multiple levels of the Social Ecological Model. At the intrapersonal level, mothers' and caregivers' autonomy emerged. At the interpersonal level, child-led and familial influences emerged. At the organizational level, health-care provider influences emerged; and at the policy level, the Special Supplemental Nutrition Program for Women, Infants, and Children emerged as the most salient influence. CONCLUSIONS: Marshallese immigrant women's infant and child feeding practices are influenced at intrapersonal, interpersonal, organizational and policy levels. Understanding these multidimensional influences is necessary to inform the creation of culturally tailored interventions to reduce health disparities within the Marshallese community.

Adverse Pregnancy and Neonatal Outcomes Among Marshallese Women Living in the United States.

Objective Despite heterogeneity among Pacific Islanders, most studies aggregate them regardless of origin. Thus, limited information is available about perinatal outcomes among various subgroups of Pacific Islanders in the United States, including immigrants from the Republic of the Marshall Islands. We sought to evaluate perinatal outcomes among Marshallese women. Methods We conducted a cross-sectional study of women with at least one singleton live birth between 1997 and 2013 in two Arkansas counties using birth certificate data from the Arkansas Department of Health. Unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI) were calculated from modified Poisson regression models. Results Of the 91,662 singleton births in both counties during the study period, 2488 were to Marshallese women. In adjusted analyses, Marshallese women had higher prevalence of "other medical risk factors" (PR = 1.47; 95% CI 1.30, 1.65) than NH White women. Marshallese women had higher rates of precipitous labor and fetal distress during labor compared to NH White women (PR = 2.65; 95% CI 2.22, 3.17 and 1.89; 95% CI 1.62, 2.21, respectively). Marshallese were also more likely to have tocolysis (PR = 1.43; 95% CI 1.16, 1.76), forceps (PR = 1.68; 95% CI 1.16, 2.43) or vacuum (PR = 1.89; 95% CI 1.60, 2.22) used in delivery and cesarean section (PR = 1.13; 95% CI 1.01, 1.27). Marshallese infants had higher rates of anemia (PR = 3.10; 95% CI 2.01, 4.77), birth injury (PR = 2.13; 95% CI 1.50, 3.03), assisted ventilation < 30 min (PR = 2.11; 95% CI 1.64, 2.71), preterm birth (PR = 1.67; 95% CI 1.50, 1.83), and small-for-gestational age (PR = 1.25; 95% CI 1.12, 1.39) than NH White infants. Conclusions Marshallese women and infants had higher rates of adverse perinatal outcomes compared to their NH White counterparts. Additional studies are needed to determine if perinatal outcomes among the Marshallese differed from other Pacific Islander subgroups.

Using CBPR to address health disparities with the Marshallese community in Arkansas.

CONTEXT: Arkansas currently has the largest Marshallese community in the continental US. The limited research available demonstrates that Marshallese have significant health disparities, with higher rates of obesity, diabetes, cardiovascular disease and infectious diseases than the US population. OBJECTIVES: The purpose of this paper is 2-fold: (1) to describe the formation and capacity building efforts of a community-based participatory research partnership with the Marshallese community in Arkansas and (2) to describe key findings and lessons learned from 5 years of collaborative research. METHODS: A community-based participatory research approach was implemented to build alliances and improve health disparities in a Marshallese community. RESULTS: Overarching lessons learned from collaboration with the Marshallese community include the: (1) Intensive involvement of Marshallese from multiple sectors of the community and in multiple roles in the research process, (2) Importance of interprofessional teams, (3) Importance of church, (4) Consideration of sex, (5) Importance of family and definition of family, (6) Talk Story and qualitative methods and the (7) Importance of cultural humility. CONCLUSIONS: This research helps fill important gaps in documenting the health disparities and interventions to address those disparities in the Marshallese community.

The use of home brew in Pacific Islands countries and territories.

This review examines what is known about the production and use of home brew in the Pacific Islands countries and territories. Data collection involved interviews of 78 men and women from the Marshall Islands, Papua New Guinea, Toga, and Tuvalu. The interviews were conducted in 2013 by local interviewers. The questions fell into four key areas: people's history of home-brew consumption, the reasons for home-brew use, the effects of home brew, and people's perceptions about home brew. An open ethnographic approach revealed that males are the main consumers of home brew, that home brew is consumed in private venues by those with low socioeconomic status, and that there are positive and negative outcomes associated with the use of home brew. Finally, policy implications of the findings are included in this article.

Neocolonialism and Health Care Access among Marshall Islanders in the United States.

In the Marshall Islands, a history of extensive nuclear weapons testing and covert biomedical research, coupled with the U.S.'s ongoing military presence in the country, has severely compromised the health of the local population. Despite the U.S.'s culpability in producing ill health along with high rates of emigration from the islands to the mainland United States, the large portion of Marshallese who reside in the United States face substantial barriers to accessing health care. Drawing from ongoing field research with a Marshallese community in Arkansas, this article explores the multifaceted impediments that U.S.-based Marshall Islanders face in receiving medical treatment. Calling on an expansive and inclusive notion of neocolonialism, I argue that Marshallese structural vulnerability with regard to health and health care treatment derives from their status as neocolonial subjects and from their limited claims to health-related deservingness associated with this status. [Marshall Islanders, health care access, neocolonialism, radiation exposure, immigrant health] L̗omn̗ak ko rottin̗o: Ilo M̗ajel̗, juon bwebwenato kon kommalmel im nuclear baam̗ ko im ekkatak ko rottin̗o̗ kon wawein an baijin ko jelot armej, barainwot an to an ri tarinae ro an Amedka pad ilo aelon̄ kein, em̗oj an jelot ajmour an armej ro ilo aelon̄ kein. Men̄e alikkar bwe Amedka in ear jino nan̄inmej kein im ej un eo armej rein rej em̗m̗akut jan ane kein ane er n̄an ioon Amedka, elon̄ iaan ri M̗ajel̗ rein rej jelm̗ae elon̄ apan̄ ko n̄an aer del̗o̗n̄e jikin ajmour ko. Jan ekkatak eo ej bok jikin kio, jerbal in ej etali kabojrak rak kein rolon̄ im armej in M̗ajel̗ ro ioon Amedka in rej jelm̗ae ilo aer jibadok lo̗k jikin takto. Ilo an kar Amedka jibadok juon jea eo eutiej imejan lal̗ in, ij kwal̗ok juon ao akweelel bwe apan̄ ko an armej in M̗ajel̗ ikijjeen ajmour im jikin takto ej itok jan aer kar ri kom̗akoko ilo an kar Amedka lelon̄ l̗o̗k etan ilo mejan lal̗ im jan aer jab pukot jipan kein ej aer bwe kon jokjok in.

Younger and Sicker: Comparing Micronesians to Other Ethnicities in Hawaii.

OBJECTIVES: We compared the age at admission and the severity of illness of hospitalized Micronesians with 3 other racial/ethnic groups in Hawaii. METHODS: With Hawaii Health Information Corporation inpatient data, we determined the age at admission and the severity of illness for 162,152 adult, non-pregnancy-related hospital discharges in Hawaii from 2010 to 2012. We performed multivariable linear regression analyses within major disease categories by racial/ethnic group. We created disease categories with all patient refined-diagnosis related groups. RESULTS: Hospitalized Micronesians were significantly younger at admission than were comparison racial/ethnic groups across all patient refined-diagnosis related group categories. The severity of illness for Micronesians was significantly higher than was that of all comparison racial/ethnic groups for cardiac and infectious diseases, higher than was that of Whites and Japanese for cancer and endocrine hospitalizations, and higher than was that of Native Hawaiians for substance abuse hospitalizations. CONCLUSIONS: Micronesians were hospitalized significantly younger and often sicker than were comparison populations. Our results will be useful to researchers, state governments, and hospitals, providers, and health systems for this vulnerable group.

Breast-feeding perceptions, beliefs and experiences of Marshallese migrants: an exploratory study.

OBJECTIVE: To determine perceptions, beliefs and experiences affecting breast-feeding in Marshallese mothers residing in Northwest Arkansas, USA. DESIGN: A qualitative, exploratory study using a brief survey and focus groups. Marshallese women, 18 years or older who had a child under 7 years of age, were included in the study. SETTING: Community-based organization in Northwest Arkansas. RESULTS: The majority of mothers viewed breast milk as superior to formula, but had concerns about adequate milk supply and the nutritional value of their milk. The primary barriers to exclusive breast-feeding in the USA included public shaming (both verbal and non-verbal), perceived milk production and quality, and maternal employment. These barriers are not reported in the Marshall Islands and are encountered only after moving to the USA. Breast-feeding mothers rely heavily on familial support, especially the eldest female, who may not reside in the USA. The influence of institutions, including the Special Supplemental Nutrition Program for Women, Infants, and Children, is strong and may negatively affect breast-feeding. CONCLUSIONS: Despite the belief that breast milk is the healthiest option, breast-feeding among Marshallese mothers is challenged by numerous barriers they encounter as they assimilate to US cultural norms. The barriers and challenges, along with the strong desire to assimilate to US culture, impact Marshallese mothers' perceptions, beliefs and experiences with breast-feeding.

Marshallese COFA Migrants in Arkansas.

Arkansas is home to one of the largest populations of Marshallese in the world. Marshallese communities suffer from a disproportionate incidence of chronic diseases, including obesity, cardiovascular disease, diabetes, and infectious diseases, such as Hansen's disease (leprosy), tuberculosis, and types of hepatitis. There are a number of structural, legal, economic, and social issues that must be addressed in order to reduce health disparities and increase access to health care for Marshallese living in Arkansas.

Effect of US health policies on health care access for Marshallese migrants.

The Republic of the Marshall Islands is a sovereign nation previously under the administrative control of the United States. Since 1986, the Compacts of Free Association (COFA) between the Republic of the Marshall Islands and the United States allows Marshall Islands citizens to freely enter, lawfully reside, and work in the United States, and provides the United States exclusive military control of the region. When the COFA was signed, COFA migrants were eligible for Medicaid and other safety net programs. However, these migrants were excluded from benefits as a consequence of the Personal Responsibility and Work Opportunity Reconciliation Act. Currently, COFA migrants have limited access to health care benefits in the United States, which perpetuates health inequalities.

Maternal risk factors and perinatal outcomes among pacific islander groups in Hawaii: a retrospective cohort study using statewide hospital data.

BACKGROUND: Studies suggest Pacific Islander women have disparate rates of preterm birth, primary cesarean delivery, preeclampsia, gestational diabetes, and low birthweight infants. However, data is limited. In order to improve the health of Pacific Islanders, it is essential to better understand differences in obstetric outcomes in this diverse population METHODS: This study compared perinatal outcomes between Pacific Islander (9,646) and White (n = 5,510) women who delivered a singleton liveborn in any Hawaii hospital from January 2010 to December 2011 using the Hawaii Health Information Corporation (HHIC) database. Pacific Islanders were disaggregated into the following groups: Native Hawaiian, Samoan, Micronesian, and Other Pacific Islanders. Perinatal outcomes (e.g. hypertensive diseases, birthweight, mode of delivery) were compared using multivariable logistic models controlling for relevant sociodemographic and health risk factors (e.g. age and payer type). RESULTS: Significant differences in perinatal outcomes between Pacific Islander and White women and newborns were noted. All Pacific Islander groups had an increased risk of hypertension. Outcome differences were also seen between Pacific Islanders groups. Native Hawaiians had the highest risk of low birthweight infants, Samoans had the highest risk of macrosomic infants and Micronesians had the highest risk of cesarean delivery. CONCLUSIONS: Important differences in perinatal outcomes among Pacific Islanders exist. It is important to examine Pacific Islander populations separately in future research, public health interventions, and policy.

Maternal quality and safety outcomes for Asians and Pacific Islanders in Hawai'i: an observational study from five years of statewide data.

BACKGROUND: Empirical evidence regarding maternal quality and safety outcomes across heterogeneous Asian and Pacific Islanders subgroups in the United States is limited, despite the importance of this topic to health disparities research and quality improvement efforts. METHODS: Detailed discharge data from all Hawai'i childbirth hospitalizations (n = 75,725) from 2008 to 2012 were considered. Validated measures of maternal quality and safety were compared in descriptive and multivariable models across seven racial/ethnic groups: Filipino, Native Hawaiian, other Pacific Islander (e.g., Samoan, Tongan, Micronesian), Japanese, Chinese, white, and other race/ethnicity. Multivariable models adjusted for age group, payer, rural vs. urban hospital location, multiple gestation, and high-risk pregnancy. RESULTS: Compared to whites, Japanese, Filipinos, and Other Pacific Islanders had significantly higher overall delivery complication rates while Native Hawaiians had significantly lower rates. Native Hawaiians also had significantly lower rates of obstetric trauma in vaginal delivery with and without instruments compared to whites (Rate Ratio (RR):0.66; 95% CI:0.50-0.87 and RR:0.62; 95% CI:0.52-0.74, respectively). Japanese and Chinese had significantly higher rates of obstetric trauma for vaginal deliveries without instruments (RR:1.52; 95% CI:1.27-1.81 and RR:1.95;95% CI:1.53-2.48, respectively) compared to whites, and Chinese also had significantly higher rates of birth trauma in vaginal delivery with instrument (RR 1.42; 95% CI:1.06-1.91). Filipinos and Other Pacific Islanders had significantly higher rates of Cesarean deliveries compared to whites (RR:1.15; 95% CI:1.11-1.20 and RR:1.16; 95% CI:1.10-1.22, respectively). Other Pacific Islanders also had significantly higher rates of vaginal births after Cesarean (VBAC) deliveries compared to whites (RR: 1.28; 95% CI:1.08-1.51) and Japanese had significantly lower rates of uncomplicated VBACs (RR:0.77; 95% CI:0.63-0.94). CONCLUSIONS: Significant variation was seen for Asian and Pacific Islander subgroups across maternal quality and safety outcomes. Notably, high rates of obstetric trauma were seen among Chinese and Japanese vaginal deliveries. Filipinos and other Pacific Islanders had high rates of Cesarean deliveries. Native Hawaiians had better quality and safety outcomes than whites on several quality and safety measures, including obstetric trauma during vaginal delivery. Other Pacific Islanders had high rates of VBACs, while Japanese had lower rates. This information can help guide clinical practice, research, and quality improvement efforts.

Reconstruction of health-seeking behaviors: a comparative study of three Asian Pacific immigrant groups.

In this article, I explore how health-seeking behaviors of immigrants are reconstructed and shaped during the adaptation process by comparing the experiences of three Asian Pacific immigrant groups in Hawaii: Filipinos, Koreans, and Marshallese. A total of 91 participants (52 new immigrants, 22 ethnic community key informants, and 17 service providers) completed in-depth interviews. All three groups of immigrants experienced significant changes in their health-seeking behaviors, but in different ways. Koreans experienced a dramatic decrease in seeking both primary and preventive health care after immigration, whereas Filipinos and Marshallese increased their health-seeking behaviors. Coupled with the previous health care experiences in their home country and individual characteristics, the social context of the host country, to a great degree, influenced the formation of health-seeking behaviors after immigration. The study findings suggest that tailored interventions should take into account the source of behavioral change and difficulties that each immigrant group experiences.

The effect of a community garden on HgA1c in diabetics of Marshallese descent.

A mixed-convergent parallell designed intervention study was created to learn whether a community garden could provide improved diabetes control for members of a Midwest community of immigrants from the Marshall Islands. Qualitative data gathered through field observations on cultural norms and beliefs, food perceptions, and barriers to health care corrobrorated data gained at medical appointments for diabetes follow-up. Marshallese clients from a local community health center were recruited to participate in a community garden. Persons who participated in a community garden had significant reduction in their HgA1c postintervention, compared to persons who did not participate actively.

Post-Austronesian migrational wave of West Polynesians to Micronesia.

This study examines Y-chromosome and mtDNA markers in the population of the island of Kiritimati in the context of geographically targeted reference populations from the Pacific. Kiritimati derives its population from the atoll islands of the Gilbert Archipelago and representsa geographicaltransitional region between Micronesia, Polynesia and Melanesia that likely played a critical role during theAustronesian expansion. The large presence(84.1%)of individuals withO-M175, O2a-M324 and O2a2b-P164 sub-haplogroups, 69.9% being O2a2b-P164, the Y-STR homogeneity within O2a2b-P164 and the very recent age of the sub-haplogroup(363-548 years ago)inKiritimati suggestthe arrival ofa genetically homogenous population to the Gilberteses followed by a population expassion.The close Y-STR haplotype affinities with profiles from the Samoa and Tonga Archipelagos point to an unprecedented massive post-Austronesian expansionexodus from West Polynesia.Contrasting the abundance of AustronesianO2a2b-P164 sub-haplogroup, the most abundantMelanesian/Papuansub-haplogroup,C-M130is present at a frequency of 13.5%. Thenetwork topology suggests that C-M130 arrived to theKiribati Archipelago from West Polynesia, specifically from West Samoa, Tonga and/or Tutuila subsequent to the Austronesian expansion about 832-1408 years ago. The haplotype affinities withinO2a2b-P164 argue for anoriginal source in Taiwan and its dispersal to West Polynesia and then to Southeast Micronesia. The present investigation provides an understanding of the genetic composition and complex migration history of an understudied region of the Pacific and provides evidence for recent dispersals towards Micronesia from West Polynesia subsequent to the initial Austronesian expansion.

Hansen disease among Micronesian and Marshallese persons living in the United States.

An increasing proportion of Hansen disease cases in the United States occurs among migrants from the Micronesian region, where leprosy prevalence is high. We abstracted surveillance and clinical records of the National Hansen's Disease Program to determine geographic, demographic, and clinical patterns. Since 2004, 13% of US cases have occurred in this migrant population. Although Hawaii reported the most cases, reports have increased in the central and southern states. Multibacillary disease in men predominates on the US mainland. Of 49 patients for whom clinical data were available, 37 (75%) had leprosy reaction, neuropathy, or other complications; 17 (37%) of 46 completed treatment. Comparison of data from the US mainland with Hawaii and country-of-origin suggests under-detection of cases in pediatric and female patients and with paucibacillary disease in the United States. Increased case finding and management, and avoidance of leprosy-labeled stigma, is needed for this population.