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Running head: DANCE REGIMEN FOR DIABETES 1

Traditional Dance as an Exercise Regimen for Marshallese Patients with Type 2 Diabetes Mellitus

Brayden L. Walker

University of Hawai’i at Hilo

This practice inquiry project has been approved for meeting full requirements for the Doctor of Nursing Practice Degree at the University of Hawai’i at Hilo School of Nursing.

Committee Co-Chairs

Dr. Alice Davis

Dr. Kimberly Shmina

DANCE REGIMEN FOR DIABETES 2

Table of Contents

Abstract…………………………………………………………………...……………………….3

Chapter 1: Statement of Problem, Project Aims and Objectives………….………………………4

Chapter 2: Review of Literature and Conceptual Framework……………………………..……...9

Chapter 3: Project Design and Evaluation Plan………………………………...………………..35

Chapter 4: Results………………………………………………………………………………..43

Chapter 5: Recommendations and Conclusions………………………………………………….74

References……………………………………………………………………….……………...105

Appendix A: Informed Consent for Dancers………………………………………….……...…120

Appendix B: Informed Consent for Evaluators…………………………………...…………….123

Appendix C: CITI Documents..…...…………………………………………………….……...126

Appendix D: Budget/Resources/Timeline…...…………………………………………….…....128

Appendix E: IRB Approval Letter ……………………………………...…………….……..…129

Appendix F: Cultural Survey…...……………………………………...…………………..…...131

Appendix G: Exercise Survey…………………………………………...…………………..….133

Appendix H: Cultural Basis for Dance Questionnaire…….…………………...….…………....135

Appendix I: Results from Cultural Evaluation……………………………………………..…..136

Appendix J: Results from Exercise Evaluation………………………………………..……….137


Abstract

Diabetes is a global health care problem. It is associated with several health

complications such as overweight/obesity, cardiovascular complications, vision complications,

and renal complications among others. Some groups are more disproportionally affected by

diabetes and one of these such groups are the Marshallese people (Naseem, 2010).

Exercise can be a useful way for patients to manage their diabetes. The problem is about

65% of Marshallese do not exercise at all or only exercise for less than 20 minutes a day which

does not meet the recommended weekly value of 150 minutes per week (Reddy, Shehata, Smith,

& Maskarinec, 2005; WHO, 2011). Culturally appropriate exercise may be a better fit for these

people as compared to other forms of exercise such as running or weight-lifting.

The purpose of this project was to develop a dance regimen which was culturally

appropriate. Once the regimen was recorded, it was evaluated by a group of stakeholders for

feasibility, cultural appropriateness and whether it met the current recommendations for physical

activity. It was designed to target the East Hawai’i Marshallese adult population who have been

diagnosed with type 2 diabetes mellitus (DM2). Results include the creation of a culturally

appropriate dance exercise regimen which met recommendations for physical activity overall and

that this regimen is a tool to aid providers and patients meet and exceed their diabetes

management goals.


Traditional Dance as an Exercise Regimen for Marshallese Patients with Type 2 Diabetes

Mellitus

Chapter 1: Statement of Problem, Project Aims and Objectives

Nearly every population of people throughout the world is subject to diabetes and its

potentially life-threatening complications and in fact, since 1980, the prevalence of diabetes has

increased (or at least stayed the same) in 200 countries of the world (Zhou et al., 2016). Some

populations have higher incidence of diabetes than others; African Americans, Hispanic

Americans, American Indians, and Asian and Pacific Island populations have higher diabetes

rates as compared to Whites (Agency for Healthcare Research, 2001). Among Pacific

Islanders, a particularly vulnerable group are the Marshallese, a small population from the

Marshall Islands. Diabetes affects an estimated 28% of Marshallese over the age of 15 and 50%

of those over age 35 (Naseem, 2010). In comparison, 12.2% of people 18 years of age or older

have diabetes in the United States (US) (Centers for Disease Control and Prevention, 2017b).

Background

Diabetes is classified and defined by elevated blood glucose levels. These are measured

as either fasting blood glucose/sugar (FBS) or hemoglobin A1c. A person with three FBS levels

at or above 126 mg/dL or a hemoglobin A1c level of 6.5% or above is said to have diabetes

(American Diabetes Association, 2015). Diabetes has afflicted many people of Micronesia over

the past several decades. Micronesia consists of Guam, the Commonwealth of the Northern

Mariana Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, and

Palau (PATA Micronesia Chapter, n.d.). Nuclear testing on the Marshall Islands has subjected

the Marshallese people to environmental circumstances which lead to an increased incidence of

diabetes (Alvares, 2010).


Following many years of disease and cultural and lifestyle destruction which resulted as a

byproduct of the United States testing nuclear weapons on the Marshall Islands, the Compact of

Free Association was created in 1983 and amended in 2003 (Department of State, n.d.; Guyer,

2001). Because of this agreement, Marshallese peoples are free to move to Hawai’i where they

are provided health care, housing, and employment among other things. One well known aspect

of the Marshallese people is they get very little exercise as compared to life before the

destruction of their homelands which, along with a drastic change in traditional diet, has led to

the high incidence of diabetes among this population (Reddy, Shehata, Smith & Maskarinec,

2005). Approximately 65% of Marshallese do not exercise at all or only exercise for less than 20

minutes per day which does not meet the recommendation of 150 minutes per week (Reddy et

al., 2005; WHO, 2011.).

Dance means “to move one’s feet or body, or both, rhythmically in a pattern of steps,

especially to the accompaniment of music” (Dance, 2016). Patients and providers alike have

approached diabetes prevention and management in many different ways including diet,

exercise, and medications. Adherence to specific exercise recommendations from providers may

be a challenge for diabetic patients. Many Marshallese do not exercise much, but, they do love

to dance (Adams, 2016; Reddy et al., 2005). Dancing stands as an important aspect of their

culture (Adams, 2016). So, in order to incorporate exercise as dance and something which is

enjoyable and familiar, a traditional dance regimen was developed and evaluated to meet cultural

expectations and exercise recommendations. Dance can be an excellent type of aerobic exercise

with benefits ranging from weight control and heart health to improved balance and mood

(Berkeley Wellness, 2014). Also, dance has been used effectively as a form of exercise in


diabetic patients (Krishnan et al., 2015; Murrock, Higgins, & Killion, 2009; Natesan et al.,

2015).

Problem Statement

Although exercise is known to be an effective component of a treatment regimen for type

2 diabetes (O’Hagan, De Vito, & Boreham, 2012), Marshallese individuals do not engage in

sufficient physical activity to meet the minimum guidelines for overall health.

Support for the Problem

Diabetes is a disease of national concern. The Office of Disease Prevention and Health

Promotion (ODPHP) (2016) released the Healthy People 2020 (HP2020) topics and objectives.

Healthy People is a “science-based, national health promotion and disease prevention” initiative

with goals to improve health of all US citizens (CDC, 2017a). Regarding diabetes, the overall

goal for the US and HP2020 is to “reduce the disease and economic burden state of diabetes

mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM”

(ODPHP, 2016). The ODPHP (2016) also states “people from minority populations are more

like to be affected by type 2 diabetes.” “Minority groups constitute 25 percent of all adult

patients with diabetes in the United States” and Pacific Islanders are part of the group of persons

who “are at particularly high risk” for developing DM2 (ODPHP, 2016).

Each state has its own goals, objectives and outcomes based upon the priorities identified

by the HP2020 report. Hawai’i has focused their effort on eight different indicators related to

diabetes (Hawai’i Health Matters, 2016). The only two objectives currently being met are

diabetes death rate and the number of diabetics who receive annual eye exams (Hawai’i Health

Matters, 2016). This means 75% of Hawai’i’s objectives are not being met for diabetes. The

updated data as of 2017, shows Hawai’i is now meeting two other objectives including diabetic


foot checks and biannual hemoglobin A1c checks (Hawai’i Health Matters, 2017). Other

objectives not currently being met include “new cases of diabetes,” decreasing those with

hemoglobin A1c above 9.0%, daily blood sugar tests, and formal education on diabetes (Hawai’i

Health Matters, 2017). If implemented beyond this pilot project, the culturally appropriate and

physically active dance regimen may help in reaching one of Hawai’i’s HP2020 diabetes

objectives, decreasing hemoglobin A1c, since dance as exercise has been shown to reduce

hemoglobin A1c (Natesan et al., 2015).

Project Goal

The goal for this project is to promote dance as a valuable exercise option for

Marshallese persons with diabetes mellitus through the promotion of regular physical exercise.

The project is based on Pender’s Health Promotion Model and will use a culturally appropriate

dance regimen.

Project Aims and Objectives

There were three aims for this project which helped in accomplishing the main project

goal. These aims were (a) setting the project foundation, (b) developing a culturally congruent

dance-based exercise program and (c) evaluating the dance-based exercise program.

Aim 1: Setting the project foundation. The first aim was to determine the

underpinnings necessary for undertaking this project. The objectives for this aim were to:

Objective 1: Determine the key stakeholders from the Marshallese community who

assisted in planning the project.

Objective 2: Identify the cultural basis for dance in the population, including who dances

(young/old), types of dance, dance music, significance of dance within the culture and

impact of dance on the community.


Objective 3: Identify the target population for a dance/exercise program.

Aim 2: Develop a culturally congruent dance-based exercise program. The second

project aim was to develop a structured dance regimen that met the minimum physical activity

standards for health and was culturally congruent with Marshallese traditions/expectations.

There were four objectives for this aim. They included:

Objective 1: Analyzing the use of dance as a health intervention according to Pender’s

Health Promotion Model.

Objective 2: Identifying cultural preferences of Marshallese migrants related to dance and

exercise.

Objective 3: Combining the elements of effective dance-as-exercise programs with

identified cultural preferences creating a culturally congruent dance regimen for

Marshallese adults.

Objective 4: Using a dance instructor, a video exercise program was created and recorded

using a culturally congruent dance regimen to achieve the minimum recommended

physical activity standards for adults.

Aim 3: Evaluate the dance-based exercise program. The third aim was to evaluate the

dance regimen for implementation feasibility and whether it met cultural and exercise

expectations. The objectives for this third aim were:

Objective 1: Assemble a team of stakeholders that evaluated the recorded dance program.

Objective 2: Analyze evaluation results, determining possible changes to the program and

identifying barriers and facilitators to program implementation.


Chapter 2: Review of Literature and Conceptual Framework

Guiding the completion of this project’s aims, objectives and goals was Pender’s Health

Promotion Model. Chapter two addresses the HPM and the review of literature that set the

foundation for this project. The literature review covers areas such as (a) Marshallese history

and the health barriers they face, (b) the pathophysiology of diabetes, (c) benefits of exercise in

diabetes and (d) dance in the Marshallese culture.

Conceptual Framework

The framework which guided this project was the Health Promotion Model (HPM)

developed by Nola Pender and described in Health Promotion in Nursing Practice (4th ed.),

(2002). There are seven assumptions and 14 theoretical propositions on which the HPM is based

and on which this project was based. The 14 propositions include:

1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and

enactment of health-promoting behavior.

2. Persons commit to engaging in behaviors from which they anticipate deriving

personally valued benefits.

3. Perceived barriers can constrain commitment to action, a mediator of behavior as well

as actual behavior.

4. Perceived competence or self-efficacy to execute a given behavior increases the

likelihood of commitment to action and actual performance of the behavior.

5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health

behavior.

6. Positive affect toward a behavior results in greater perceived self-efficacy, which can,

in turn, result in increased positive affect.


7. When positive emotions or affect are associated with a behavior, the probability of

commitment and action is increased.

8. Persons are more likely to commit to and engage in health-promoting behaviors when

significant others model the behavior, expect the behavior to occur, and provide

assistance and support to enable the behavior.

9. Families, peers, and health care providers are important sources of interpersonal

influence that can increase or decrease commitment to and engagement in health-

promoting behavior.

10. Situational influences in the external environment can increase or decrease

commitment to or participation in health-promoting behavior.

11. The greater the commitment to a specific plan of action, the more likely health-

promoting behaviors are to be maintained over time.

12. Commitment to a plan of action is less likely to result in the desired behavior when

competing demands over which persons have little control require immediate

attention.

13. Commitment to a plan of action is less likely to result in the desired behavior when

other actions are more attractive and thus preferred over the target behavior.

14. Persons can modify cognitions, affect, and the interpersonal and physical

environments to create incentives for health actions. (Pender, Murdaugh, & Parsons,

2002, pp. 63-64)

The Health Promotion Model was the guiding force for this project. This model was used due to

its applicability to dance in this setting of an exercise regimen. The ways in which this project

fits with the health promotion model are discussed later in this paper.


The Health Promotion Model is Pender’s way of describing the multidimensionality of

people while interacting with the environment during the pursuit of health (Petiprin, 2016). This

models health as a positive, active way of living and not just sans disease (Petiprin, 2016). The

HPM focuses on three main areas including “individual characteristics and experiences,

behavior-specific cognitions and affect, and behavioral outcomes” (Petiprin, 2016). It seems as

if this model is intended place individuals at the forefront of their own health, placing

responsibility on them for their own wellbeing. Everyone’s experiences and characteristics are

unique and therefore affect their actions differently while their knowledge and affect play an

important motivational role in their health promotion (Petiprin, 2016). The goal of the model is

echoed in its title, health promotion and health promoting behavior (Petiprin, 2016). The result

is healthier individuals overall. Therefore, this behavioral engagement by persons should

ultimately lead to improved health status, enhanced functioning and lastly, a better quality of life

(Petiprin, 2016). Thus, with the HPM as a guide, the goal of this project was to promote dance

as a valuable exercise option for Marshallese persons with diabetes mellitus through the

promotion of regular physical exercise and in the future, result in the same improved health

status, enhanced functioning and better quality of life exampled by the HPM as described by

Petiprin (2016).

Dance and this project fit the propositions of the HPM in several ways. The dance

regimen designed in the project fits the first proposition, “prior behavior and inherited and

acquired characteristics influence beliefs, affect, and enactment of health-promoting behavior”

(Pender et al., 2002, p. 63), because it was supposed to be and actually was familiar to the

population’s understanding of the dance, and dance as a physical activity can thereby initiate a

health-promoting behavior in the participants. It was our hope that this project meet proposition


two, “persons commit to engaging in behaviors from which they anticipate deriving personally

valued benefits” (Pender et al., 2002, p. 63), by helping this population see there are benefits for

them in managing diabetes with exercise through dance. Propositions three, four, six and seven

which collectively deal with perceived barriers, commitment, self-efficacy and positive affect

(Pender et al., 2002) were also met by this project. They, the Marshallese, were familiar with the

dances and have a cultural and personal view of dance. Though not assessed, Marshallese can be

familiar with the dances and confident in their abilities to perform the dances, thereby removing

some of their perceived barriers to exercise. Having other community members lead and/or

participate in the classes would assist in meeting the eighth and ninth propositions of the HPM.

These propositions relate to the importance of significant others, friends, family members and

health care providers’ influence on behavior (Pender et al., 2002). These are a few ways in

which dance fits the HPM.

The concept map (Figure 1) developed for this project is centered on the main concept of

culture. One definition of culture is “the customary beliefs, social forms, and material traits of a

racial, religious, or social group” (Culture, 2017). Culture greatly impacts both health and health

care (Clarke, 2016), therefore, culture was a central concept for this project. Staying within the

bounds of the Marshallese migrant culture, those with diabetes were the focus for this project.

Secondary prevention springs from the concept of diabetes as an important aspect of the

management of patients with diabetes. Secondary prevention is focused not upon preventing the

development of diabetes, but, instead upon managing and reducing the morbidity and mortality

associated with diabetes. Dance served as the exercise intervention that was evaluated in this

project. It was important for this dance to be both enjoyable (to help people maintain interest

and participation) and traditional in nature because culture impacts health and health care


(Clarke, 2016). Culture and diabetes were the main concepts in this project. The concepts of

Marshallese and migrants contribute to the overall concept of culture as well as diabetes.

Secondary prevention and dance are concepts related to diabetes in that secondary prevention

targets those with diabetes already and dance is a potential method for secondary prevention for

diabetes. Finally, exercise, enjoyment, and traditions are part of the concept of dance.

Figure 1. Diabetes among East Hawai’i adult Marshallese migrants: responses to dance. A

concept map developed for this project.

Literature Review

According to the World Health Organization (WHO) DM2 is a form of chronic metabolic

disease and causes and devastating effects for people (WHO, 2016a). Complications of diabetes


include renal failure, amputations, blindness, cardiac disease and stroke (Centers for Disease

Control and Prevention, 2011). Given these complications, diabetes can be catastrophic for those

individuals, their family and friends, their communities and the health care system who cares for

them. Worldwide, there are 422 million adults with diabetes (WHO, 2016a). In the US, 9.1% of

people have diabetes and 35% of the population is considered physically inactive (WHO, 2016c).

In contrast, in the Marshall Islands, nearly 21% of the population have diabetes (WHO, 2016b).

The Marshallese have more than twice the incidence of diabetes when compared to the United

States.

Cost of diabetes. Diabetes costs make up a significant amount of health care spending in

the US. According to the Centers for Disease Control and Prevention (CDC), a total of 20% of

spending on health care is for those who are diagnosed with diabetes (includes both type one and

type two diabetes though about 90-95% of diagnosed diabetes is DM2) (CDC, 2016). This

means that 20% of healthcare spending goes for about nine percent of the US population. The

American Diabetes Association (ADA) states that diabetes cost the US $245 billion in 2012, up

from $174 billion in 2007 (ADA, 2013a). Diabetes is a costly chronic disease for the US and for

states individually. Diabetes costs Hawai’i $1.11 billion (ADA, 2013b). Patients with diabetes

have medical expenditures that are about 2.3 times higher than patients without diabetes,

totaling, on average, $13,700 each year (ADA, 2013a). This is a costly condition for a disease

that can, for the most part, be prevented. Government insurance covers about 62.4% of diabetes

costs, private insurance covers about 34.4% of diabetes costs and those who are uninsured makes

up 3.2% of diabetes costs (ADA, 2013b). Uninsured diabetic patients have 79% fewer office

visits, 68% fewer prescriptions, and visit the emergency department 55% more than those with

insurance (ADA, 2013b). The costs associated with diabetes, lower incomes, lack of insurance


and difficulty navigating the health care system makes diabetes management potentially

challenging for the Marshallese population by forming barriers to health as discussed in latter

sections.

Diabetes pathophysiology. Diabetes is complex, progressive and debilitating and its

pathophysiology involves the pancreas, liver, adipose tissue, skeletal muscle, gastrointestinal

tract, kidneys and the brain (Cornell, 2015). Diabetes inflicts lasting and devastating effects on

the vital body systems and organs. β-cells in the pancreas are responsible for insulin production

and declining β-cell function can be attributed to several factors including genetics, age, diet and

exercise, glucotoxicity and lipotoxicity (Cornell, 2015). Proper function of β-cells is necessary

for control of insulin and therefore, blood sugar and when disrupted in their function by intrinsic

or extrinsic factors, can result is diabetes. Decreased insulin secretion by β-cells is “likely the

most critical functional β-cells defect in the development of type 2 diabetes” (Fonseca, 2009, p.

S151). When these β-cells function declines, then the signs and symptoms of diabetes would

begin to appear as discussed in the next section. The liver contributes to diabetes because it

becomes resistant to insulin suppression and overproduces glucose (DeFronzo, 2009). One

expert asserts insulin resistance of muscle could be responsible for 90% of the impairment of

type 2 diabetics’ glucose disposal (DeFronzo, 2009). When these and other body tissues become

resistant to insulins effect, they become unable to utilize glucose which increases blood glucose

levels until blood glucose increases enough to classify a person as diabetic. In DM2, adipocytes

also become resistant to insulin’s effect thereby creating increased amounts of free fatty acids

which lead to lipotoxicity (Cornell, 2015; DeFronzo, 2009). Understanding the pathophysiology

of diabetes is important when considering treatment and management options. Both health care

providers and patients should understand the pathophysiology as it can affect medication choice


and influence lifestyle modification. Lipotoxicity consists of gluconeogenesis stimulation, liver

and muscle insulin resistance, and insulin secretion impairment (DeFronzo, 2009). The

gastrointestinal tract in diabetes is also affected, resulting in increased motility, glucagon

secretion and glucose release by the liver and a decrease in glucose-dependent secretion of

insulin which all negatively impact glycemic control (Cornell, 2015). These result, again, in

more glucose not being used by the body and less insulin being produced. It is an additive effect

with more glucose being produced and less insulin being produced and then with less insulin

being produced, more glucose is released, with each worsening the other. Kidneys also increase

glucose production in DM2 through gluconeogenesis (Cornell, 2015). All these factors and body

systems contribute to the development of DM2.

Diabetes complications. There are more than 29 million Americans who have diabetes

and in 2013, diabetes was a leading cause of mortality in the US (CDC, 2016). Furthermore,

diabetes itself is not the only health concern for diabetic patients. There are many chronic

complications of diabetes people may suffer as comorbidities which can affect most of the organ

systems of the body including the neurologic, cardiovascular, integumentary, peripheral vascular,

renal, endocrine, and ophthalmic systems.

Chronic neurological complications of diabetes mellitus include neuropathy, strokes,

neuralgia and arthropathy (ADA, 2013b). These are complications that may never resolve or are

managed with additional medication. Peripheral vascular complications may include

atherosclerosis and varicose veins resulting in amputations (CDC, 2016). Amputations may be

necessary after damage caused by diabetes leads to infection following nerve and blood vessel

damage (CDC, 2016), and ulcers (ADA, 2013b). Diabetes causes both micro- and macro-

vascular changes in the body. These vascular changes are responsible for many of the


complication of diabetes. Cardiovascular disease is a chronic complication of diabetes and may

include aneurisms, heart failure, myocardial infarction and hypertension (ADA, 2013b). It is

astonishing that one problem, elevated blood glucose, can be responsible for such drastic

complications and comorbidities. Furthermore, diabetics are twice as likely to suffer a stroke or

heart disease as nondiabetics – and earlier in life also (CDC, 2016). Diabetes is not a disease that

respects one’s age, it inflicts its effects regardless. Renal complications may also occur in

diabetes and include kidney infections, renal failure, urinary tract infections, and end-stage renal

disease (ADA, 2013b). There can also be complications of the endocrine/metabolic system

(ADA, 2013b). Both renal and endocrine complications can further exacerbate diabetes and lead

to a decline in health and can lead to expensive, specialist care and treatment. These

complications include hyperlipidemias, hyperkalemia, hypercholesterolemia and renal glycosuria

(ADA, 2013b). Once patients begin on the path of uncontrolled diabetes, it can be difficult to

prevent further complications. The longer diabetes goes undiagnosed or uncontrolled, the more

likely serious comorbidities are to occur. The eyes may also be affected by diabetes (ADA,

2013b; CDC 2016). Vision problems common to diabetes include diabetic retinopathy,

glaucoma and cataracts which may all lead to vision loss (CDC, 2016). Ultimately, diabetes is a

major contributor to significant morbidities. For example, the CDC (2016) reports that diabetes

is the leading cause of lower-limb amputations, renal failure, and blindness with onset in

adulthood. It becomes a game of catch-up once the degeneration of body systems due to

diabetes has begun. Other chronic complications of diabetes may include bacteremia,

degenerative skin disorders, candidiasis, osteomyelitis and impotence (ADA, 2013b).

Marshallese population. The Marshall Islands are two chains of islands, with a

combined total of more than 1200 islands, located in the central Pacific Ocean (Kiste, n.d.). The


Marshall Islands are a remote and isolated island county. This sovereign nation consists of

nearly 70 square miles of land and more than 750,000 square miles of water (U.S. Department of

State, 2018). That is 70 square miles spread out over an area roughly the size of Idaho, Utah,

Colorado, Wyoming, Montana, North Dakota, South Dakota, and Nebraska. The islands were

settled around 30 BC, based on the earliest carbon dating, by skilled navigators who were likely

influenced by Polynesian culture (Kiste, n.d.). The islands were explored by various persons

including Christian missionaries from the US and Hawai’i who began preaching there around

1850 (Kiste, n.d.).

In 1886 Great Britain had a protectorate of the islands (Kiste, n.d.). A few years later in

1914, Japan took over the islands and in 1919 administered them as part of a League of Nations

mandate (Kiste, n.d.). During World War II, the US took over occupation of the islands after

gaining control in 1944 from Japan (Kiste, n.d.; U.S. Department of State, 2018). The area

became part of the United Nations Trust Territory of the Pacific Islands under US jurisdiction

from 1947 until 1986 (Kiste, n.d.). For 12 years, starting in 1946, the US tested nuclear bombs

on some of the islands/atolls of the Marshalls leading to contamination which would render the

Bikini Atoll inhabitable (Kiste, n.d.; U.S. Department of State, 2018). The radiation and fallout

from the nuclear testing devastated the islands. The radioactivity from these bombs destroyed

the health of many Marshallese (Guyer, 2001).

After separating from the Trust Territory of the Pacific Islands in 1978, the Marshall

Islands drafted and approved a constitution in 1979 (Kiste, n.d.). Despite this constitution, the

Marshall Islands Still remained a trust territory under US jurisdiction and after nuclear testing

had ended, the Compact of Free Association (COFA) was approved in 1983 which states the US

is responsible for the protection and financial assistance of the Marshall Islands (Kiste, n.d.).


The Compact of Free Association was signed in 1983 and the Marshall Islands became

independent in 1986 upon COFA implementation (U.S. Department of State, 2018). They

became a sovereign nation though the US still have a strong hold, influence and responsibility in

the islands. The COFA also allows US access to a missile testing range and provides for the

Marshall Islands to be fully independent at any time (Kiste, n.d.). The COFA is what allows

Marshallese people to freely migrate to the US and provides compensation for those affected by

the testing, covers injury claims by the islanders, and provides money for improving Ebeye

island’s (an island in the Marshall Islands) living conditions (Kiste, n.d.). It appears that the

COFA in part is an attempt at restitution for the destruction the US sponsored nuclear testing

cause the islanders. To Marshallese migrants, the COFA is more than a legal document and is

rather, as one migrant stated, “a law that binds the friendship between the Marshall Islands and

the United States” (McElfish et al., 2016b).

As of 2003, nearly 89% of the then 3000 Marshallese migrants living in Hawai’i

migrated after the COFA implementation (Graham, n.d.). There were relatively few Marshallese

living in Hawai’i prior to the COFA agreement took effect. According to the U.S. Census

Bureau, Summary File 2, released March 1, 2012, as of 2010, more than 6300 Marshallese

resided in Hawai’i (State of Hawai’i Department of Business, Economic Development &

Tourism, n.d.). So, it is likely this percentage of post-COFA Marshallese migrants in Hawai’i

has stayed roughly the same or has maybe even seen an increase in the number of migrants

moving to Hawai’i. According to a study of Marshallese migration conducted by Pobutsky,

Krupitsky, and Yamada (2009), respondents report the following reasons for migrating to

Hawai’i: (a) better medical and/or health care (34.7%), (b) better education (33.1%) and (c)

better job opportunities (22.3%). It is interesting to note that devastation from nuclear testing


was not listed as a reason to migrate to the US. It may be part of peoples’ reason for seeking

better health care if they are ill because of the testing whether directly or indirectly. The

devastation may also be included in the job opportunities if their or their families’ livelihood of

agriculture or fishing was impacted by the nuclear testing.

Morbidity and mortality. In the Marshall Islands, nearly 21% of the total population

have diabetes (more than double the US average) and 47.6% are considered physically inactive

(WHO, 2016b). This indicates that diabetes is, or should be, a problem of significance for the

Marshallese people. One way to improve these numbers would be to increase the number of

people who are physically active. In a study of an Arkansas population of Marshallese migrants

it was found that Marshallese discuss diabetes as a certainty for many community members

instead of a preventable condition (McElfish et al., 2016a). It is as though they have already

accepted that part of being Marshallese is being diabetic and lack optimism that there are ways to

prevent this widespread disease. Micronesians may have higher diabetes rates than other

Melanesians because of their Austronesian genetics (Hughes & Marks, 2009). Austronesians are

a group of people who share the Proto-Austronesian language who migrated and settled, among

other areas, the Southwest Pacific Ocean (Thomas, 2011) and whose genetics may be

predisposed to diabetes as described by the thrifty genotype theory (Hughes & Marks, 2009;

Neel, 1962). This Austronesian genetic may be a predisposing factor for the Marshallese

population. Environmental factors such as inactivity, obesity and stress combined with

hereditary components lead to the development of DM2 (Ali, 2013). As noted previously and

hereafter, the Marshallese deal with all these contributing risk factors of diabetes: inactivity,

obesity, stress, and genetics. Along with inactivity, people of the Marshall Islands have high

rates of overweight and obesity, 74.9% and 42.3% respectively (WHO, 2016b).


In a study of Marshallese and Chuukese migrants living on Hawai’i Island, Tan, Haumea,

Juarez, and Grimm (2014) found that 42.9% of Marshallese with diabetes were obese, about 66%

had hypertension and 80% had dyslipidemia. It is somewhat surprising that there were not

higher levels of obesity in those with diabetes. This would indicate that over half of Marshallese

diabetics are not obese and therefore may not be recognized by the health care system as being at

risk for diabetes. Therefore, they would go undiagnosed and develop comorbidities likely

contributing to the increased healthcare costs of Micronesians discussed in relation to social

determinants of health below. They also found that 1.5%, 0.9%, and 0.9% of these Marshallese

patients were on medication for diabetes, hypertension and dyslipidemia respectively (Tan et al.,

2014). This shows one or more of the following: (a) these diabetic Marshallese people in the

study have not been diagnosed and therefore are not being treated, (b) they have been diagnosed

but are either not being treated or are not compliant with their treatment plan, or (c) they have

been diagnosed but do not understand the diagnosis and treatment due to communication

barriers.

A study conducted on the island of Oahu, Hawai’i found that 24% of Marshallese

participants never exercise and 43% of the participants exercise for less than 20 minutes per day

(Reddy et al., 2005). This means that over two-thirds of Marshallese on Oahu do not get an

adequate amount of exercise each week. In another study of Marshallese migrants in Arkansas it

was found that obesity, not graduating from high school, and no time or place for exercise are

associated significantly with no physical activity (Felix et al., 2017). It is unclear from this

summary whether the lack of exercise contributes to obesity or being obese contributes to the

lack of exercise. It is likely that both statements are at least, in part, valid. This study also found

that over 90% of people surveyed liked walking for their exercise (Felix et al., 2017). The


problem is though, just because a person likes walking for exercise, does not mean they exercise.

Obese patients were almost two times more likely to say they are never physically active

compared to non-obese participants (Felix et al., 2017). If obesity is a risk factor for diabetes

and obese patients are twice as likely to not exercise than non-obese persons, then targeting

exercise would decrease risk factors of diabetes. Therefore, and exercise regimen would seem

like an appropriate intervention in the prevention and management of DM2 in the Marshallese

population. They found that even those participants who had been diagnosed with DM2 were

not any more likely to be physically active than nondiabetic participants (Felix et al., 2017).

Either the nondiabetic patients are very active and thus so are the diabetics or they are not getting

enough exercise. Given the subject matter, it would lend that the latter is more accurate.

Researchers assert the increasing diabetes epidemic in this population can be blamed, in part, on

turning away from subsistence living and becoming more sedentary (Yamada & Pobutsky,

2009).

Diabetes is but one of the many health disparities faced by Marshallese. For example, a

health assessment of an Arkansas population of Marshallese found that only 10.4% of those

surveyed had a normal body mass index (BMI), 28% were overweight and 61.7% were obese

(McElfish et al., 2016c). If being obese/overweight are independent risk factors of diabetes

development, nearly 90% of those surveyed are at risk of developing diabetes regardless of any

other risk factors they may have. This same assessment found that about 40% of Marshallese

studied were pre-hypertensive, about 40% had hypertension, and about 20% had both

hypertension and diabetes (McElfish et al., 2016c). Diabetes is not the only manageable or

treatable health concerns facing Marshallese individuals. Elevated blood pressure is also very

prevalent in this population. There are also many other health concerns for the Marshallese.


In the freely associated states, which includes the Marshall Islands, infectious disease

such as Hansen’s disease, hepatitis B, sexually transmitted diseases, tuberculosis along with

measles and dengue fever outbreaks are a continual occurrence (Yamada & Pobutsky, 2009).

Many of these diseases are not encountered as frequently in the US. Anemia, iron deficiency,

and vitamin A deficiency may be the result of malnutrition (Yamada & Pobutsky, 2009). There

has been an “explosion of chronic diseases” such as diabetes, obesity, high cholesterol,

hypertension and heart disease, arthritis, asthma, and cancer of both lifestyle-associated and

radiation-induced etiology (Yamada & Pobutsky, 2009). The anemias, malnutrition and chronic

disease resulted, at least somewhat from the years of nuclear testing in the islands. Also, in the

US, Marshallese mothers have preterm labor and give birth to low birth weight babies at a

significantly higher rate than non-Hispanic White women (Schempf, Mendola, Hamilton, Hayes,

& Makuc, 2010). Low birth weight puts infants at risk for further health complications and

likely more medical expenses at birth.

Barriers to health. The Marshallese people face many barriers to health. According to

the State of Hawai’i laws, Marshallese migrants who are children, pregnant women, aged, blind

or disabled are eligible for state-funded Medicaid services or similar services (State of Hawai’i

Department of Human Services, 2014). This is beneficial aid for those persons who qualify.

They are not, however, eligible for federally funded Medicaid (State of Hawai’i, 2009 as cited in

Yamada & Pobutsky, 2009). The state is able to help with Medicaid, but the federal government

is not helping the COFA migrants, so it is either up to the states to fund their health care or to the

Marshallese to find other means of health insurance or go without. Marshallese migrants who do

not meet the above criteria cannot qualify for Medicaid and are left to purchase insurance on

their own (Department of Human Services, 2014). They are, however, required to have health


insurance, face the penalty if they do not have insurance, and are eligible for tax credit subsidies

(Kellams, 2013; McElfish et al., 2016b). Though they are not eligible for Medicaid, they still

pay Medicaid tax along with other state and federal taxes (McElfish et al., 2016b). It does not

seem fair that they are required to pay for something that they are not even eligible for obtaining.

They are not eligible for food stamps unless they become citizens, are permanent residents, or

are veterans, active duty service members or service member dependents (Yamada & Pobutsky,

2009). Without Medicaid access, the Affordable Care Act is not affordable to the majority of

Marshallese who are low-wage workers (McElfish et al., 2016b). Without health insurance,

Marshallese do not fill prescriptions or seek health care because of costs (McElfish et al., 2016b).

Prescription and health care costs can be very expensive for those who are uninsured or born by

facilities such as emergency rooms or other facilities that provide services for uninsured persons.

For those who are uninsured, the Marshallese feel as though they are discriminated against and

are provided less effective or different care than insured patients (McElfish et al., 2016b).

Limited access to the system is made worse by lacking an understanding of the US’s complex

health system. The US health care system, with its open enrollment, insurance premiums,

primary care providers, and co-pays, is confusing and very different than in the Marshall Islands

(McElfish et al., 2016b).

In a study of Marshallese migrants to Arkansas, it was found that many participants were

very confused and lacked understanding of the ACA (McElfish et al., 2016b). With the entire

document well over 1000 pages long, it is likely that very few, if any, read the document.

Marshallese have expressed being confused and frustrated about co-pays, insurance premiums,

varying levels of coverage, the tax penalty and inconsistency with who is and is not covered

under the ACA and open enrollment (McElfish et al., 2016b). Frustration and difficulty also


arose because of a lack of follow-up when participants applied for ACA and after no one helps,

one participant shared how giving up was the option (McElfish et al., 2016b). When a person

does not understand the health care system, the ACA and no one is readily offering help, it is no

wonder why giving up would be the preferred choice. Navigating this system can be difficult for

Marshallese migrants who are trying to understand financing, insurance plans, primary care

provider assignment, and seeing more than one provider for various needs and specialties

(Yamada & Pobutsky, 2009). These struggles are only compounded for those in which a

language barrier affects effective communication. Nearly 29% of Micronesians (Chuukese and

Marshallese) surveyed reported difficulties accessing health insurance or health care (Pobutsky

et al., 2009). This means that they encountered challenges when trying to receive health care or

when applying for and/or utilizing health insurance. Marshallese often depend on others such as

family or friends to take them to appointments which can complicate scheduling and keeping

appointments (Yamada & Pobutsky, 2009). There are many barriers that prevent adequate

access to health care for the Marshallese residing in the United States.

With the COFA and commitment to friendship, migrants to the US believed their access

to health care here would be the same as in the Marshall Islands because the US funds most of

their health care in the Marshall Islands (McElfish et al., 2016b). To emphasize this point, one

participant shared how (s)he thought seeing a doctor would be simple and affordable like it was

in the Marshall Islands but, seeking health care in the US was much different and more difficult

than previously thought (McElfish et al., 2016a). (S)he continued sharing how (s)he was

particularly confused because the easy access health care in the Marshall Islands is funded

entirely by the US and is not the same as in the Marshall Islands even though there is an

agreement by the US to help the Marshall Islands (McElfish et al., 2016a). This research


participant shared something that is likely not an uncommon feeling among Marshallese because

why would health care be different when the same people, the US, are paying for the costs of

health care. It is widely felt by Marshallese that the US has not fulfilled their duty in the COFA

partnership (McElfish et al., 2016b). Some even feel the US is responsible for providing access

to health care because of the nuclear testing which was performed on their islands and that the

US is betraying them through denying access to Medicaid Expansion (McElfish et al., 2016b).

Expecting services that were believed to be encompassed in the COFA agreement and then not

having those services available like contributes further to the poor access to health care for the

Marshallese.

Social determinants of health. If a Marshallese migrant is able to access the health care

system, there are still other barriers to health they may face. Barriers such as limited ability for

speaking English and limited job skills are problems for Marshallese migrants (Yamada &

Pobutsky, 2009). These barriers are examples of social determinants of health. Social

determinants of health have been defined as “conditions in the environments in which people are

born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and

quality-of-life outcomes and risks” (HealthyPeople.gov, 2014). Many of these social

determinants of health affect the Marshallese population in Hawai’i, especially those who are

migrants, who knew a different life in the Marshall Islands and have had to adapt to the changes

they face in Hawai’i. A study of Marshallese migrants living on Oahu and Hawai’i island found

that about 30% of adults surveyed had less than a high school education, 28.1% graduated from

high school, and only 1.7% graduated from college (Pobutsky et al., 2009). This is a relatively

small amount of people who graduated from college. Though not always the case, college

education means better socioeconomic status and those with higher socioeconomic status are


healthier. A small proportion, 14.6% and 28% respectively, received public assistance in the

form of food stamps and/or Temporary Assistance for Needy Families (TANF)/Temporary

Assistance for Other Needy Families (TANOF) (Pobutsky et al., 2009). Twenty-eight percent of

households reported members were unemployed and those who are employed work mostly in the

service industry (Pobutsky et al., 2009) which is likely why many are low-income wage earners.

Roughly the same amount of people who were unemployed were also provided assistance with

TANF funding. Sixteen percent of the families (including both Chuukese and Marshallese)

reported homelessness or living in a homeless shelter (Pobutsky et al., 2009). These social

determinants such as lower educational attainment, homelessness and lower wages are more

barriers to health that this Marshallese population faces. Living in otherwise less than desirable

conditions is not congruent with improved overall health status. Health disparities are seen

among those of low socioeconomic status (Chen & Miller, 2013).

In a study of health care costs in Hawai’i Hagiwara, Juarez, Yamada, Miyamura and

Sentell (2016) found that Micronesian’s hospitalization health care costs were higher than other

racial or ethnic groups overall, though specific costs for diabetes were not significantly higher

than other groups. These high costs must be borne by someone and if the Marshallese patients

who are hospitalized do not have insurance then the health facilities must deal with the costs

associated with care provided adding further strain to the health care system. Another study also

found that Micronesians in Hawai’i are also hospitalized at a younger age and often more sick

than other population groups (Hagiwara, Miyamura, Yamada, & Sentell, 2016). This likely

signals the lack of seeking health care at early signs of illness or disease and because they wait so

long, there are more complications and comorbidities thereby resulting in higher costs for those

involved.


Lifestyle determinants of health. There is consensus agreement that adults should get

at least 150 minutes of moderate intensity or half that amount of high-intensity aerobic exercise

each week to receive substantial health benefits (U.S. Department of Health and Human

Services, 2008; WHO, 2011). When broken down, that is 30 minutes a day five days a week on

average. Finding that amount of time for exercise every day can be a challenge but the proven

benefits of exercise should be reason enough to sacrifice time elsewhere for health promotion.

For those who find the goal of 150 minutes per week too daunting, any activity is better than no

activity (U.S. Department of Health and Human Services, 2008). This is important because often

when people who are sedentary, starting a full 150 minute/week exercise regimen may not be the

best thing for them at that time. This is a general recommendation for overall health but going

from zero to a lot of exercise just might not be feasible. They could get discouraged and give up

or they could even cause injury to muscle, bone, joint, etc. which would be further detrimental, at

least in the short term, to their exercise plan. Those who do participate in any physical activity,

regardless of the amount, will gain at least some benefits for their health (U.S. Department of

Health and Human Services, 2008). It can be encouraging for persons to realize that any amount

of exercise is better than none and then following through by exercising.

The benefits of exercise on patients with DM2 is documented in the literature (Balducci

et al., 2014). In a metaepidemiologic study it was found that there is no significant difference

between exercise and medication therapies as they relate to mortality outcomes associated with

diabetes but, rather, are quite similar in their secondary prevention benefits (Naci & Ioannidis,

2013). This means that exercise is just as effective as medication in relation to secondary

prevention of complications and mortality associated with diabetes. Considering the costs of

diabetes medications, exercise seems the cheaper option. In a group of people where many are


low-income earners, exercise would appear to be the ideal option financially. O’Hagan et al.

(2012) state exercise effectively treats type 2 diabetes. This does not mean that it will cure

diabetes because if a person were to stop exercising after effectively treating DM2 with exercise,

they would revert to their diabetic state as indicated by increased hemoglobin A1c and elevated

blood glucose levels. Exercise leads to plasma glucose stabilization in the short term and

improved hemoglobin A1c, insulin resistance, and body composition with continuation of

exercise long term (O’Hagan et al., 2012). In a population of women with a history of

gestational diabetes, each increase of 100 minutes of moderate-intensity exercise, decreased their

risk of developing DM2 by nine percent (Bao et al., 2014). So not only does exercise treat

diabetes, exercise can also prevent the development of type two diabetes mellitus. This study

also found that the more hours watching television (inactivity) the greater the association was

with developing DM2 (Bao et al., 2014). It makes sense that if exercise prevents and treats

diabetes that the opposite would also be true, a sedentary life is more likely to lead to the

development of DM2. The Diabetes Aerobic and Resistance Exercise (DARE) clinical trial

found that aerobic and resistance exercise both decreased hemoglobin A1c 0.51 and 0.38

percentage points respectively over a six-month period (Sigal et al., 2007). Hemoglobin A1c

decreased even further when resistance and aerobic exercise were combined (Sigal et al., 2007).

The exercise recommendation of 150 minutes a week does not specify what type of exercise

other than moderate-intensity, so it would be beneficial, given the above study, to recommend a

combination or resistance and aerobic exercise that meets the moderate-intensity criteria for

those wanting to decrease hemoglobin A1c. Body composition improved and caloric intake

decreased slightly over the same time whereas blood pressure and lipid counts did not differ


significantly among groups (Sigal et al., 2007). It seems counter-intuitive that caloric intake

would decrease with exercise but may further explain the decrease in hemoglobin A1c.

Exercise and weight loss are important in glycemic management (Ismail-Beigi, 2012).

These two principles of health promotion are independent and interdependent aspects of diabetes

management. According to the ADA, regular exercise improves blood glucose control, aids in

weight loss, improves well-being and reduces cardiovascular risk factors (2012). The ADA

recommends diabetics get 150 minutes of moderate-intensity aerobic exercise (heart rate of 50-

70% of maximum) each week (2012). Their recommendation for exercise is no different than

the 150-minute recommendation for the general population. This exercise is to occur over at

least three days during the week without skipping exercise on more than two days in a row

(ADA, 2012). These 150 minutes can be broken down however a person wishes but would be

something like 50 minutes a day on 3 days a week, 35-40 minutes 4 days a week, 30 minutes 5

days a week, 25 minutes 6 days a week or just over 20 minutes each day. Interestingly, a study

of type 2 diabetic persons found as people undergo the exercise stages of change, they increase

their self-determined motivation and this motivation is maintained through regular exercise

(Fortier et al., 2011). So basically, the more you exercise, the more you will be motivated to

continue exercising. It is further recommended that, among those who are obese/overweight,

physical activity is a specific intervention which can be used as a secondary preventative

measure for the consequences of diabetes (Yamada & Pobutsky, 2009).

Though the ADA recommends specific intensity levels as well as time considerations for

exercise, Balducci et al. (2012) suggests a slightly different approach. In type 2 diabetics who

are sedentary, the intensity of exercise is not as important as the amount and type of exercise

when used as a therapy method for these patients (Balducci et al., 2012). Drawing from this, the


150-minute recommendation time limit is still true but maybe not the moderate-intensity

requisite when it comes to diabetic patients. They state a low-to-moderate exercise intensity is

approximately as beneficial as moderate-to-high intensity exercise (Balducci et al., 2012). These

two exercise intensities, low-to-moderate and moderate-to-high, improve risk factors and the

burden of cardiovascular disease (Balducci et al., 2012). This same study also found that

moderate-to-high intensity exercise did slightly, but significantly, improve hemoglobin A1c,

triglycerides and total cholesterol as compared to low-to-moderate intensity exercise (Balducci et

al., 2012). Thus, for reducing hemoglobin A1c, higher intensity exercise is more beneficial but

for cardiovascular benefits, intensity is not as important. Low-to-moderate intensity exercise did

decrease hemoglobin A1c from 6.99% to 6.66% (Balducci et al., 2012). This is a decrease in

A1c but not a significant decrease from baseline for these patients. Therefore, aerobic exercise is

effective in improving blood glucose control (Craven, Bane, & Kolasa, 2013).

Dance as exercise. Worldwide, 25% of people are physically inactive and this physical

inactivity contributes to nearly 3.2 million deaths annually and is the number four risk factor

overall for death throughout the world (Shahid & Shahid, 2016). Inactivity is not just a problem

for the Marshallese living in Hawai’i but rather a worldwide struggle. Dance has been promoted

as exercise through aerobic activities such as Zumba®. Zumba® is a workout combining music

and low and high intensity exercise (Zumba Fitness, LLC, 2018). A traditional dance regimen

for Marshallese would be like Zumba® in that it is structured, follows certain steps and involves

varying intensities of exercise. In a study of Zumba’s® effect upon diabetic and/or

overweight/obese women, it was reported that Zumba® significantly decreased body weight,

BMI and hip circumference though it did not demonstrate significant changes in blood pressure,

fasting blood glucose or hemoglobin A1c (Krishnan et al., 2015). Though this study did not


show a significant decrease in hemoglobin A1c, it did decrease BMI and weight thereby

reducing one of the major contributing factors to diabetes – obesity. In previously inactive

women who participated in a six-week aerobic dance regimen, health benefits of improving

blood oxidative stress were elucidated (Leelarungrayub et al., 2011). Dance has also been shown

to benefit elderly women’s physical performance and balance (Eyigor, Karapolat, Durmaz,

Ibisoglu, & Cakir, 2009). These two studies do not necessarily show health benefits for diabetes

but do indicate that there are health benefits through dance as exercise. A study by Murrock et

al. (2009) demonstrated an improvement in blood pressure and reduction of body fat in diabetic

African American women who participated in their 12-week, low impact, instructor led dance

regimen. This study on the other hand, does show that dance in diabetic patients, when used as

exercise, improves their health.

Dance is not only beneficial in adults with, or at risk of, diabetes. In a study of

overweight/obese New York City children, it was found that a culturally familiar freestyle dance

and lifestyle education program resulted in statistically significant improvements in BMI, fat-free

mass, cholesterol, endurance, and resting heart rate showing a decreased risk of diabetes and

cardiovascular disease (Hogg et al., 2012). It does not appear that dance as exercise is only

effective for certain age groups since studies show benefits in both children and adults. This

project is focused on the adult population but if there are Marshallese children who are obese that

were to participate in a regimen like this, they may also benefit from the dance exercise. A study

of diabetic and obese adult participants found that a ballroom and Latin dance program for two

hours twice weekly significantly decreased weight and waist circumference and led to a

decreased hemoglobin A1c over a three- and six-month period (Mangeri, Montesi, Forlani, Dalle

Grave, & Marchesini, 2014). Likewise, the Culturally Relevant Exercise for Type 2 Diabetes


(CURE-D) study followed an eight-week Bollywood dance intervention for South Asian women

with DM2 (Natesan et al., 2015). Similar to the wide age range of these studies, the type of

dance performed for exercise does not seem to matter when aimed at improved health outcomes

of diabetic patients. Given the results of these studies, a culturally appropriate dance exercise

intervention for the diabetic Marshallese population would likewise decrease weight and

improve BMI and hemoglobin A1c in this population. This regimen consisted of one-hour dance

classes twice weekly and showed a significant reduction in hemoglobin A1c among the

intervention group as compared to the control group (Natesan et al., 2015). Weight loss

improved insulin resistance and glycemic control and interestingly, even those participants in the

control group who did not lose weight as part of the dance classes still showed reduced

hemoglobin A1c levels (Natesan et al., 2015). This illustrates the fact that just because someone

is overweight/obese does not mean that they are also diabetic. Even without losing weight, A1c

was improved with exercise. Zumba® did not decrease A1c but these other studies did show

decreases in hemoglobin A1c. Those who attended at least 10 of the 16 dance classes also had a

statistically significant reduction of weight as compared to those who did not attend as many

sessions (Natesan et al., 2015). Natesan et al. (2015) continue to state that a culturally

appropriate dance intervention successfully promotes control of hemoglobin A1c when

compared to typical care. If this is true, then a culturally appropriate dance regimen would likely

promote that same A1c control in the diabetic Marshallese population if they were to follow

through with the regimen.

Dance is important to many cultures, Marshallese included. “The Marshallese also love

dancing” (Adams, 2016). The surveys received in this project likewise suggest the love for

dancing. The “beet” is a popular dance performed by the Marshallese (Adams, 2016). Another


dance is the Jobwa stick dance performed only on special occasions and for chiefs or those with

the high chief’s permission (Adams, 2016; Our Cultures Our Pride, n.d.). Local hula dancing has

become popular again as well (Carucci, n.d.). Even children are performing traditional dances

(iExplore, n.d.). Dance is also an important part of holidays, celebrations and ceremonies

(Carucci, n.d.; Our Cultures Our Pride, n.d.). Dance is a very important part of the Marshallese

culture as expressed by these various dances and statements regarding dance in the culture.

Thus, the reason for creating a dance as exercise regimen for diabetic Marshallese persons in this

project.

Summary of literature. There is ample evidence supporting diabetes as a pandemic and

that diabetes is of particular concern for Marshallese persons. Exercise is a known and widely

used part of managing diabetes for patients and providers alike. Dance has been used in many

applications of exercise and has been used specifically for diabetic patients (Murrock et al.,

2009). There is no available evidence showing a traditional dance regimen being implemented

for use among the Marshallese population in East Hawai’i or elsewhere. This necessitates the

project as yet one more way to help patients in East Hawai’i more effectively manage their

diabetes. Dance is a viable exercise option for the Marshallese of the Big Island because it is

already part of their culture, something they enjoy and dance has been shown to be effective in

the management of diabetes and a practical exercise option.


Chapter 3: Project Design and Evaluation Plan

Chapter three addresses the functional workings of this project including methods,

evaluation plan, expected outcomes and practice implications of this project and protection of

human subjects. Further delineated within the methods section are the project design,

population, sampling and data collection and analysis. The project aims and objectives are again

discussed here along with how they were to be accomplished.

Methods

Design. This was a pilot project to investigate the viability of a dance regimen in the

Marshallese population of East Hawai’i. It utilizes a qualitative and quantitative evaluation

design. It also involved the development and evaluation of a culturally appropriate dance

regimen for increasing physical activity in a vulnerable population.

Population. The target population for the dance regimen was the East Hawai’i, on the

island of Hawai’i, population of diabetic adult Marshallese migrants. The project focused upon

creating and evaluating a dance regimen for maintaining overall health which met exercise

recommendations and was also culturally appropriate. The dance regimen was designed to assist

a population who 1) are 18 years of age or older, 2) must have been diagnosed with DM2

sometime during their life, 3) must be of Marshallese descent but not necessarily born in the

Marshall Islands.

Sampling. A patient population was not utilized in this project but rather recruited dance

volunteers and evaluators. The dance instructor(s) and evaluators were sought out specifically

based on certain criteria and were not considered research participants. The dance leader was

competent in Marshallese dance and able to lead dance class sessions for recording. The

evaluators were either Marshallese persons or those who are very familiar with the culture to


evaluate the cultural aspect and appropriateness of the regimen or health care providers, exercise

scientists, diabetes educators, exercise/dance instructors, or other persons who were capable and

competent to evaluate the exercise standard of the regimen. Inclusion criteria for the dance

instructor and dancers were they must be Marshallese, adults aged 19-45, be able to perform the

dance and healthy individuals. The inclusion for evaluators were aged 19 years or older and any

of the following: Marshallese, familiar with the Marshallese culture, a health care provider,

exercise scientist, personal trainer, diabetes educator, or others qualified to evaluate the exercise

and/or cultural aspects of the dance program. The exclusion criteria for the dancers and dance

instructor were if they were diabetic, younger than age 19 or 46 years of age or older, taking

more than three medications, hypertension, or any other medical condition which would keep

them from participation such as heart failure or back pain limiting their ability to perform the

dance. The exclusion criteria for evaluators was if they were under the age of 19.

Data collection. Data was collected using survey instruments (see Appendices F, G and

H). The survey instruments were given to evaluators and stakeholders to complete and then

gathered for evaluation.

Data analysis. Surveys used for this project included Likert scale questions. Likert

scales allow for subjective data to be assigned a quantitative (numerical) value making the data

quantitatively analyzable (Hodgson, 2010). This data was entered into Microsoft Excel for

analysis. Qualitative data was entered into a table format to see if there were commonalities

among responses.

Evaluation Plan

The evaluation plan for this project involved the REAIM method for evaluation which

includes the areas of reach, effectiveness, adoption, implementation, and maintenance.


Reach: This was evaluated by determining the potential to reach the target population.

Effectiveness: Evaluation of effectiveness of the dance regimen looked at the potential to

meet current exercise standards and recommendations.

Adoption: Evaluation of the adoption of the dance regimen looked to see that, if effective,

people were willing to implement the dance regimen on their own. Also, evaluation of

adoption looked to see, if effective, if health care providers were willing to adopt this

regimen as a beneficial tool in helping diabetics manage their diabetes.

Implementation: Given this does not involve the dance regimen being implemented, but

rather evaluation of the regimen cultural and exercise standards, implementation was not

evaluated during this project.

Maintenance: Likewise, maintenance or sustainability was not evaluated as part of this

project.

Delineated next, are the specific methods for each objective included in this project.

Project goal: promote dance as a valuable exercise option for Marshallese persons with

diabetes mellitus through the promotion of regular physical exercise.

Aim 1: Setting the project foundation. The first aim was to determine the

underpinnings necessary for undertaking this project. The objectives for this aim were to:

Objective 1: Determine the key stakeholders from the Marshallese community who

assisted in planning the project.

o Utilize Micronesians United of the Big Island for help in accomplishing this

project. They agreed to be of assistance in any way for the implementation of this

project.


Objective 2: Identify the cultural basis for dance in the population, including who dances

(young/old), types of dance, dance music, significance of dance within the culture and


o This was accomplished through literature review.

o Stakeholders were also asked questions about the cultural basis for dance,

supplementing the review of literature.

Objective 3: Identify the target population for a dance/exercise program.

o Target population was sought from literature review, state and county statistics

and through stakeholder input as well as input from other contacts within the

community.

Aim 2: Develop a culturally congruent dance-based exercise program. The second

project aim was to develop a structured dance regimen which met the minimum physical activity

standards for health and was culturally congruent with Marshallese traditions/expectations.

There were four objectives for this aim. They included:

Objective 1: Analyzing the use of dance as a health intervention according to Pender’s


o The articles as well as other data and information obtained during the preceding

objectives were compared with the tenets of Pender’s Health Promotion Model.

Dance as an intervention was looked at to see if and how it fits the Health

Promotion Model.

Objective 2: Identifying cultural preferences of Marshallese migrants related to dance and

exercise.


o We surveyed a panel of stakeholders and one dance instructor for feedback

regarding dance and exercise.

o A question in the evaluation survey asked how culturally appropriate this regimen

was to the evaluator to help determine appropriateness.

Objective 3: Combining the elements of effective dance-as-exercise programs with

identified cultural preferences creating a culturally congruent dance regimen for

Marshallese adults.

o Elements of dance and culture were combined into a dance regimen.

Objective 4: Using a dance leader, a video exercise program was created and recorded

using a culturally congruent dance regimen to achieve the minimum recommended

physical activity standards for adults.

o We combined a culturally congruent dance regimen with exercise

recommendations to meet the minimum standards for physical activity.

o The video was to be created by recording a dance instructor(s) as he/she

performed dance moves set to culturally appropriate music of their choosing.

Other dancers were used to create the video.

o Implementation was to be via recorded videos available to be viewed on DVD or

YouTube.

o The videos were intended for use following a schedule of three times per week to

be completed at a convenient time by users.

Aim 3: Evaluate the dance-based exercise program. The third aim was to evaluate the

dance regimen for implementation feasibility. The objectives for this third aim were:


Objective 1: Assemble a team of stakeholders who evaluated the recorded dance

program.

o The stakeholder team was to consist of members of the local Marshallese

community, dance instructor(s), sports scientists, trainers, primary care providers

and others familiar with the Marshallese culture.

o Stakeholders were to be recruited through networking with the Micronesians

United of the Big Island (MU-BI) group. Also, exercise scientists, personal

trainers, primary care providers, diabetes educators, etc. were reached out to for

recruitment through contacting them via email or in person.

o Once stakeholders were identified, they were given either one or two surveys,

depending on qualifications. One survey addressed cultural preferences regarding

dance/exercise and the other evaluated the dance program.

Objective 2: Analyze evaluation results determining possible changes to the program and

identifying barriers and facilitators to program implementation.

o Quantitative survey data was analyzed by entering it into Microsoft Excel. Likert

scales allow for qualitative data to be assigned a quantitative (numerical) value

making the data able to undergo quantitative statistical analysis (Hodgson, 2010).

Qualitative data from the survey was analyzed for barriers and facilitators to

implementation and response commonalities.

Expected Results and Practice Implications

Expected results for this project were threefold. First, that there was a culturally

appropriate dance regimen created, as a form of exercise, for the local Marshallese population.

The literature review revealed that other culturally familiar dance and/or music has been


effectively used in dance exercise regimens for diabetics. Second, it was expected that the dance

regimen would meet the standards for exercise. Lastly, it was expected that there would now be

a program developed to help providers and this patient population meet and exceed diabetes

management goals. Given all the challenges facing the Marshallese migrants, utilizing a

treatment/management plan that incorporates something that is familiar to them would lend itself

to patients and providers realizing their diabetes goals. It is expected that this regimen would

ultimately lead to improved biomarkers such as decreased weight, BMI and hemoglobin A1c as

the literature review showed others’ work has likewise done.

Based on these expected results from this project, there were several anticipated

implications for nursing practice. The first is that this was a way to breach cultural barriers.

Culturally competent care is a corner stone of health care today, especially in culturally diverse

populations such as are found in East Hawai’i. The second expected outcome was similar to the

first and included the culturally competent exercise regimen, dance, being created. By utilizing a

dance regimen which is culturally appropriate practitioners would find a beneficial way to reach

those who may not like other types of exercise such as running, swimming, biking, lifting

weights, etc. This would add another tool to our ever-expanding care plans and methods for

managing diabetes in individual and population health care.

Protection of Human Subjects

Participants in this project are to include key stakeholders which will be evaluating the

dance regimen via surveys and those answering the cultural questionnaire. Dance instructor(s)

and dancers were not considered research participants for this project according to the University

of Hawai’i institutional review board which also approved this project (see Appendix E).

Identifying information was not to be included in the surveys. The data gathered from the


surveys were stored in a locked place. There was no expected risk for evaluators other than

potential stress or not being able to or wanting to answer a question. There is minimal risk for

the dance instructor(s) and dancers as they perform dances for recording. Possible risks for

dancers and dance instructors include muscle soreness and/or aches from dancing. Injury could

occur such as spraining an ankle while performing the dance moves. While possible, the

exercise was considered minimal risk and therefore, these risks were not likely to occur. If

severe shortness of breath occurred, referral of the participant to the emergency department was

to be made. These risks are inherent with dancing and if injury should occur, follow up with a

primary care provider was also to be advised.


Chapter 4: Results

Chapter four discusses the results of this pilot project. This chapter introduces each aim

and respective objectives and presents the results of each objective. The results from the cultural

basis for dance questionnaire and video evaluations are reported and analyzed accordingly.

Aim 1: Setting the project foundation

The first aim was to determine the underpinnings necessary for undertaking this project. The

objectives for this aim were:

Objective 1. Determining the key stakeholders from the Marshallese community who

would assist in planning the project.

The Micronesians United of the Big Island (MU-BI) were contacted since members of

the MU-BI board had stated they would help in any way possible with this project. Therefore,

MU-BI was the main focus in helping determine key stakeholders. Finding stakeholders was a

grass roots effort with this project. Initially the efforts were directed toward the MU-BI, an

organization that supports Micronesians who transition to American culture and manage their

cultural lifestyle in Hawai’i. Support from the MU-BI organization, although potentially the

most influential and connected to the people, was not forthcoming as planned. Therefore,

seeking stakeholders through other avenues was initiated. This approach resulted in connecting

with an influential member of the Marshallese community. Another unexpected entry to the

community was found through employees at the University of Hawaii at Hilo (UHH) who were

connected to other Marshallese individuals at UHH. Ironically, this second UHH employee had

a student working for him/her. The Marshallese student employee was a former president of the

Marshallese Iakwe Club (MIC) on campus. The MIC is a UHH and Hawai’i Community

College student association whose mission is to promote “cultural awareness and understanding


among its members, its college campuses and the community of the county of Hawai’i, develop

programs of mutual assistance, and to do active recruiting of Marshallese students to” these

campuses (UH Hilo & Hawcc Marshallese Iakwe Club, n.d.). Once contact was made with the

MIC, interest in the project and willing to help evolved. Through this series of grass roots

connections, MIC members and their faculty advisor along with one other leader of the local

Marshallese community became the primary stakeholders supporting the project.

Objective 2. Identify the cultural basis for dance in the population, including who

dances (young/old), types of dance, dance music, significance of dance within the culture and


The literature review revealed important information about dance in the Marshallese

culture including the idea that the Marshallese love to dance (Adams, 2016).

A 5-question questionnaire regarding dance in the Marshallese culture was developed and

given to members of the MIC. The project director was invited to a MIC meeting on campus by

one of the club’s officers. It was through the MIC president that access was gained to the MIC

membership. At a MIC meeting the project was explained. Sixteen MIC members completed

the questionnaire about dance in the Marshallese culture. The results from their answers are as

follows:

1. Who in the population dances? Old, young, all ages, no one, etc.


Table 1 Cultural Questionnaire Results for Who DancesAnyone who is still able to move without physical pain.

All ages usually dance.

Mostly young ages.

Usually all Marshallese, depending on if they want to or not.

All ages.

All ages.

Everyone except babies.

All ages.

All ages.

I would say the young ones dance.

All ages can dance.

All ages (those who are not disabled).

All ages.

All ages.

All ages.

I would say all ages of both gender.

Note. This table shows participants’ responses to the question, “Who in the population dances?

Old, young, all ages, no one, etc.”

For the first question, “Who in the population dances? Old, young, all ages, no one, etc.”

87.5% of participants responded that all ages dance (seven stated “all ages” and seven others

stated something similar indicate Marshallese people of all ages dance who are able and wanting

too). The other two responses were about how young people dance. One respondent who stated

all ages dance, clarified that both genders dance (see Table 1).

2. What type(s) of dance are there in this culture/population?


Table 2Cultural Questionnaire Results for Type of DanceFoot work, beat.

In the traditional form there are stick dances whereas for the more recent dances there is mostly beat dances with footwork and hand motions along with other fold dances.

Biit (mostly foot works).

Biit (Modern Marshallese culture dancing).

Biit; Jidbak.

Biit, jirbak, jobwa (stick dance).

Chanting, war dance.

Biit, Jirbak, stick dance (Jobwa).

Jobwa (stick dance), a cultural dance that only specific people dace to it. An elder chants.

Jobwa & biit.

We call it Biit dance and Jidrbak dance.

Dances called “Biit” and “Jidrbak.”

Stick dances, Fan (traditionally made) dance, Biit (Step dance), Jirdbak (stomp/tap) dance.

A dancing called Biit.

Biit, jiribak.

There is the “piit”, the “jobwa” which is mainly for the chiefs.

Note. This table shows participants’ responses to the question, “What type(s) of dance are there

in this culture/population?”

The second question establishing the cultural basis for dance in the Marshallese culture

was “What type(s) of dance are there in this culture/population?” Every respondent except one

listed at least one of the four dances, “Biit,” footwork, Jidrbak or Jobwa. Spelling was different

among respondents, but “Biit,” beat, and “piit” seem to be the same thing. Fourteen of sixteen

(87.5%) respondents listed “Biit” (or a spelling variation) as either their sole answer or part of

their answer. Footwork was mentioned by three people (18.75% of participants). Jidrbak (or a


spelling variation) and Jobwa (stick dance) were both mentioned by seven (almost 43.75%)

respondents. Other dances mentioned by one or two respondents include hand motions, other

folk dances, chanting, war dance, and fan dance (see Table 2).

3. What type(s) of music is listened to when dancing?

Table 3Cultural Questionnaire Results for Type of MusicAny music that one [?].

A lot of folk music and disco and cha-cha genres.

Any kind of music.

Depending on the person in charge of the choregraphy. Music differ, from modern to old music with ancient words and story lines.

Traditional Marshallese music/chant.

Marshallese music.

Old songs.

Traditional Marshallese music that tells a story.

Chants, some sing.

Chants.

Traditional music.

Marshallese traditional Biit music.

Traditional Marshallese music (folk music), chants (mostly historical).

Marshallese music.

Marshallese traditional music.

We have traditional songs whereas its almost like chanting & singing. Every song represents a story.

Note. This table shows participants’ responses to the question, “What type(s) of music is

listened to when dancing?”


The third question for the cultural basis of dance in the Marshallese culture included in

the questionnaire was “What type(s) of music is listened to when dancing?” Responses varied

for this question. Most respondents listed traditional Marshallese music, folk music or chants

(which appear to be the same thing). Twelve out of the sixteen respondents (75%) listed one of

these as the type of music listened to while dancing and two others (12.5%) listed old songs or

music in their answers. Two other people (12.5%) stated any music could be used to dance.

Other music types listed included disco, cha cha, modern and one person indicated it depended

on the choreographer (see Table 3).

4. What is the significance of dance within this culture?


Table 4Cultural Questionnaire Results for Significance of DanceThe dances mostly show a story or how to work.

In many cases, the dances depict a story or things we do in everyday life such as gardening, sailing the canoe, or even about playing sports.

Showing the importance of the culture. Most likely telling a story.

It shows modern or cultural activities & stories.

Tells a story about the Marshallese culture and traditions.

It tells a story about our culture & traditions.

It preserves our culture and who we are as a Marshallese.

Our dances tell stories of our everyday lives.

Story telling.

It tells or shows how we Marshallese showcase our culture to others by doing there dances.

The Biit is about our island’s stories.

Telling a story.

*It tells the store of our people from the past to present (conveys cultural practices and lifestyle).

A story.

It tells a story.

It is the coming together of a community. Some dances tells a story about a land or building a canoe.

Note. This table shows participants’ responses to the question, “What is the significance of

dance within this culture?”

The fourth question asks, “What is the significance of dance within this culture?” All but

two people (or 87.5% of participants) said dance tells a story or used the word story/stories in

their answer. The other two responses were about culture, with one person writing dance

showcases their culture and the other writing dance “preserves our culture.” These stories are

about “everyday life.” (see Table 4).


5. What impact do dance have on the community?

Table 5Cultural Questionnaire Results for Impact of DanceTo get them active.

It brings many people together and it brings joy to people especially keeping our culture alive.

Bring (?) all the yong teenagers in the community to get together and part of cultural awareness.

Gathering the community together (for enjoyement).

It is just a cultural thing to do.

Can also be a remembrance of the past (story, history, etc.).

Brings the community together.

Dance impacts our community in so many ways. One way is that it keeps our traditions or culture alive. The dances and chants have meaning to it that signifys our unity.

Brings all young, old, all ages together.

Brings the community together.

Keeping culture and traditions alive.

It reminds the younger generation to keep their or our tradition & culture alive.

Make us feel good and strong about our culture.

It’s really significant as part of the culture and it brings the community together.

*Keeps our traditions and cultural practices alive.

To celebrate Christmas & Birthdays.

It brings community together.

The closeness of each other.

Note. This table shows participants’ responses to the question, “What impact to dance have on

the community?”

The final question was “What impact do dance have on the community?” This question

received several different responses from participants. The two most common answers were


about bringing people together/unity/closeness (10 of 16 (62.5%) respondents) and about

“cultural awareness” and “keeping our culture alive” or culture mentioned by 9 of 16

respondents, or 56.25%. Other answers included getting people active, bringing joy,

“remembrance of the past,” and to “celebrate Christmas & Birthdays.” (see Table 5). The

cultural basis for dance in the population was established through this questionnaire to include

who dances, types of dance, dance music, significance of dance within the Marshallese culture

and impact of dance on the Marshallese community.

Objective 3. Determine the target population for a dance/exercise program.

Stakeholders were identified through literature, statistics, stakeholders and others in the

community. As mentioned earlier, over 6,300 Marshallese live in Hawai’i (U.S. Census Bureau,

2012). Of all Marshallese migrants to the US, one-in-three reside in Hawai’i (Hixson, Hepler, &

Kim, 2012). There is a large Marshallese population in Hawai’i County with the 2011-2015

American Community Survey 5-Year Estimates stating there is an estimated 2,868 Marshallese

living in Hawai’i County (United States Census Bureau, n.d.). The target population for the

dance program was the diabetic population living in this area. According to a MU-BI member,

about 100 Marshallese families live up the Hamakua Coast and large populations of Marshallese

are living in Kau and Ocean View on Hawai’i Island. Diabetic patients in these geographic

clusters would be potential participants for a culturally appropriate dance intervention.

Aim 2: Develop a culturally congruent dance-based exercise program

The second project aim was to develop a structured dance regimen which met the

minimum physical activity standards for health and was culturally congruent with Marshallese

traditions/expectations. There are four objectives for this aim.


Objective 1. Analyze the use of dance as a health intervention according to Pender’s


The Health Promotion Model was developed by Nola Pender (Petiprin, 2016). The HPM

describes how health promoting behaviors can lead to a better quality of life and an improved

health status (Petiprin, 2016). There are 14 propositions in the HPM and the analysis consisted

of comparing how dance fits within these 14 propositions. Some of the propositions were

grouped together in this analysis since they address similar ideas.

HPM proposition 1. “Prior behavior and inherited and acquired characteristics influence

beliefs, affect, and enactment of health-promoting behavior” (Pender et al., 2002, p. 63).

Only one participant stated that dance helps to get people active. People may not view

dance as a health-promoting behavior. Literature suggests dance can be a health-promoting

behavior as dance has previously been used in exercise lifestyle interventions (Eyigor et al.,

2009; Hogg et al., 2012; Krishnan et al., 2015; Leelarungrayub et al., 2011; Mangeri et al., 2014;

Murrock et al., 2009; Natesan et al., 2015). According to survey responses, this population

engages in dance as a way to bring people together, celebrate, and cultural preservation and not

for exercise.

HPM proposition 2. “Persons commit to engaging in behaviors from which they

anticipate deriving personally valued benefits” (Pender et al., 2002, p. 63).

Many respondents shared how the benefit of dance may be more about culture,

preserving culture and telling stories. No commitment to action was garnered from this project.

That was not the purpose of this project. The evaluators’ reviews, to be discussed later, show an

overall positive view about the dance video and project. The hope is to help people realize this

dance may be able to have health benefits in addition to uses and purposes of dance already


established within the Marshallese. As of October 26, 2017, there were 115 views of the video

on YouTube. If people are watching the video, more than for the evaluation, maybe it is being

used for its intended purpose.

HPM propositions 3-6. Proposition three is “Perceived barriers can constrain

commitment to action, a mediator of behavior as well as actual behavior” (Pender et al., 2002, p.

63). Proposition four is “Perceived competence or self-efficacy to execute a given behavior

increases the likelihood of commitment to action and actual performance of the behavior”

(Pender et al., 2002, p. 63). The fifth proposition is “Greater perceived self-efficacy results in

fewer perceived barriers to a specific health behavior” (Pender et al., 2002, p. 63). Proposition

six is “Positive affect toward a behavior results in greater perceived self-efficacy, which can, in

turn, result in increased positive affect” (Pender et al., 2002, p. 63).

These four propositions, numbers three, four, five, and six, are all similar in the aspects of

health promotion that they address. Specific barriers were not discussed in the cultural

questionnaire survey by respondents. However, participants did mention that as long as people

are healthy or able to, then they dance. Applying dance to the HPM (Pender et al., 2002), one

can deduce if someone perceives they may have a barrier such as a physical limitation, then they

may not commit to dancing for exercise. Barriers were ascertained in the evaluation of the dance

video and will be discussed later under Aim 3 since there are specific questions about barriers

and facilitators to implementation in the evaluation forms.

Almost every respondent to the cultural basis for dance questionnaire listed “Biit,”

“beat,” or “piit” as one of the forms of dance for the Marshallese suggesting this “Biit” style/type

of dance is well known by most people (surveyed) in the Marshallese culture. If Marshallese are

familiar with the dance, perhaps as these propositions state (Pender et al., 2002), they will be


more committed to dancing for exercise. Familiarity with the particular dance in the dance video

is also discussed under Aim 3.

HPM proposition 7. “When positive emotions or affect are associated with a behavior,

the probability of commitment and action is increased” (Pender et al., 2002, p. 63).

The overall responses to the impact and significance of dance within the culture and

community seemed to be positive in nature. For example, one person stated this “seems like an

exciting project” (J. Genz, personal communication, September 29, 2017). Therefore, it would

appear there is a positive view of dance within the Marshallese people surveyed. This positive

view, would in turn, hopefully increase commitment and action like listed in proposition seven of

the HPM (Pender et al., 2002). One respondent even mentioned, for the impact of dance on the

community question, that dance “brings joy to people.” If dance brings people joy, then

commitment may be increased.

HPM propositions 8-10. Proposition eight is, “Persons are more likely to commit to and

engage in health-promoting behaviors when significant others model the behavior, expect the

behavior to occur, and provide assistance and support to enable the behavior” (Pender et al.,

2002, p. 64). Proposition nine is, “Families, peers, and health care providers are important

sources of interpersonal influence that can increase or decrease commitment to and engagement

in health-promoting behavior” (Pender et al., 2002, p. 64). Proposition 10 is, “Situational

influences in the external environment can increase or decrease commitment to or participation

in health-promoting behavior” (Pender et al., 2002, p. 64).

There were no responses by participants regarding these propositions.

HPM proposition 11. “The greater the commitment to a specific plan of action, the more

likely health-promoting behaviors are to be maintained over time” (Pender et al., 2002, p. 64).


Having a specific plan (such as how many days per week to use the video regimen) for

the dance would help in meeting the tenets of proposition 11 (Pender et al., 2002). There was

not a specific plan suggested to the evaluators before they evaluated the video. Evaluators were

not committing to an action plan but only watching and evaluating the video.

HPM propositions 12 and 13. Proposition 12 is, “Commitment to a plan of action is less

likely to result in the desired behavior when competing demands over which persons have little

control require immediate attention” (Pender et al., 2002, p. 64). Proposition 13 is “Commitment

to a plan of action is less likely to result in the desired behavior when other actions are more

attractive and thus preferred over the target behavior” (Pender et al., 2002, p. 64).

The cultural questionnaire and evaluations did not address these tenets specifically.

HPM proposition 14. “Persons can modify cognitions, affect, and the interpersonal and

physical environments to create incentives for health actions.” (Pender et al., 2002, p. 64)

The cultural questionnaire and dance evaluations did not address this tenet specifically.

One evaluator’s response was, “it would be a new concept to dance for the intention of exercise.”

If Marshallese identified the need for cognitive modification of dance as exercise, dance as

exercise may become an option for them in managing diabetes and overall health.

Overall, propositions one through seven and fourteen were found to be achieved in this

project either completely or in part. Propositions eight through thirteen were not achieved in this

project. Further discussion of the HPM will be continued in chapter five.

Objective 2. Identify cultural preferences of Marshallese migrants related to dance and

exercise.

Both the cultural basis for dance questionnaire and the final cultural evaluation form for

the video address cultural preferences of dance and/or exercise. Stakeholders were surveyed


about who dances, types of dance, music for dancing, and significance and impact of dance in/on

the community in the cultural questionnaire. Stakeholders were also asked about the importance

of dance personally and in their (the Marshallese) culture and the importance of exercise

personally. Results for the questionnaire and the evaluations are delineated under Aim 3.

Overall, the importance of exercise personally was given an average score of 4.18/5 whereas

importance of dance personally was given an average score of 4.91/5 and importance of dance in

Marshallese culture a 5/5 score. One evaluator mentioned a specific preference of dancing to

guitar music instead of keyboard music. In the evaluation form, a question in the survey asked

how culturally appropriate this regimen was to the evaluator to help determine cultural

appropriateness.

Objective 3. Combine the elements of effective dance-as-exercise programs with

identified cultural preferences to create a culturally congruent dance regimen for Marshallese

adults.

Elements of dance and culture were combined into a dance regimen to be recorded for

use as an exercise video. Dance-as-exercise programs were reviewed in the literature.

Information was gathered from the literature and used in the creation of a Marshallese dance-as-

exercise video. Cultural aspects of dance and the Marshallese were also included in the video-

making process. The inclusion of cultural considerations in the dance video was accomplished

by having a Marshallese person coordinate the dance. A recording timeframe was selected based

on the dancers’ and other stakeholders’ schedules. In order to comply with the project protocol,

a private room on campus was secured to record the video. One person volunteered to be the

dance instructor and their specific role and expectations were reviewed. Although the intent was

to plan the dance regimen together, the instructor had the dance already planned at the time of


the recording session. According to the instructor, the dance had been previously choreographed

for a performance by some Marshallese members of the community. It fit cultural preferences as

the Marshallese were the dance’s choreographers.

Objective 4. Using a dance instructor, create and record a video exercise program which

uses a culturally congruent dance regimen to achieve the minimum recommended physical

activity standards for adults.

At the scheduled time, the dance video was recorded. Space was ample to provide room

for the dancers and a location for the music personnel so they could remain out of camera view.

Recording was from the back of the dancers, again, to maintain privacy as much as possible.

There was not a typical dance instructor for the video since Marshallese dance is not performed

in an ideal manner to facilitate the use of a dance instructor. Four individuals participated in the

dance and a vocalist and keyboardist/vocalist performed the music. The main dancer

coordinating the dance, wrote the order of the dances on the chalkboard for everyone to follow.

There were five total parts to the dance regimen.

The dancers and musicians practiced each part prior to recording. Each part was then

recorded until all parts had been recorded. Once the recording was completed, the dancers and

musicians were free to leave.

Editing of the dance video was performed by the project director. The goal of editing

was to meet minimum exercise recommendations. There was approximately five-and-a-half

minutes of recorded dance video. Having five to six minutes of exercise even every day, does

not meet the minimum recommendation of 150 minutes per week (U.S. Department of Health

and Human Services, 2008; WHO, 2011). Therefore, the length of the video was extended. To

do this, a slower warm-up section was created as the first round of the dance video. This was


meant to help people learn the dance steps and as an exercise warm-up. The warm-up phase was

set at 0.8 times the actual recording speed. Then the entire dance routine was repeated three

more times. The first repeated round was at the actual recorded speed. The next repeated round

was set at 1.1 times the actual recording speed and then again at 1.15 times the normal speed.

Two of the individual pieces of the routine were also repeated during this fastest tempo round.

There was time for a one-minute water break between the actual speed round and the first sped

up round of 1.1 times actual speed. Finally, the dance was slowed back down as a cool-down for

the last round at 0.95 times normal speed. Doing this, the video was manipulated from five-and-

a-half minutes to a 30 minute 33 second video recording. If people were to perform this five

days a week, they would be a couple minutes short of the recommended 150 minutes/week (U.S.

Department of Health and Human Services, 2008; WHO, 2011) because of the short water break

included in the video. Marshallese words and phrases were added to the video as it played to

help those viewing the video prepare for and explain what was happening in the video. An

English-Marshallese dictionary to translate to Marshallese and then a Marshallese-English

dictionary to back translate were used in order to better ensure a correct translation. Some words

and/or phrases did not really have a direct translation from English to Marshallese.

The finished video was made available to the public on YouTube under the title

Traditional Marshallese Dance – Exercise Video, so people could watch as they please. In order

to meet exercise recommendations, it is suggested that this particular video be used five times

weekly.

Aim 3: Evaluate the dance-based exercise program

The third aim was to evaluate the dance regimen for implementation feasibility. The

objectives for this third aim were:


Objective 1. Assemble a team of stakeholders to evaluate the recorded dance program.

The stakeholder team consisted of members of the local Marshallese community, the

dancers and person coordinating the dance, personal trainers/exercise dance instructors, primary

care providers and certified diabetes educators in the East Hawai’i/Hilo community.

Stakeholders were recruited through networking with the MIC as well as the initial Marshallese

member identified in Aim 1. Personal trainers/exercise dance instructors, primary care providers

and diabetes educators were sought out from previously established relationships as well locating

others through Internet searches for potential evaluators in the community. Most of the exercise

evaluators were found by the project director going from gym to gym. At least 12 cultural

evaluators and 13 exercise evaluators were recruited for evaluations. Eleven cultural evaluators

(91.67%) and seven exercise evaluators (53.85%) returned evaluations.

Once stakeholders were identified, they were given either one or two surveys, depending

on qualifications. One survey evaluated Marshallese cultural preferences regarding

dance/exercise and how well the video met cultural expectations. This survey was given to those

who were Marshallese or very familiar with the Marshallese culture. Only Marshallese

individuals ended up evaluating the video. The other survey evaluated the exercise qualities of

the dance video and the evaluators’ thoughts on the utility and implementation of the dance

regimen. This evaluation was given to those qualified to evaluating the exercise aspect of the

dance video such as primary care providers, diabetes educators and personal trainers/exercise

dance instructors.

Six potential exercise evaluators did not respond to inquiries to evaluate the dance

program. There were two evaluators who did not return evaluations on time and therefore did

not get responses from them.


All of the data collection tools, which include the Cultural Basis for Dance Questionnaire

and the cultural and exercise evaluation forms were developed by the project coordinator with

assistance from others as needed. These tools, to include both evaluations and the cultural

questionnaire were determined to have validity because they measure the intended data points

(Walonick, 2012) for this project. The data intended to be measured for this project were

cultural basis for dance, how Marshallese people felt about dance and exercise, how well the

video met those cultural expectations of dance, and how well the video met current exercise

recommendations based on evaluators’ responses. Reliability was not established for any of

these tools.

Objective 2. Analyze evaluation results to determine possible changes to the program

and identify barriers and facilitators to program implementation.

Two evaluation surveys were used in this project. The cultural evaluation was intended

for Marshallese individuals evaluating the dance according to cultural expectations (see

Appendix F). Eleven of twelve evaluators (91.67%) completed this evaluation. The exercise

evaluation was intended for evaluating the video regarding current exercise recommendations

(see Appendix G). Seven of thirteen evaluators (53.85%) returned evaluations.

Quantitative survey data was analyzed using Microsoft Excel. Likert scales allowed for

qualitative data to be assigned a quantitative (numerical) value enabling the data to undergo

quantitative statistical analysis (Hodgson, 2010). The numbers reported for these questions are

rounded to the nearest one-hundredth. Qualitative data from the survey was analyzed for barriers

and facilitators to implementation and response commonalities. The results are as follows:

Survey 1 (cultural survey) results. The survey was developed to determine cultural

perspectives of dance and exercise and how well the recorded video met expectations of the


Marshallese community (see Appendix F). For an answer left blank or not answered by the

participant the (-) was used. This survey consisted of nine Likert-type questions with a five-

point Likert scale for each question. An additional four qualitative questions regarding cultural

appropriateness and barriers and facilitators to implementation were included in the survey.

Though only three people out of eleven (27.27%) answered the qualifier question for this

survey, everyone who evaluated it was Marshallese (see Table 6). Dance was scored as ‘very

important’ by 10 of 11 (90.91%) evaluators. The other evaluator scored dance as ‘important’

giving an average rating of 4.91/5 for the importance of dance (see Appendix I and Figure 2).

There was one evaluator who added qualitative comments on some of the Likert scaled

questions. When asked about the importance of dance personally, this evaluator scored it 5/5

and added “it make me like to jump up and dance.” One-hundred percent of evaluators said

dance was ‘very important’ to Marshallese culture (see Appendix I and Figure 2). This question

also garnered a qualitative answer from the afore mentioned evaluator, who stated “cause I’m a

dancer and I love the moves” after scoring the question 5/5. While most respondents said

exercise was ‘very important’ to them, there were two participants who said exercise was of

‘very little’ importance to them and two others said exercise was ‘important’ giving an average

score of 4.18/5 for the importance of exercise (see Appendix I and Figure 2). Again, there was a

qualitative answer given along with a 5/5 score by the one evaluator who stated here “good for

my health.” Eight of eleven (72.73%) evaluators said this dance regimen was ‘very appropriate’

culturally. There were two respondents (18.18%) who said it was ‘somewhat’ and one person

indicated ‘many aspects are’ culturally appropriate. The average score for cultural


appropriateness was 4.55/5 (see Appendix I and Figure 2).

02468

1012

Likert Score of 1Likert Score of 2Likert Score of 3Likert Score of 4Likert Score of 5

Survey 1 Questions

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Figure 2. Survey 1 results. This figure shows Likert score responses to questions and how many

participants scored each question with which Likert score for Survey 1.

The next two questions go into more detail regarding cultural appropriateness (see Table

6 and Table 7). Many of the participants did not respond to either of these questions. Four of

eleven (36.36%) did not respond to the question “What aspects are culturally appropriate?” and

10 of 11 (90.91%) did not respond to the question “What aspects are not culturally appropriate?”

Only the respondent who gave the appropriateness a ‘many aspects are’ or 4/5 score gave insight

into what could be improved to better the cultural appropriateness of the regimen. This person

stated “using of the keyboard, prefer guitars” was not culturally appropriate. Several people

commented on what parts were culturally appropriate saying the “foot movement,” storytelling,


“art of fishing” (which the dance and song in the video are about), “formation, uniformity,

appropriately dressed” and “music” were culturally appropriate.

Table 6Survey 1: Results for “What Aspects are Culturally Appropriate?”Appropriate.

Feet movement for telling the story of the dance.

-

-

Formation, uniformity, appropriately dressed.

-

The theme of the song and dance is about the art of fishing which is a vital part of life in the Marshallese culture.

Yes.

-

The actions & music express the art of fishing which is important to our way of life.

Yes, the fishing part.

Note. A dash (-) indicates the answer was left blank by the respondent.

Table 7Survey 1: Results for “What Aspects are not Culturally Appropriate?”

- -

Using of the keyboard, prefer guitars. -

- -

- -

- -

-



Eighty-two percent (9 of 11) of respondents assured they would be ‘very comfortable’

participating in this dance regimen based on cultural appropriateness alone. The other two

(18.18%) respondents specified they would have ‘very little’ comfort participating based on

cultural appropriateness. The average score here was 4.45/5 (see Appendix I and Figure 2).

When asked about participants’ familiarity with these dances, an average score of 4.18/5 was

given with six of eleven (54.55%) indicating they were ‘very familiar’ with the dances, three

(27.27%) indicating they were ‘pretty familiar’ with the dances and two (18.18%) respondents

indicating they were ‘a little bit’ familiar with the dances (see Appendix I and Figure 2).

Another qualitative answer was added by the same evaluator who stated this time, “the beat,

music song, and action.” Nearly three quarters of the evaluators, 8 of 11, or 72.73%, indicated

they ‘definitely will’ recommend this regimen to friends and/or family. There were two

(18.18%) evaluators who marked they ‘might recommend it’ and one (9.09%) marked (s)he

‘probably will’ recommend it to friends/family. The average score for recommending this

regimen was 4.55/5 (see Appendix I and Figure 2).

Participants were also asked if this method of implementation was a fitting way to help

people be active. Nine of eleven (81.82%) indicated it was ‘very fitting,’ with one person each

scoring it ‘neutral’ and ‘somewhat fitting’ respectively. The average score for a how well this

method would help people be active was 4.73/5 (see Appendix I and Figure 2). There was a

final qualitative answer from this evaluator again, who wrote “on the music” for this question.

The last two questions evaluators were asked were about any barriers or facilitators to

implementation (see Table 8 and Table 9). In regard to barriers to implantation, four respondents

(36.36%) left the question blank and three (27.27%) others wrote “none.” One respondent added


to “None. Even when you’re on bedrest or wheelchair you still can do your moves, cause of the

music.” “Disability,” “arthritis,” and “numbness in their extremities” were also written down as

barriers to implementation. One person wrote “definitely is a barriers to implementation” though

a specific barrier was not mentioned by this participant. Another respondent wrote “interest in

Marshallese culture integrated with dance.”

Table 8 Survey 1: Results for “Can you Think of any Barriers to Implementation? If so, What?”Definitely is a barriers to implementation.

-

Disability.

Interest in Marshallese culture integrated with dance.

-

-


Some of the moves may be difficult for the elderly with arthritis or numbness in their extremities.

None.

None.

-

None. Even when you’re on bedrest or wheelchair you still can do your moves, cause of the music.


Table 9Survey 1: Results for “Can you Think of and Facilitators to Implementation? If so, What?” It is very important for the video because it helps people exercise.

-

-

-

-

-


Taking their meds & prevent injury by limiting movements that are difficult.

Yes.

Yes. Give watching & moving.

If a 75 year old person was to exercise to this dance, those who can’t stand may sit and do the motions with theirs hands. And those who can stand, I believe if the want to be healthier and reduce their diabetes, they can.

Yes, keep watching the video and do your best.


In regard to facilitators to implementation five (45.45%) respondents left the question

blank. Three (27.27%) evaluators wrote “yes” with two of these evaluators providing additional

information of “give watching & moving” and the other added “keep watching the video and do

your best.” Other responses to the facilitators question were “it is important for the video

because it helps people exercise,” “taking their meds & prevent injury by limiting movements

that are difficult,” and “if a 75 year old person was to exercise to this dance, those who can’t

stand may sit and do the motions with theirs hands. And those who can stand, I believe if the[y]

want to be healthier and reduce their diabetes, they can.”

Survey 2 (exercise survey) results. This survey was developed to determine whether or

not the recorded video would meet exercise recommendations, whether evaluators would be

willing to use the regimen for patients and if evaluators thought the regimen could be useful in

practice (see Appendix G). Figure 3 below provides the Likert-score responses for each

question. The survey consisted of six Likert-type questions with a five-point Likert scale for

each question in the evaluation and two qualitative questions regarding barriers and facilitators to

implementation.


0123456

Likert Score 1Likert Score 2Likert Score 3Likert Score 4Likert Score 5

Survey 2 Questions

Num

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Figure 3. Survey 2 results. This figure shows Likert score responses to questions and how many

participants scored each question with which Likert score for survey 2.

A total of seven evaluators responded to the survey. There were three health care

providers who completed evaluations, one of which was also a certified diabetes educator. There

was another certified diabetes educator who completed the evaluation. Three evaluators did not

mark their qualifications for evaluation. They were exercise/dance instructors.

The first Likert-scaled question on the evaluation asked how likely this regimen would be

able to meet the minimum recommended standards for physical activity. The current

recommendation for physical activity is 150 minutes per week of moderate intensity exercise

(U.S. Department of Health and Human Services, 2008; WHO, 2011). Three of seven evaluators

(42.86%) answered ‘very likely’ with two of seven evaluators (28.57%) each answering

‘somewhat likely’ and ‘neutral.’ The average score for meeting physical activity


recommendations was 4.14/5 (see Appendix J and Figure 3). The evaluators were then asked

how likely they would be to recommend this to patients/persons with five of seven evaluators

(71.43%) answering ‘somewhat likely’ and one of seven evaluators (14.29%) each answering

‘somewhat likely’ and ‘very likely’ to recommend this regimen. The average score for this

question was 4/5 (see Appendix J and Figure 3).

Respondents were queried on “Do you anticipate patients being willing to participate in

this type of exercise?” Responses included five of seven (71.43%) ‘somewhat likely’ answers

and one of seven evaluators (14.29%) each answering of ‘neutral’ and ‘very likely.’ The average

for this question was also 4/5 (see Appendix J and Figure 3). Respondents were queried on

whether or not the evaluators had ever tried anything similar to this dance regimen before with

their patients. Three of seven (42.86%) evaluators indicate they had ‘never’ tried it, two of seven

evaluators (28.57%) indicated they had ‘tried on a few patients,’ one evaluator (14.29%)

indicated they had ‘tried for many patients’ and one (14.29%) left the question blank. The

average rating here was 2.17/5 (see Appendix J and Figure 3). Evaluators were again queried on

how likely they would be to recommend this to patients to which the results were the same with

five of seven (71.43%) answering ‘somewhat likely’ and one of seven (14.29%) each answering

‘neutral’ and ‘very likely’ giving the same average as before 4/5 (see Appendix J and Figure 3).

Interesting to note, two people switched their answers from one of the previous questions which

asked the same thing as this question. This was noted in comparing the original evaluation

responses before results were compiled into a conglomerate of numbers. The last of the Likert

scale questions was “How likely do you think this program would promote increased exercise for

this patient population?” Again, five of seven evaluators (71.43%) responded, indicating they

thought it would ‘somewhat likely’ promote increased exercise and one of seven evaluators


(14.29%) each answering ‘neutral’ and ‘somewhat likely’ giving the average of 4/5 again (see

Appendix J and Figure 3).

Evaluators of the exercise portion were asked the same two questions the cultural

evaluators were asked about barriers and facilitators to implementation (see Table 10 and Table

11). Every answer was different, and responses included: “lack of motivation to change lifestyle,

limited mobility,” “depend on age group and fitness level. Music,” “lack of access to computer

or internet,” “should have actual classes or get a gathering for participants if watching the

video,” “most cultural dances are celebration specific, it would be a new concept to dance for the

intention of exercise,” and “I would say the only barrier I can think of is after maybe viewing

this video and participating in the exercises a few times, the participant may begin to lose interest

because they are performing the same routine over and over again.” One evaluator left this

question blank.

Table 10Survey 2: Results for “Can you Think of any Barriers to Implementation? If so, What?”Lack of motivation to change lifestyle, limited mobility.

-

I would say the only barrier that I can think of is after maybe viewing this video and participating in the exercises a few times, the participant may begin to lose interest because they are performing the same routine over and over again.

Depend on age group and fitness level. Music.

Should have actual classes or get a gathering for participants if watching the video.


Lack of access to computer or internet.

Most cultural dances are celebration specific, it would be a new concept to dance for the intention of exercise.


Table 11Survey 2: Results for “Can you Think of any Facilitators to Implementation? If so, What?”Class offer by age group in a social setting (i.e. at church).

-

Yes, you should include a warm-up (which is normally separate) from the actual routing and a cool-down. Both the warm-up and cool-down should include some type of stretches. This will help to reduce injury for the participant. Note: In addition you would want to make sure the participants in the video wear proper footwear – shoes!

Good for beginners.

The cultural aspect would facilitate implementation. Cultural aspect is a large draw to participants.

Place flyers in waiting area of clinic. Play video in waiting area to encourage . share info about video with other clinic staff – nutrition and beh. Health. – could also be used to help those with mood disorders (depression).

My experience with the Marshallese patients has been that they are are culturally inclusive in adapting to the American/Western culture, however the primary influence with greatest involvement and impact remains to be within their social and ethnic circle. They are very family based. This program could be effective if leadership in this activity was owned by someone within the social circle.


One evaluator also left the facilitator question blank. The other responses were again

quite varied and different from each other as in the previous question. Evaluators answered:

“class offer by age group in a social setting (i.e. at church),” “yes, you should include a warm-up

(which is normally separate) from the actual routine and a cool-down. Both the warm-up and

cool-down should include some type of stretches. This will help to reduce injury for the

participant. Note: In addition, you would want to make sure the participants in the video wear


proper footwear – shoes,” “good for beginners,” “the cultural aspect would facilitate

implementation. Cultural aspect is a large draw to participants,” “place flyers in waiting area of

clinic. Play video in waiting area to encourage . Share info about video with other clinic staff

– nutrition and beh. [behavioral] health. – could also be used to help those with mood disorders

(depression),” and “my experience with the Marshallese patients has been that they are are

culturally inclusive in adapting to the American/Western culture, however the primary influence

with greatest involvement and impact remains to be within their social and ethnic circle. They

are very family based. This program could be effective if leadership in this activity was owned

by someone within the social circle.”

Summary of Results

There were two objectives for which data were gathered in this project. Cultural data

from the cultural questionnaire was gathered to determine the foundation of dance within the

Marshallese community. Cultural data were also gathered from the evaluations of the dance

regimen. The results from the cultural questionnaire regarding dance allowed for the

establishment for dance as a part of Marshallese culture. Dance plays important roles within this

group of people which include bringing community members together and through the telling of

stories keeps cultural practices as well as traditions alive.

There were two main goals for this project. The first goal was to develop a culturally

appropriate dance regimen for use in our target population. The second goal, which built upon

the first goal, was to make this dance regimen meet current exercise recommendations. These

goals were essentially met according to the above results and as discussed in chapter five.


Chapter 5: Recommendations and Conclusions

Chapter five includes a discussion of the results and explores the results in regard to

current literature. An understanding of the results as well as what was learned while working on

this project are also included in this chapter. Project specific barriers and facilitators are

addressed. Project strengths and weaknesses/limitations are addressed as well. Also included in

chapter five are discussions of allostatic load and recommendations for future research.

Discussion

Population and culture. This project was originally undertaken as a way to help

decrease morbidity and mortality associated with diabetes in the Marshallese migrant population,

particularly on the island of Hawai’i, Hawai’i. There are many aspects of holistic diabetes

management involving both the health care provider and patient such as education,

pharmacologic therapy, exercise, self-management, and diet. It was determined to focus only on

one piece of care management for this project, exercise. Inactivity and insufficient amounts of

exercise is a problem for people worldwide and of particular concern for Marshallese in Hawai’i

since only 35% fit the recommended amount of exercise into their weekly routine (Reddy et al.,

2005; Shahid & Shahid, 2016). The traditional Marshallese lifestyle has been greatly impacted

by nuclear testing which the US had historically conducted in the Marshall Islands and it is

suggested that this testing is, in part, responsible for the diabetes epidemic among the

Marshallese (Alvares, 2010; Guyer, 2001; Reddy et al., 2005; Yamada & Pobutsky, 2009).

Diabetes is very prevalent in the Marshall Islands with estimates suggesting 21% of the total

population have diabetes (WHO, 2016b) and 28% over age 15 and about 50% over age 50 have

diabetes (Naseem, 2010). Compared to other minority populations in the US, the prevalence of

diabetes seems highest among the Marshallese. According to the 2013-2015 National Health


Interview Survey and 2015 Indian Health Service National Data Warehouse for their respective

data, the total percentage of diabetes among other races/ethnicities in the US listed from highest

to lowest is as follows: American Indian/Alaska Native – 15.1%, Mexican – 13.8%, Black, non-

Hispanic – 12.7%, Hispanic, overall – 12.1%, Puerto Rican – 12.0%, Asian Indian – 11.2%,

Cuban – 9.0%, Filipino – 8.9 %, Central/South American – 8.5%, Other Asian – 8.5%, Asian,

non-Hispanic, overall – 8.0%, White, non-Hispanic – 7.4%, Chinese – 4.3% (Centers for Disease

Control and Prevention, 2017b). Since the Marshallese love to dance (Adams, 2016) and it is an

important part of their culture as verified by this project, traditional dance was chosen as the

method of exercise to be used. Therefore, this pilot project created and recorded a culturally

congruent exercise (dance) video as a way to promote increased physical activity among

Marshallese migrants.

A crucial part of this project was being able to break into the local Marshallese

community and to establish trust among its members and leaders. Although this can be difficult

for an outsider to do, it is possible. It took quite a concerted effort to make connections with

people within the Marshallese community to find stakeholders for this project. Several different

leads were followed, some from my past associations and others from referrals received from

various people. Most valuable connections were a prominent member of the local Marshallese

community and another member of the MIC of the University of Hawai’i at Hilo campus. They

became key role personnel for the completion of this project.

The target population was determined from available statistics and stakeholders and other

acquaintances. Over 33% of the Marshall Island’s 70,000 people now live in the US (Duke,

2017). This step of determining the target population has occurred really, since the early stages

of this project and was confirmed in a MU-BI meeting. At this meeting, one member stated


there were about 100 Marshallese families living on the Hamakua Coast and other large

concentrations of Marshallese in the Kau and Ocean View areas. There are Marshallese

scattered throughout the island of Hawai’i and in the state of Hawai’i with about 3,000

Marshallese living on the Big Island and 6300 living in the state as a whole (U.S. Census Bureau,

2012; United States Census Bureau, n.d.). While this project was set to target those living on the

East side of Hawai’i Island, it may be successful in Marshallese living elsewhere in Hawai’i, the

US mainland, or even in the Marshall Islands.

Role of dance in the Marshallese culture. Once access to the community was obtained,

the role of dance in the culture was identified by several Marshallese people. Marshallese

individuals had to be found Marshallese people who were willing to answer five questions

regarding dance in the Marshallese culture to identify the cultural basis for dance within the

population. It was established that, at least for those people surveyed, dance was a significant

part of the culture. Cultural preservation through story telling appears to be dance’s major role

in the Marshallese community as is common in many other cultures such as Hula in Hawai’i and

Griotic dances in Africa (African dance, 2016; TextProject, 2014). All ages of Marshallese

people dance, as long as they are able and want to dance. Dance’s impact is bringing people

together and bringing “joy,” therefore it seems dance is not only a vital part of their culture and

community, it also is enjoyable. Enjoyable was a main concept in the concept map for this

project and is supported as such by the response of one participant who stated, “it brings joy to

people, especially keeping our culture alive.”

Culture was also a key concept in the concept map. Adams (2016) stated that

Marshallese “love dancing.” The role of culture in the concept map, project, and dance is


supported by Adams (2016) statement as well as the results from both the cultural and exercise

evaluation results.

Health promotion. The Health Promotion Model served as the framework for this

project. The HPM was developed by Nola Pender as a way to describe how individuals’ health-

promoting behaviors can result in improved health status, enhanced functioning and better

quality of life (Petiprin, 2016). The use of dance was analyzed in accordance with the 14

propositions of the HPM. Looking at the propositions of the HPM through the eyes of dance was

a crucial part of this analysis. The ideas contained within the HPM served as important guides

for this project and are supported by others’ work. Peer, provider, and family support facilitates

exercise adherence (Morgan et al., 2016). Also supporting the notion of peer and family support

is the work by Sun, J. et al. (2016) which states, essentially, if a person is diabetic or

overweight/obese their spouse will likely be(come) obese/overweight or diabetic also.

Overcoming this spousal diabetic relationship could occur through positive peer modeling as

discussed in the HPM (Pender et al., 2002).

If dance is a way to bring people together and all ages commonly dance, then significant

others may be involved in the dance. This fits with propositions eight and nine of the HPM

(Pender et al., 2002). If health care providers were to use this as a way to help manage diabetes,

then they could also show culturally appropriate ways of encouraging good health-promoting

behavior. It would seem classes should be conducted in a way to decrease negative influences of

the external environment in conforming to proposition 10 (Pender et al., 2002).

Cultural authenticity. The video designed, recorded, and made available met both

cultural expectations as well as exercise recommendations. With the help of a Marshallese

community member, dancers volunteered to assist in the creation of the dance video. There were


a few modifications from the original plans for the dance made by the dance leader but, these

changes better fit the dance better fits the Marshallese culture. The desire and cultural

preference for live music was unexpected. It ended up working very well and although live

music was not planned, this modification made by the dancers and dance leader was more

culturally appropriate than recorded music would have been.

The dance video. The final dance video contained five different segments. It ended up

working well for editing purposes but was a challenge because there was only about five-and-a-

half minutes of recorded video time. It was a challenge to use the recordings to meet the current

exercise recommendations of 150 minutes per week (U.S. Department of Health and Human

Services, 2008; WHO, 2011) out of an approximately five-minute video. Editing resulted in a

30-minute video which was different from the original plan of 60-minute, instructor led, video

which was more aligned with research findings (Murrock et al., Natesan et al., 2015). There

was not enough material to make a 60-minute video. Other dance classes in the literature used

an instructor and music of the instructors/participants choosing (Murrock et al., 2009). If done

well, a Western version of an instructor-led dance class model could possibly work for a

Marshallese dance class as long as there was both a male and a female instructor to model both

groups’ steps as needed. One participant or dancer shared that in Marshallese dance there are

male and female steps.

Plans and execution. An interesting phenomenon of “ownership” occurred once the

Marshallese were involved in the project. Instead of the aerobic dance class format envisioned,

the dance was more authentically Marshallese. This new format was more culturally congruent

and did take on the look of a Western exercise video. Thus, evaluations of the video confirmed

the video was culturally appropriate.


Plans for executing the filming of the video were shared with the dance leader. Prior to

the filming of the video, the dance had not been planned by the project director and dance leader.

This is when the “ownership” began appearing. At the filming of the dance, the dance leader had

already planned on doing a dance the dance leader and dancers had previously done. There were

four people who volunteered to dance and two other people were going to perform the music for

the dancing. Out of the six people involved, only a couple showed up on time for the recording

and the others trickled in over the next 30 minutes or so. Sowa (2012) noted in her article one

view on life the Marshallese have is “deadlines and schedules are loose and fluid” so this

schedule fluidity may not be out of the ordinary for this population. The volunteers conversed in

Marshallese among themselves and would occasionally say something in English about what was

going on. The volunteers, again taking “ownership” decided they were going to make the initial

dance shorter than what they had planned. There was that could be done but record and edit the

video it to try and make the video meet exercise recommendations. Through ownership of the

video by the dance leader and dancers, they made the video both theirs and culturally congruent.

Outcome. The original instructor-led format for this dance class may have worked but it

would be quite different than a Marshallese participant would expect to see. There were three

things about the video production that were not in congruence with the original plans. The dance

better fits Marshallese culture because of the modifications though. The first change was there

was not an official dance instructor to lead the class. There are not dance instructors for

Marshallese dance traditionally and it would be a paradigm shift for them to think of dance as

exercise as one evaluator stated. The class was recorded with all four people participating as a

group, all doing their steps, as defined by male and female dance steps, together without one

separate person leading the group. The second modification was the live music for dancing.


Live music was not planned but was introduced once the Marshallese participants took over the

dance format. Lastly, the plan to record the instructor performing the dance moves separately

from the dance class setting to help people learn the dance steps, was not done. Again, the

familiarity of the dance, the music and ownership of the dance made practice steps unnecessary.

Exercise as dance – meeting an exercise requirement. The edited video was 30

minutes long. It was to be used three times a week. Other researchers Murrock et al. (2009) and

Mangeri et al. (2014) used longer classes and with twice weekly scheduling for their classes.

The ADA (2012) recommends exercising at least three days a week. Because of the shorter

video length, it would have to be recommended for use five times weekly to more fully meet the

current exercise recommendations. Dance has been effectively used as exercise (Eyigor et al.,

2009; Leelarungrayub et al., 2011; Krishnan et al., 2015). Dance has been specifically used as

exercise in diabetic patients of other populations such as African American women (Murrock et

al., 2009) and South Asian women (Natesan et al., 2015).

Since this is a pilot project, examination or study of the effects of the dance regimen on

diabetic patients was not performed. Therefore, an essential part of this project was to establish

whether or not this video met both cultural expectations as well as current exercise

recommendations. If the regimen did meet cultural and exercise criteria, then the regimen could

serve as a model and method for helping to manage DM2 in the local Marshallese population.

Response to project. In talking with members of the community, evaluators and others

not even involved in the project, there seemed to be an overall positive response to this project

and its intended use. This positive outlook is represented in the evaluation forms received. Most

of the answers were suggestive of the regimen’s utility in practice as a tool for helping manage

diabetes in this Marshallese population.


Exercise as dance in the Marshallese culture. Everyone evaluating the cultural aspect

of the video was Marshallese though not everyone marked that answer on the evaluation forms.

Specific ages or birthdays of evaluators were not gathered. There was a wide age range with

evaluators from both a younger and older generation Marshallese. Almost every cultural

evaluator said dance was ‘very important’ to them individually and they all said dance was ‘very

important’ to Marshallese culture. These responses help to confirm the significance of dance

within the Marshallese culture that was obtained during the original cultural questionnaire.

Exercise was not rated as important overall by the Marshallese. They do not see dance as

exercise, in fact, Felix et al., (2017) reported 90% of Marshallese survey in their study reported

they liked walking for exercise.

O’Hagan et al. (2012) suggests that even though exercise for use in treating DM2 has

been established as beneficial, physician and patient use of exercise in DM2 treatment is low.

Furthermore, they state that current exercise recommendations for exercise in DM2 are

nonspecific and many recommendations do not address the metabolic changes which lead to

worsening diabetes and comorbidities (O’Hagan et al., 2017). Their suggested solution is to

create exercise recommendations “that both target the specific metabolic disturbances of the type

2 diabetes and incorporate individualization of prescription for the patients may improve

adherence, improve clinical outcomes and contribute to reducing the economic burden of the

disease” (O’Hagan et al., 2012, p. 46).

Cultural dance as a prescription for health (DM). The overall rating of the video at

4.55/5 for cultural appropriateness indicates, that as a whole, this video met the cultural

expectations of the evaluators. Culturally appropriate dance interventions promote hemoglobin

A1c control when compared to typical care (Natesan et al., 2015). This also noted in a study


using exercise interventions which were culturally appropriate and community-based targeting

those at risk of DM2 suggesting the importance of culturally appropriate exercise regimens

(Rowan, Riddell, Gledhill, & Jamnik, 2016). Brathwaite and Lemonade (207) suggest it is

important to have culturally appropriate interventions for DM2 patients tailored to the ethnic

group for which the interventions are targeted.

There were three other questions on the cultural evaluation about cultural

appropriateness. The Likert-scaled question was about how comfortable evaluators would be

participating in the dance regimen based solely on cultural appropriateness which scored overall

4.45/5. This was a two percent lower score than the previous question about cultural

appropriateness. Furthermore, when queried on whether the dance video was culturally

appropriate or culturally inappropriate, there was agreement that it was indeed culturally

appropriate.

The other two questions regarding cultural appropriateness asked, “What aspects are

culturally appropriate?” and “What aspects are not culturally appropriate?” Participant

understanding of the first question seemed to vary. For example, one person responded “yes” to

the question about cultural appropriateness. One respondent provided constructive feedback to

use guitar music instead of keyboard music as guitar music is preferred. Another person

suggested the Marshallese used a keyboard for their dance music. Instrument preference may be

each individual’s view on which instrument is more culturally appropriate. Either way, live

music seems to be preferred over recorded music.

In regard to aspects which were culturally appropriate, many people mentioned the idea

of fishing as culturally appropriate. Part of the cultural appropriateness of this particular video is

that it tells a story, as the evaluators discussed in their answers. The idea of dance telling a story


is supported by the cultural questionnaire results where storytelling was described as the purpose

of dance. The “music,” the dancers attire, and “formation” were also described as appropriate by

evaluators. If there had been a dance instructor(s) then “formation” may not have been listed as

appropriate.

Familiarity with the dance was also assessed. While most people scored it as ‘very

familiar’ or ‘pretty familiar’ there were two people who scored it as ‘a little bit’ familiar. There

are two things about this question worth discussing. Some of the people evaluating the dance

were also those who knew the dance from recording it or may have even danced it before

elsewhere so their familiarity score could skew the overall results to being more familiar. The

two people who were not very familiar with the dance obviously had not seen it enough before

this video to be familiar with it. This is not completely a negative thing. Just because they did

not know the dance does not mean the dance does not meet cultural expectations. It does appear

though, these same evaluators also scored the cultural appropriateness of the dance at a level of

‘somewhat’ appropriate and said they also had ‘very little’ comfort based on cultural

appropriateness alone to participate in this dance regimen though they did say it was a ‘very

fitting’ way to help people be active. Maybe there needs to be some minor adjustments to make

the video regimen more culturally appropriate but neither of these two participants listed any

specific items that were not culturally appropriate. Making cultural improvements without input

from those who scored the regimen lower would be challenging when others gave it higher

overall scores for cultural appropriateness. Of note, those who will use the video in their homes,

may or may not be familiar with the dance. However, if they find it culturally appropriate, they

will learn it as they continue to use the video.


Overall cultural evaluators were also very willing to share this regimen with friends

and/or family with 8 of the 11 evaluators saying they ‘definitely will’ recommend this regimen to

others. Nine of the eleven evaluators said this method of implementation was a ‘very fitting’

way to help people be active. They were then asked about barriers and facilitators to

implementation. It is not clear in the responses if everyone understood the questions being

asked, for example one person stated, “definitely is a barriers to implementation.” This response

does not seem to fit the context of the question. Valuable insight was displayed on

implementation of this regimen. One participant shared that even a person who is on bedrest or

who may be in a wheelchair could still perform the “moves” even with these limitations. Other

barriers mentioned were “disability,” “arthritis,” and “numbness in their extremities.” These

may limit more than just the ability to perform the dance steps such as getting to and from the

dance class if going to a live class or just being able to stand and/or walk let alone being able to

dance. Additional positive feedback was given on the question about facilitators to

implementation such as just “keep watching the video and do your best” and again someone

mentioned that even people could sit and do some of the exercises with their hands. As stated

previously, quantity is important for diabetics when it comes to exercise and any activity is better

than no activity to benefit health (Balducci et al., 2012; U.S. Department of Health and Human

Services, 2008). As suggested, even just using your hands is possible with this dance regimen if

one chooses to do so. Overall, for the cultural evaluations, this regimen seemed to hold up to

cultural expectations. There may need to be slight adjustments to improve this regimen, but the

video regimen fared well overall.

Evaluation of dance. Evaluation of the dance by stakeholders as well as the analysis of

those evaluations were the next steps in this project. Stakeholders who evaluated the video did


so according the evaluation questions given them. There was one evaluation form for the

cultural aspect of the dance video and one evaluation form for the evaluation of the exercise

component of the dance video.

Evaluators were to watch the video and then answer the questions on the evaluation form.

There were seven people who were able to evaluate the video for its exercise components. Some

did not watch the video in its entirety, which could be a limitation of this study. There was a mix

of diabetes educators, health care providers and dance/exercise instructors who were able to

evaluate the video. On the question of the likelihood this video regimen would be to meet

minimum standards for physical activity, two of the dance/exercise instructors gave the lowest

scores out of everyone and rated it as ‘neutral’ with the other five saying it was either ‘somewhat

likely’ or ‘very likely’ to meet the standards.

Overall, evaluators were likely to recommend the video to participants. Support from

evaluations suggest options for including exercise through dance in the diabetic Marshallese

population. If people are even ‘somewhat likely’ to recommend the dance, then this is an option

worth pursuing. It was notice during analysis of the data, evaluators were queried twice on

recommending the regimen to patients. Interestingly, two evaluators switched their answers to

this question. The numbers overall were identical for the group as a whole for both questions.

One person decreased their recommendation from ‘somewhat likely’ to ‘neutral’ and the other

person did just the opposite, increasing their recommendation from ‘neutral’ to ‘somewhat

likely.’ Maybe this had something to do with the other questions in between these two or just by

chance or some other reason.

Also scoring the same ‘somewhat likely’ overall, was a question about how likely this

program would be to promote increased exercise for this patient population. This goes along


with what the HPM states in propositions four through eight which collectively discuss how

competence, self-efficacy, and positive affect can lead to increases in health promoting behaviors

(Pender et al., 2002). This questions rating is also linked to what Fortier et al. (2011) says about

how exercising increases motivation to exercise in diabetic persons. So, if Marshallese would

use this regimen, their motivation to continue exercising should increase.

Half of the people who answered the question about whether or not they have tried

something like this for their patients answer that they have ‘never’ tried anything like this before

and two people said they ‘tried on a few patients’ with one evaluator (a dance/exercise

instructor) saying they ‘tried for many patients.’ Even though this type of exercise has not been

used by many of these evaluators for their particular patients, the average score for likelihood of

recommending this regimen to their patients was 4/5 or ‘somewhat likely.’ This may prove to be

beneficial in practice for patients and providers who are trying together to manage diabetes in

this population.

Similarly to the cultural evaluators, dance evaluators were queried about any facilitators

or barriers to implementation. Even though the word facilitators was confusing to some people

in this group as well, responses to these questions were similar, such as mobility issues as a

barrier, to the cultural evaluators’ feedback, other ideas regarding health and wellbeing emerged

here.

Much of what was suggested in the answers to these two questions could be used to

improve upon the dance regimen. There are relatively simple solutions to many of the barriers

mentioned by the evaluators. For example, in the future, a dance class would be used and classes

would be recorded. Those recordings would then be made available on YouTube and DVD. By


making these three changes, the barriers of losing interest due to repetition, no computer or

internet access, and having a group setting for participation would be overcome.

One other area of discussion is that of the exercise itself. A few of the exercise

evaluators shared how the exercise regimen presented was “for beginners” or something similar

and justified a lower rating because the intensity was not what they would expect from a dance

video. There is agreement the intensity the intensity is lower than what it could be, but this may

be a good starting point for the target population. As described above, for this population, one

evaluator even said the video could be wheelchair appropriate.

The evaluations revealed other key data for this project. Through the cultural evaluators’

responses, this regimen was established as being in accordance with Marshallese cultural

expectations. This was a major goal of the project, to establish a culturally appropriate dance

regimen for exercise in our target population. While it may not fully meet physical activity

guidelines of intensity, if people were to use it five times weekly they would essentially meet the

number of minutes recommended to exercise each week. With all data considered, a culturally

appropriate dance regimen which also somewhat meets current physical activity

recommendations was established.

Dance as exercise for health. Moderate-intensity exercise “results in increased work of

breathing, increased heart rate and feeling of warmth, but individuals can still complete a short

sentence” (Shahid & Shahid, 2016, p. 231). Interestingly, Shahid and Shahid (2016) noted that

even if minimum activity levels are reached, being sedentary still puts people at risk for poor

health outcomes. Hidalgo-Santamaria et al. (2017) found that people participating in vigorous

physical activity had a 37% lower risk of metabolic syndrome than light physical activity though

they did not find a significantly improved glucose metabolism with vigorous compared to light


physical activity. In a recent literature review, it was concluded that physical activity performed

on a regular basis reduces the risk of DM2 and aerobic exercise improves insulin resistance even

without improved fitness levels (Bird & Hawley, 2017). Also, the more exercise performed and

the higher the intensity level may benefit insulin resistance more, although this was not a

consistent finding (Bird & Hawley, 2017).

Many Marshallese are sedentary (Reddy et al., 2005; WHO, 2016b). In addition, many

persons with DM2 have other health problems which could limit mobility such as

overweight/obesity, age, arthritis, and cardiovascular disease. In Arkansas, 28% of Marshallese

surveyed were overweight and 61.7% were obese (McElfish et al., 2016c). So for this

population, like one of the cultural evaluators said, even wheelchair-bound individuals or those

on bedrest may benefit from exercise or in fact, dance as exercise. The project was trying to

increase physical activity levels in individuals to meet minimum recommendations. Getting

people off the couch and active is an important part of increasing exercise. Understanding this,

something that could be done is to have different intensities of exercise based on participants’

fitness levels to better tailor the exercise to individual needs. Another option would be to have a

moderate-to-high intensity dance regimen designed and let participants choose what they do and

do not do in terms of dance moves which is what Murrock et al. (2009) suggested.

When asked if participants would willingly participate in this type of exercise, a

‘somewhat likely’ score was found. Willingness is hard to compare to other studies because in

order to be a participant in a study, certain inclusion and exclusion criteria need to be met. For

example, in the Murrock et al. (2009) project, which seems most similar to this project, only 22

of the 46 people who met inclusion/exclusion criteria made it through their baseline period and

were able to participate. For the purposes of science and safety, everyone who is willing may


not be allowed to participate in clinical research studies. Willingness and ability to perform is a

deciding factor in exercise participation in the Murrock et al. (2009) study.

Facilitators to implementation. When asked about facilitators to implementation, great

suggestions were offered. These included: 1) offering the class divided into group by age, 2)

having warm-up and cool-down sections that would be used to make the regimen better for

exercise according to one evaluator and 3) stretching as part of the cool-down and warm-up

process as suggested by the same evaluator. Having both a warm-up and cool-down is consistent

with what Murrock et al. (2009) did with a five-minute warm-up and 10-minute cool down for

participants in their dance regimen. However, Daub (2013) shows that stretching cold muscles is

not beneficial and does not prevent injury or reduce soreness.

Distributing the video was another strategy to facilitate the use of the program. Examples

included making health care teams aware of the videos, using flyers and playing the video in the

lobby of the office. Such strategies would increase exposure to the video. Increased use of the

video by the Marshallese would be enhanced if someone within their cultural or social circles

took leadership of this project. In a systematic review of barriers and facilitators of exercise

adherence it was found that lacking cultural awareness and language barriers were barriers to

exercise adherence (Morgan et al., 2016). This same study found that support and the social

atmosphere, location, exercise variety, flexibility in timing of exercise, tailored regimens and

perceived overall benefits serve as facilitators to exercise adherence in inactive people (Morgan

et al., 2016).

Cultural appropriateness. There were two different conflicting suggestions made by

the cultural evaluators and those evaluating the exercise portion of the regimen. The first

conflicting suggestions are in regard to attire. One of the cultural evaluators said the dancers


were dressed appropriately while one of the exercise evaluators made particular note of the

dancers’ footwear. It was suggested that “proper footwear – shoes” be worn by the dancers.

While slippers, flip-flop or sandals do not provide much support or protection while exercising,

they fit the Marshallese culture. The idea of what type of shoes to wear would need to be

discussed before making more videos or studying participants who participate in the dance

regimen. Athletic shoes could certainly be encouraged.

Project Barriers and Facilitators

There were several barriers in regard to this project. Barriers included language, being

accepted, and timeframe. The first barrier was the language and communication barrier. Though

the Marshallese people who participated spoke English, it was still a challenge to be understood

by them at times. Also, this language difference led to some potential miscommunications. A

translator from the community helped to translate for some participants when going over the

consent form and questions. Communication issues went both ways. Many times, participants

would be talking in Marshallese and therefore the project director did understand. Ideally, it

would have helped to know and understand what was being communicated between participants

in order to resolve any issues or problems. For example, after days of waiting, suddenly

someone would communicate there was a group of people who wanted to help the project.

Apparently they were talking with each other and planning via calls or text. A study of different

bilingual research workers found that bilingual research workers could assist in recruitment,

clarification of questions, and understanding cultural context (Lee, Sulaiman-Hill & Thompson,

2014). A bilingual research team member could have benefited this project in these same ways

as well.


Another barrier was being accepted into the Marshallese community. Initially, support

from the MU-BI leadership was anticipated, but it took nearly an entire week to finally get in

contact with someone from within the Marshallese community and then to hear back from them

again. Once the initial contact was made and others in the group caught word of the project and

its goals, the project went well. There was a lot of waiting but people were willing to help.

Being outside of a culture, it is not clear if the communication issue was a factor related to

culture or a product of a Western mindset. That is, wanting this project to happen quickly.

Another barrier for this project was timeframe. Ideally there would have been a much

longer timeframe available for all aspects of this project. A longer time frame was not feasible

though. With a longer time frame there could have been many more evaluations or cultural

questionnaires obtained and more dances recorded. With a longer time frame, the video could

have been more professionally done. Arrangements for an interpreter to be present at all stages

of the project could have been realized with more time. The goals of this project, to create and

have a dance regimen be evaluated based on cultural and exercise criteria were still

accomplished though.

The biggest facilitator to this project came as a result from one of the initial barriers of

the project. Once accepted, in a way, by the Marshallese community work on this dance project

proceeded. Questionnaires were completed, the video was recorded and the evaluations by

Marshallese community members were completed. This progression reinforces the need to

understand the cultural processed embedded in working with other cultures. It can explain the

delay and also the engagement by the community.

Another facilitator to the project was having health care providers available in the

community to evaluate the project. There was support from others within the community who


could contact potential evaluators who were unknown to the project director. In this way, a rich

and diversified group of evaluators participated.

REAIM

The REAIM method was intended to be used for evaluating this project. The areas of

evaluation for the REAIM method include reach, effectiveness, adoption, implementation and

maintenance.

Reach: This was evaluated by determining the potential reach to the target population.

By making the video regimen available online, essentially anyone anywhere in the world

with internet access can use the program. So its reach is almost limitless in terms of who

could view and use the program. By looking at the statistics on YouTube, 14% of the

overall 927 views (as of December 4, 2017) have been watched by people in the Marshall

Islands and there are other views from the region of Micronesia as well.

Effectiveness: To evaluate the effectiveness of the regimen the dance was evaluated for

its potential to meet current exercise recommendations. Effectiveness was not wholly

supported by the evaluators. Dance instructors were less convinced compared to health

care providers. This difference may be related to the interpretation of dance as exercise

compared to dance as a way to improve activity in a population with many comorbidities.

Adoption: In the evaluation of adoption willingness to use this regimen or to refer and

use this regimen for patients to help with diabetes was the focus. Overall, the feedback

seemed to be that culturally, the regimen would be adopted and health care personnel

would refer patients to use the dance regimen.

Implementation: This project was a pilot project. As such, it did not involve the

implementation and evaluation of the dance class’s effect on diabetes outcomes in


Marshallese persons. It only evaluated the regimen based on whether or not it met

cultural and exercise expectation. Therefore, implementation was not evaluated as part of

this project.

Maintenance: Likewise, because of the nature of this pilot project, maintenance was not

evaluated.

Project Strengths and Weaknesses

Strengths of this project include using health care providers in the community, its narrow

focus on culture and exercise evaluations, and having Marshallese people evaluate the video.

It would have been very easy to find health care providers on the mainland to evaluate

this video. The likelihood of them caring for Marshallese patients though is not as high as in

Hawai’i. Participants also gave their insights into Marshallese patients in their evaluations which

helped to deepen the cultural aspects and outlook of this project.

The focus of the project was narrow. As a first step, the project was able to establish that

dance is indeed an important part of the lives and culture of Marshallese people. To date, there

was no evidence-based data to suggest this. In addition, educational feedback on both the

cultural and exercise aspects of the dance regimen were obtained. This information will inform

future projects by providing data on cultural relevance and dance as exercise when designing

projects. This project serves as a baseline to better create a culturally appropriate exercise

experience which is enjoyable, interesting and able to meet exercise recommendations and

expectations.

By having Marshallese individuals evaluate the regimen video, feedback was obtained

from people who were born and grew up in living the Marshallese way of life and culture. Only

Marshallese participants evaluated the cultural aspect of the dance. Along with this, there were


evaluators from different generations who participated thereby giving a more rounded overview

of dance and the appropriateness of the regimen. One of the key strengths of this project is the

cultural foundation of dance within the lives and culture of the Marshallese people. Since dance

is a form of storytelling for the Marshallese, cultural recognition of this dance as a story about

fishing is a strength of this project.

Along with the strengths of the project, there were also some weaknesses. It was not

clear if all participants understood the questions asked on the surveys. Cultural interpretation of

the questions may also be considered a weakness, for example, the response by the evaluator

who stated, “definitely is a barriers to implementation.” Another potential weakness was guitar

music was not used, which one evaluator pointed out as being more appropriate than keyboard

music. Some of the evaluators were already familiar with the dance from dancing it before

which may have skewed the familiarity results and this could be considered a project weakness.

Lastly, there were two evaluators who scored the dance as ‘somewhat’ appropriate and said they

had ‘very little’ comfort based on the cultural appropriateness of the dance. This could be

conceived as a weakness in that not every cultural evaluator gave the dance 5/5 scores on cultural

appropriateness. These lower scores may be the result of a generational difference between

evaluators or potentially due to where the evaluators grew up, in the Marshall Islands or in the

US.

Contributions to Practice

The major contribution of this project is the culturally appropriate dance regimen as a

form of exercise for Marshallese patients with diabetes mellitus. The project provides a bridge to

the gap in literature of exercise as dance. To date, no literature is available regarding an exercise

dance regimen targeting any Micronesians population in general or specifically Marshallese


migrants. The dance was choreographed by Marshallese and the evaluation results indicate the

dance regimen is culturally congruent with Marshallese expectations. The idea of a culturally

congruent exercise regimen is not a new idea, but it is novel within this population. While it may

not be ideal to use one video over-and-over again, it could be used in this manner and if done

five days per week, a person would be able to reach the recommended 150 minutes of exercise

weekly. It may not be moderate-high intensity but like Balducci et al. (2012) said, intensity is

not as important as quantity and low-to-moderate exercise intensity is approximately as

beneficial as moderate-to-high intensity exercise.

Allostatic Load

Another way to view the contributions to practice is to understand allostatic load and the

role it may play in Marshallese lives. Allostatic load was defined in 1993 by McEwen and

Stellar. Allostatic load is “the cost of chronic exposure to fluctuating or heightened neural or

neuroendocrine response resulting from repeated or chronic environmental challenge that an

individual reacts to as being particularly stressful” (McEwen & Stellar, 1993, para 5).

Homeostasis is an important part of life, but, according to McEwen and Stellar (1993) is unable

to explain chronic stress’s toll on human bodies. Hence, the need for allostasis, which is when

body systems work to meet fluctuating external demands (McEwen & Stellar, 1993). The cost of

adaptation which initiates pathophysiology is ‘allostatic load’ (McEwen, 1998, p. 34; McEwen &

Stellar, 1993, p. 2093). This means, over time, allostatic load can result in a disease state

(McEwen, 1998).

Adversity speeds up the disease process resulting in an increase in the incidence of

mortality and morbidity (McEwen, 1998). A load is placed on the body when allostatic

functions of the metabolic, nervous, immune and cardiovascular systems, with the sympathetic-


adrenal-medullary and hypothalamic-pituitary-adrenal axis playing a central role, do not turn on

or off as appropriate, a load is placed on the body (Beckie, 2012; McEwen, 1998). Diet and

exercise affect an individual’s allostatic load such that poor diet increases load and exercise can

decrease load (McEwen, 1998; Upchurch, Rainisch, & Chyu, 2015).

No studies specifically targeted Marshallese and allostatic load, neither did they target

Micronesians and allostatic load by measuring allostatic load in these populations. In a review of

literature regarding Pacific Islanders’ risk of diabetes and cardiovascular disease no studies were

found that specifically targeting Pacific Island populations (Siaki & Loescher, 2011). The

research available for allostatic load is intriguing when looked at from the perspective of the

Marshallese population which is a minority population with many health disparities. The

following are a few examples from current research.

In a national sample of women, it was found that there are differences in allostatic load

among different races/ethnicities, though Pacific Islanders were not included in this study (Chyu

& Upchurch, 2011). Higher socioeconomic status, education beyond high school and being

foreign born (for Mexican Americans) were all associated with lower allostatic load measures

(Chyu & Upchurch, 2011). Socioeconomic status hardship leads to higher allostatic load in

adulthood (Gruenewald et al., 2012). Interestingly though, a co-twin study showed that

education itself might not actually decrease allostatic load directly (Hamdi, South, & Krueger,

2016). Marshallese who have little education overall and at a lower socioeconomic status

(Pobutsky et al., 2009) could have higher allostatic loads when compared to other populations.

Other researchers state also, the higher the socioeconomic status, the lower the allostatic load

(Upchurch et al., 2015).


Another example is seen in pregnancy outcomes. Allostatic load is a contributor to and

risk factor of preterm delivery (Olson et al., 2015). In a sample of 17 to 35-year-old women,

both small-for-gestational-age and preterm birth mothers had higher allostatic load than the

reference group (Hux, Catov, & Roberts, 2014). Preterm and small-for-gestational-age children

are more likely to be obese and diabetic than normal children (Hux et al., 2014). The fact that

Marshallese migrant women have preterm labor and give birth to low birth weight babies at a

significantly higher rate than non-Hispanic White women (Schempf et al., 2010) may be due to

their higher allostatic load and explain some of the diabetes rates among Marshallese migrants.

Inactivity is prevalent among Marshallese migrants to Hawai’i (Reddy et al., 2005).

Upchurch et al. (2015) found a significant association between the amount of physical activity

someone engages in and lower allostatic load with increased activity. They found a 48%

decrease in allostatic load from least active people to the most active people (Upchurch et al.,

2015). Therefore, Marshallese’s inactivity may lead to higher allostatic load for individuals

within the population.

The traditional diet of Marshallese has been affected by turning away from subsistence

living and nuclear testing on their islands (Reddy et al., 2005; Yamada & Pobutsky, 2009). In a

study of Puerto Rican older adults, a diet consisting of meat, processed meat, and French fries

was significantly associated with increased allostatic loads (Mattei, Noel, & Tucker, 2011).

Their traditional diet of beans, rice and oils had no significant associations with allostatic load

(Mattei et al., 2011). Similar diet changes may be present in Marshallese migrants to Hawai’i.

The epidemic of obesity worldwide is often attributed to modern ways of life which lead to a

positive overall balance of energy (Tremblay & Chaput). Poor diet and a sedentary lifestyle are

a common way of life for many people that can increase allostatic load (Tremblay & Chaput,


2012). There are also many non-caloric causes of an individuals’ allostatic load changes

(Tremblay & Chaput, 2012).

Diabetes is a health problem among Marshallese migrants. If they undergo chronic

allostatic stress, which likely is the case, then what Steptoe et al. (2014) states may be true for

them “chronic allostatic load may be a mechanism through which stress exposures contribute to

diabetes risk” (p. 15693). Siaki and Loescher (2011) state that interventions for this broad

cultural group (Pacific Islanders) would be beneficial since allostatic load’s secondary responses

can be modified with changes of behavior (Siaki & Loescher, 2011). This is one more reason a

culturally appropriate regimen of exercise should be employed among Marshallese migrants and

examination of its effectiveness using allostatic load markers as indices for improvement in

diabetes outcomes in this population.

Implications for Practice

There are several implications for practice in regard to this project. The first implication

is that this form of exercise may be a way to breach cultural barriers. Being able to overcome the

chasm of a more Western view of exercise versus a more traditional Marshallese view of

exercise could prove beneficial in care and managing diabetes in this population. The second

implication for practice is to actually use this regimen. It is public domain since the video is now

available on YouTube. Anyone can view it, download it, or edit it. It is free to anyone with

internet access. A DVD could be made if internet access is not available. Health care providers

and their staff can use this video or at least recommend it to their Marshallese patients with

diabetes as a way to help in the care plan for managing this chronic condition.

Along with use in help managing diabetes, other options for use in health care may be

explored. For example, on evaluator stated that it could be used for people with mental health


issues such as depression. Berkeley Wellness (2014) also suggest that dance can be used to

improve patients’ mood which would support the use of this regimen in aspects of health care

beyond its sole intended purpose of diabetes management.

Suggestions for Project Improvement

This was a pilot project and as such, it is expected that there are next steps in this overall

goal of using dance as exercise to manage diabetes mellitus in this population. The overall goal

would then be to use this idea of dance as exercise, knowing it could meet exercise

recommendations and is culturally congruent to determine if the regimen helps in biometric and

other measures of diabetes and health such as allostatic load measurements. These study

variables should at least include fasting blood sugar and hemoglobin A1c and may also include

other measurements such as weight, body mass index (BMI), blood pressure, lipid panel, self-

rated health, etc. Then, considering evaluators’ recommendations such as intensity of exercise,

age group differences, and exercise setting develop an eight to 12-week program, based on other

studies timeframes (Murrock et al., 2009; Natesan et al., 2015), for diabetic Marshallese migrants

using traditional dance as their exercise and see if variables change. A class conducted three

times a week, held at a community center, church, or other social hub where people could gather

and participate in this class would be ideal. There would be at least one male and one female

instructor since knowing there is usually a male and a female part in Marshallese dances leading

the class. There would be live music and better videography to record the classes so others who

may not participate could still have access to the dances after they were put on YouTube or made

available in another format such as DVD. Home use could be an advantageous way for people to

exercise. In a pilot project using an exercise-type video it was found that there was a trend, not


too strong but still a trend, of using a video at home to decrease sedentary behavior and increase

physical activity (Tuominen, Husi, Raitanen, & Luto, 2016).

The filming would be done, not only from the back, but also from other angles such as

front and sides of the class to better visualize the dance moves and steps as they are performed.

It is also recommended that the classes be innovative and not repetitious. In order to develop

some familiarity it is recommended the same class be repeated for one week but then to

introduce novelty dances to avoid boredom each week thereafter.

In a project based in California and focused on Pacific Islanders living there (which

included Marshallese) it was found that Pacific Island populations are reached successfully with

culturally tailored exercise programs to fit individual and community needs (Labreche et al.,

2016). Having these programs in a place such as the community center where people typically

gather can also aid in reaching these populations (Labreche et al., 2016). This Let’s Move

Program was the first of its kind to offer a culturally tailored, evidence-based program (though

only 10-minutes long) to meet the needs of Pacific Island populations in the US (Labreche et al.,

2016).

The Marshallese culture is very collectivist in nature which means the concept of “‘self-’

management” is contradictory to what they believe (McElfish et al., 2017, p. 4). In the study of a

diabetes self-management program for Marshallese people living in Arkansas McElfish et al.

(2017) also learned it is essential for behavioral change efforts to be focused on family, including

extended family, for effectiveness. They engaged the community members in the research and

they trained Marshallese investigators to be part of their research team (McElfish et al., 2017).

Hence, the reasoning for having a Marshallese individual on the research team as well as

involving families. A dance class where all members of the family could participate, since every


age group dances, including children, might be an interesting approach to aid those with DM2

and support overall health and wellness as important for families. Sun, H. et al. (2016) shared in

their research that kids who exercise are more likely to exercise as adults.

There are high rates of uninsured persons and low incomes in Marshallese persons

therefore, there may be a limited reach with an intervention located in a clinic (Felix et al.,

2017). A peer-led, community-based program method of delivery may be more effective than a

clinic-based program (Felix et al., 2017). It has been suggested a focus be placed on

interventions that obese people can perform when designing programs for Marshallese

individuals in order to facilitate exercise (Felix et al., 2017). This pilot project and the next steps

would help accomplish the Felix et al. (2017) recommendation of developing and testing

interventions which increase activity levels in order to help decrease DM2 burden in US

Marshallese migrants.

Other Changes to Make

Having at least one member of the Marshallese community be part of the project team

would facilitate engagement by the community. This concept was done by (McElfish et al.,

2017) in Arkansas and it seemed to benefit the research they have worked on. This would also

be congruent with one of the evaluators suggestions of having a member of the Marshallese

community take lead in this idea of dancing for exercise.

Revision of the evaluations would strengthen results. Many of the questions were left

blank, the evaluation as printed did not flow well, and one question was asked twice. Rewording

or better explaining the question about facilitators to implementation would also strengthen the

data obtained. Several participants, both from the cultural evaluation group and the exercise


evaluation group asked what that particular question meant. It is an important question to ask, so

rewording is necessary.

Methods for distribution and collection of evaluations and questionnaires could also be

improved to capture a wider group. Perhaps having the evaluations as a survey online with the

dance video would help. Emailing surveys and questionnaires to potential participants could also

be done. This would allow more convenience for evaluators and likely more responses from

them.

Decreasing the communication and language barriers would improve outcomes. Though

English was spoken by participants, a translated version of the surveys and questionnaire would

mitigate the misunderstandings related to the language barrier. This would require a translator to

translate answers back into English if Marshallese was used. One person did do this on their

form and it was translated back into English by a translator. Also, having a team member who

spoke Marshallese and was a member of the cultural community would be beneficial. The

research team would then be able to understand all that was being said in conversation while

working on the project.

The Marshallese community is a tight-knit community. Everyone seems to know each

other. It was almost as if they discussed the project among themselves openly, so much so that

people knew who was and was not helping with the project, and even trying to get others to help

in the project. Even one of the evaluators mentioned this when stating,

My experience with the Marshallese patients has been that they are … culturally

inclusive in adapting to the American/Western culture, however the primary influence

with greatest involvement and impact remains to be within their social and ethnic circle.


They are very family based. This program could be effective if leadership in this activity

was owned by someone within the social circle.

During the progression of the project it was not clear that an outsider would be allowed, in a

sense, to do this project within this particular population. The project happened because strong

leaders within the community approved the project and made it happen. In a sense, this was an

ethnographic experience of participant observation by the project director.

Ethnography means “the study and systematic recording of human cultures; also: a

descriptive work produced from such research (Ethnography, 2017). One researcher describes

his ethnography work in the Marshall Islands. Berta (2015) describes how he had to get

permission from the mayor of the island before he could do any research there. Similarly, in

order to accomplish this project in the migrant Marshallese population there had to be approval

and acceptance by the Marshallese community and its leaders. While not formally granted

MU-BI did lend their support for the work and a prominent member of the Marshallese

community worked on this project. In the relatively short time of this project, this project

identified dance and music in the Marshallese culture and their combined use. It was important

for this projects success to do things in ways congruent with cultural expectations. For example,

prayer was an important part of both MU-BI and MIC meetings. Deferring to these

organization’s leaders was necessary and only with their permission the project was discussed

and solicitations for assistance with the project were presented.

This idea of culturally appropriate dance regimens for exercise does not have to be

limited to the Marshallese population. While Marshallese dances may not be culturally

appropriate for a different population, a similar idea could be used for other populations using

their cultural dances.


Limitations

There was one main limitation to this project. It has a small sample size and focused on a

very specific population so the results are likely not generalizable even to other island

populations of Micronesia and maybe not even to non-migrant Marshallese still living in the

Marshall Islands or those living in other parts of the United States. One other limitation is

questionnaires and evaluations were filled out in groups, consequently, there could have been an

influence from others on answering the questions. One person was unable to write so they had

another participant fill out the form for them.

Conclusion

This project began as a way to help Marshallese migrants with their diabetes. Diabetes is

a problem throughout the world. The review of literature cited a) diabetes pathophysiology,

costs, and complications, b) Marshallese history, culture and health, and c) exercise and dance.

The Health Promotion Model developed by Nola Pender served and a foundational framework

for this project.

The cultural basis for dance within the Marshallese population was established and a

culturally appropriate dance regimen which met cultural expectations of evaluators was

developed. This pilot project can now serve as the foundation for a greater work of

implementing a redesigned dance regimen based on recommendations and feedback from

evaluators. This would hopefully lead to improved health status, enhanced functioning and

lastly, a better quality of life through the promotion and use of dance as a valuable exercise

option for Marshallese persons with diabetes mellitus and result in the improved health status,

enhanced functioning and better quality of life exampled by the Health Promotion Model as

described by Petiprin (2016).


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Ramli, M. Z. Musa & A. Jusoh (eds.). Malay World: One contribution to knowledge. (pp.

13-21). Institut Alam Dan Tamandun Melayu, Universiti Kebangsaan Malaysia.

Retrieved from https://www.researchgate.net/publication/236169876_Origins_

of_the_Austronesian_Peoples

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/s40064-016-1701-z

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Appendix A


Consent to Participate in Research Project as Dance Instructor or Dancer:


My name is Brayden Walker. I am a Doctor of Nursing Practice student at the University of Hawai’i at Hilo in the Department of Nursing. As part of the requirements for earning my degree, I am doing a practice inquiry project. The purpose of my project is to develop and evaluate a dance regimen as an effective form of exercise for Marshallese people who have diabetes. If you are Marshallese between ages 19-45, able to perform dance moves, and are healthy, I am asking you to participate. Likewise, if you are diabetic, 46 years and older, taking more than 3 medication, have high blood pressure, have any medical condition that would keep you from participation such as heart failure or back pain limiting ability to perform dance you are asked to not participate in this study.

Activities and Time Commitment:

If you are asked to help in the project as the dance instructor, you will be asked to perform and possibly help design a dance regimen to be recorded. The video(s) will then be used for evaluation. It is expected to take about 5 to 10 hours for the recording and design of the dance program. You will be asked to model dance steps and we will record you performing them. You will also be leading a small group, 3 to 5 people, in a dance program. We will record this as well.

If you are asked to help in the project as a dancer, you can expect approximately between 2 and 5 hours of time commitment. You will be recorded in a small group with about 5 other people as you follow the dance instructor and perform the dance moves or steps the instructor is modeling.

The videos will then be made available to evaluators in the form of YouTube or DVDs. They will also be made public as YouTube is public domain.

Benefits and Risks:

The potential benefits to you from your participation in this project are contributing the culturally appropriate exercise methods for the target population of Marshallese migrant diabetic patients. Other peoples and populations would be able also to use this as an exercise program.

The belief of the conductors of this study is that there is little risk to you in participating in this research project. You may also be at risk from performing dances where you may be injured. The class is designed to be moderate exercise which has been determined to be minimal risk. These


risks should not be any different than if you were to dance outside of the research project. Possible risks include muscle soreness and/or aches from dancing. Injury may also occur such as spraining an ankle while performing the dance moves. While possible, the exercise is considered minimal risk and therefore, these risks are not likely to occur. If shortness of breath does occur, referral of the participant to the emergency department will be made.

As a participant, it is understood that if injured or harmed in the course of this research procedure, cost of treating potential injuries are the participants’ responsibility.

You may withdraw from the project altogether without penalty.

Privacy and Confidentiality:

I will keep all information in a safe, locked or password protected place. Only I, my University of Hawai’i advisor(s) and potentially a translator will have access to the information. All personal information will be kept confidential to the extent allowed by law. Several public agencies with responsibility for research oversight, including the UH Human Studies Program, have the authority to review research records. At the completion of the project, all personal identifying information will be destroyed, with exception of the dance video. When I report the results of my research project, I will not use your name. I will not use any other personal identifying information that can identify you, with exception of the video. I will report my findings in a way that protects your privacy and confidentiality to the extent allowed by law.

You are going to be video recorded as a participant in this study. It will be made public. We will do our best to protect your identity but people may recognize you in the video. If you do not want to be recorded and someone may recognize you, it is not necessary that you participate. We will record the dance video from the back of the class as to reduce faces being recorded but if you a performing a move where you spin around, your faces may be recorded.

If you are the dance instructor, your face will be recognizable in the videos because you will be facing the camera during the recording and also as you model the dance moves.

Voluntary Participation:

Your participation in this project is completely voluntary. Refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled. You may stop participating at any time. If you stop participating in the study, there will be no penalty or loss of any benefits to which you are otherwise entitled.

Compensation:


You will receive a $10 Walmart gift card for participation in this project as a dancer. If you are the dance instructor, you will be compensated for your time at a rate of $10 per hour, given as a Walmart gift card. Compensation will be provided at the end of the video recording.

Questions:

If you have any questions about this study, please call or email me at (208) 369-7266 or [email protected]. You may also contact my adviser, Alice Davis, at (808) 932-7073 or [email protected]. For questions about your rights as a research participant, you may contact the University of Hawai’i Human Studies Program by phone at (808) 956-5007 or by email at [email protected].

If you agree to participate in this project, please sign and date this signature page and return it to: Brayden Walker

Please keep the section above for your records.

If you consent to be in this project, please sign the signature section below and return it to ***.

------------------------------------------------------------------------------------------------------------

Tear or cut here

------------------------------------------------------------------------------------------------------------

Signature(s) for Consent:

I give permission to join the research project entitled, Traditional Dance as an Exercise Regimen for Marshallese Patients with Type 2 Diabetes Mellitus as a dancer or dance instructor and to be

recorded in a publicly available video.

Name of Participant (Print): ___________________________________________________

Participant’s Signature: _____________________________________________

Signature of the Person Obtaining Consent: ___________________________________

Date: ____________________________


Appendix B


Consent to Participate in Research Project as an Evaluator or Contributor to the Cultural Basis of Dance:


My name is Brayden Walker. I am a Doctor of Nursing Practice student at the University of Hawai’i at Hilo in the Department of Nursing. As part of the requirements for earning my degree, I am doing a practice inquiry project. The purpose of my project is to develop and evaluate a dance regimen as an effective way of exercise for Marshallese people who have diabetes. If you at least 19 years old and meet one or more of the following criteria, I am asking you to participate because you meet needed qualifications for this project. The criteria are Marshallese, familiarity with Marshallese culture, health care provider, exercise scientist, personal trainer, diabetes educator, or others qualified to evaluate exercise and cultural aspects of the dance program.

Activities and Time Commitment:

If you participate in this project as an evaluator, you will be asked to view a recorded exercise program and then answer some questions about it in a survey. The survey will consist of nine (9) to thirteen (13) questions about dance, exercise and the videos. It is expected to take approximately 60 to 90 minutes to view the recordings and evaluate the dance program.

If you are asked to complete the Cultural Basis for Dance Questionnaire, you will answer 5 questions regarding the cultural basis of dance within the Marshallese culture and population. It should take approximately 10 minutes to complete this questionnaire.

Benefits and Risks:

The potential benefits to you from your participation in this project are contributing the culturally appropriate exercise methods for the target population of Marshallese migrant diabetic patients. Other peoples and populations would be able also to use this as an exercise program.

The belief of the conductors of this study is that there is little risk to you in participating in this research project. You may become stressed or uncomfortable answering any of the survey or questionnaire questions. If you do become stressed or uncomfortable, you can skip the question or take a break and do not have to answer it. You may also withdraw from the project altogether.


As a participant, it is understood that if injured or harmed in the course of this research procedure, cost of treating potential injuries are the participants’ responsibility.

Privacy and Confidentiality:

I will keep all information in a safe, locked or password protected place. Only I, my University of Hawai’i advisor(s) and potentially a translator will have access to the information. All personal information will be kept confidential to the extent allowed by law. Several public agencies with responsibility for research oversight, including the UH Human Studies Program, have the authority to review research records. At the completion of the project, all personal identifying information will be destroyed. When I report the results of my research project, I will not use your name. I will not use any other personal identifying information that can identify you. Your answer to the first question on the survey will be shared. I will use pseudonyms (fake names) if necessary and report my findings in a way that protects your privacy and confidentiality to the extent allowed by law.

Voluntary Participation:

Your participation in this project is completely voluntary. Refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled. You may stop participating at any time. If you stop participating in the study, there will be no penalty or loss of any benefits to which you are otherwise entitled.

Compensation:

You will receive a $5 Walmart gift card for participation in this project as an evaluator. If you fill out the Cultural Basis for Dance Questionnaire you will not be given any compensation.

Questions:

If you have any questions about this study, please call or email me at (208) 369-7266 or [email protected]. You may also contact my adviser, Alice Davis, at (808) 932-7073 or [email protected]. For questions about your rights as a research participant, you may contact the University of Hawai’i Human Studies Program by phone at (808) 956-5007 or by email at [email protected].

If you agree to participate in this project, please sign and date this signature page and return it to: Brayden Walker


Please keep the section above for your records.

If you consent to be in this project, please sign the signature section below and return it to ***.

------------------------------------------------------------------------------------------------------------

Tear or cut here

------------------------------------------------------------------------------------------------------------

Signature(s) for Consent:

I give permission to join the research project entitled, Traditional Dance as an Exercise Regimen for Marshallese Patients with Type 2 Diabetes Mellitus.

Name of Participant (Print): ___________________________________________________

Participant’s Signature: _____________________________________________

Signature of the Person Obtaining Consent: ___________________________________

Date: ____________________________


Appendix C

COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK REQUIREMENTS REPORT*

* NOTE: Scores on this Requirements Report reflect quiz completions at the time all requirements for the course were met. See list below for details.

See separate Transcript Report for more recent quiz scores, including those on optional (supplemental) course elements.

• Name: Brayden Walker (ID: 4831735) • Email: braydenw@Hawai’i.edu • Institution Affiliation: University of Hawai’i (ID: 1688) • Institution Unit: Nursing • Phone:

2083697266

• Curriculum Group: Human Subjects Research (HSR) • Course Learner Group: Non-Exempt Biomedical Researchers and Key Personnel • Stage: Stage 1 - Basic Course

• Report ID: 18577509 • Completion Date: 02/10/2016 • Expiration Date: 02/09/2019 • Minimum Passing: 80 • Reported Score*: 85

REQUIRED AND ELECTIVE MODULES ONLY DATECOMPLETED SCORE Recognizing and Reporting Unanticipated Problems Involving Risks to Subjects or Others in Bio

medical Research (ID: 14777) 02/04/16 0/5 (0%) Populations in Research Requiring Additional Considerations and/or Protections (ID: 16680) 02/04/16 5/5 (100%) Belmont Report and CITI Course Introduction (ID: 1127) 02/04/16 3/3

(100%) Cultural Competence in Research (ID: 15166) 02/04/16 0/5 (0%) Basic Institutional Review Board (IRB) Regulations and Review Process (ID: 2) 02/05/16 5/5

(100%) Informed Consent (ID: 3) 02/05/16 5/5 (100%) History and Ethics of Human Subjects Research (ID: 498) 02/05/16 7/7 (100%)

Social and Behavioral Research (SBR) for Biomedical Researchers (ID: 4) 02/05/16 4/4 (100%) Records-Based Research (ID: 5) 02/05/16 3/3 (100%)

Genetic Research in Human Populations (ID: 6) 02/05/16 5/5 (100%) FDA-Regulated Research (ID: 12) 02/10/16 5/5 (100%)

Research and HIPAA Privacy Protections (ID: 14) 02/04/16 5/5 (100%) Conflicts of Interest in Research Involving Human Subjects (ID: 488) 02/05/16 5/5 (100%)

Avoiding Group Harms - U.S. Research Perspectives (ID: 14080) 02/04/16 3/3 (100%)

For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution identified above or have been a paid Independent Learner.

CITI Program Email: [email protected] Phone: 305-243-7970 Web: https://www.citiprogram.org

COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM) COURSEWORK TRANSCRIPT REPORT**


** NOTE: Scores on this Transcript Report reflect the most current quiz completions, including quizzes on optional (supplemental) elements of the

course. See list below for details. See separate Requirements Report for the reported scores at the time all requirements for the course were met.

• Name: Brayden Walker (ID: 4831735) • Email: braydenw@Hawai’i.edu • Institution Affiliation: University of Hawai’i (ID: 1688) • Institution Unit: Nursing • Phone:

2083697266

• Curriculum Group: Human Subjects Research (HSR) • Course Learner Group:Non-Exempt Biomedical Researchers and Key Personnel • Stage: Stage 1 - Basic Course

• Report ID: 18577509 • Report Date: 02/27/2016 • Current Score**: 95

REQUIRED, ELECTIVE, AND SUPPLEMENTAL MODULES MOST RECENT SCORE History and Ethics of Human Subjects Research (ID: 498) 02/05/16 7/7 (100%)

Students in Research (ID: 1321) 02/04/16 1/5 (20%) Informed Consent (ID: 3) 02/05/16 5/5 (100%) Social and Behavioral Research (SBR) for Biomedical Researchers (ID: 4) 02/05/16

4/4 (100%) Belmont Report and CITI Course Introduction (ID: 1127) 02/04/16 3/3 (100%) Records-Based Research (ID: 5) 02/05/16 3/3 (100%)

Genetic Research in Human Populations (ID: 6) 02/05/16 5/5 (100%) FDA-Regulated Research (ID: 12) 02/10/16 5/5 (100%)

Research and HIPAA Privacy Protections (ID: 14) 02/04/16 5/5 (100%) Vulnerable Subjects - Research Involving Workers/Employees (ID: 483) 02/04/16 4/4 (100%)

Conflicts of Interest in Research Involving Human Subjects (ID: 488) 02/05/16 5/5 (100%) Avoiding Group Harms - U.S. Research Perspectives (ID: 14080) 02/04/16 3/3 (100%)

Cultural Competence in Research (ID: 15166) 02/27/16 5/5 (100%) Basic Institutional Review Board (IRB) Regulations and Review Process (ID: 2) 02/05/16 5/5 (100%) Stem Cell Research Oversight (Part II) (ID: 14584) 02/04/16 Quiz Not Taken

Recognizing and Reporting Unanticipated Problems Involving Risks to Subjects or Others in Biomedical Research (ID: 14777) 02/27/16 5/5 (100%)

Populations in Research Requiring Additional Considerations and/or Protections (ID: 16680) 02/04/16 5/5 (100%)

For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution identified above or have been a paid Independent Learner.

CITI Program Email: [email protected] Phone: 305-243-7970 Web: https://www.citiprogram.org

Appendix D


Estimated Budget:

1. Compensation for dance instructor(s). $100 for an estimated 10 hours of recording time.2. Survey participants. $5 gift card per participant survey. With an estimated 25

participants that’s $125 total.3. Dancers - $10 gift card with 4 dancers that is $40 4. Printing costs of surveys. $55. Translator to translate surveys if needed. $506. DVDs if needed - $157. Total Budget: $335

Other Resources:

1. Camera and audio equipment for recording videos2. Venue (outdoors or indoors) for recording3. Assistance from Micronesians United of the Big Island4. Computer capable of creating DVDs if necessary

Timeline:

1. PIP Proposal defense 7/21/20172. Submit to IRB 7/27/20173. After IRB approval:

• 1 week for Cultural Basis Questionnaire• 2 weeks to develop dance regimen• 1 week to record videos• 1 week for Cultural and Exercise evaluation surveys of dance regimen• 2 weeks for analysis and evaluation of survey results

Appendix E

See next page for IRB approval letter.


NOTICE OF APPROVAL FOR HUMAN RESEARCH

This letter is your record of the Human Studies Program approval of this study as exempt.

On September 19, 2017, the University of Hawai#i (UH) Human Studies Program approved this study as exempt from federal regulations pertaining to the protection of human research participants. The authority for the exemption applicable to your study is documented in the Code of Federal Regulations at 45 CFR 46.101(b) 2.

Exempt studies do not require regular continuing review by the Human Studies Program. However, if you propose to modify your study, you must receive approval from the Human Studies Program prior to implementing any changes. You can submit your proposed changes via email at [email protected]. (The subject line should read: Exempt Study Modification.) The Human Studies Program may review the exempt status at that time and request an application for approval as non-exempt research.

In order to protect the confidentiality of research participants, we encourage you to destroy private information which can be linked to the identities of individuals as soon as it is reasonable to do so. Signed consent forms, as applicable to your study, should be maintained for at least the duration of your project.

This approval does not expire. However, please notify the Human Studies Program when your study is complete. Upon notification, we will close our files pertaining to your study.

If you have any questions relating to the protection of human research participants, please contact the Human Studies Program by phone at 956-5007 or email [email protected]. We wish you success in carrying out your research project.

DATE


Appendix F

Aloha,

Thank you for taking the time to evaluate this dance regimen as part of my practice inquiry project. This survey is an evaluation of cultural preferences regarding dance/exercise. Its intended purpose is to address dance/exercise from a cultural perspective and then to address how this program fits, or does not fit, cultural preferences.

The first question regards your qualifications to evaluate the dance regimen. Then, most of the questions are based on a scale where you will circle your answer. These questions are about the cultural aspects of the dance regimen and how likely you are to participate in or recommend this dance regimen to others. There are some questions you will have to write your answer to. The last two questions are about facilitators and barriers to implementation and are to be answered be everyone also.

Most of the question are based on a 5-point Likert scale. Do your best to answer the questions. If you feel that a question does not apply to you then put N/A and skip to the next one. Mahalo.

1. What are your qualifications for evaluation? Circle all that apply. Marshallese, Very familiar with Marshallese culture, Healthcare provider, Exercise physiology/sports medicine, diabetes educator, etc.

Based on a 5-point Likert scale:

How important is dance to you?

1 – not at all 2 – very little 3 – somewhat 4 – important 5 – very important

How important is dance to your culture?


How important is exercise to you?


How culturally appropriate is this dance regimen?

1 – not at all 2 – very little 3 – somewhat 4 – many aspect are 5 – very appropriate


What aspects, if any, are culturally appropriate?

What aspects, if any, are not culturally appropriate?

Based on culturally appropriateness alone, how comfortable would you be participating in this regimen?

1 – not at all 2 – very little 3 – neutral 4 – somewhat 5 – very comfortable

How familiar are you with these dances?

1 – not at all 2 – a little bit 3 – somewhat 4 – pretty familiar 5 – very familiar

Would you recommend this dance regimen to your friends and/or family?

1 – never 2 – probably not 3 – might recommend it 4 – probably will 5 – definitely will

Is this method of implementation a fitting way to help people be active?

1 – not at all 2 – probably not fitting 3 – neutral 4 – somewhat fitting 5 – very fitting

Can you think of any barriers to implementation? If so, what?

Can you think of any facilitators to implementation? If so, what?


Appendix G

Aloha,

Thank you for taking the time to evaluate this dance regimen as part of my practice inquiry project. This survey is about the exercise and physical activity aspects of the dance regimen. Its intended purpose is to gather information regarding how well this program fits exercise needs of potential participants and implementation of the regimen.

The first question regards your qualifications to evaluate the dance regimen. The next six questions are about the physical activity and patient appropriateness of the regimen. The last two questions are about facilitators and barriers to implementation.

Most of the question are based on a 5-point Likert scale. Do your best to answer the questions. If you feel that a question does not apply to you then put N/A and skip to the next one. Mahalo.

2. What are your qualifications for evaluation? Circle all that apply. Marshallese, Very familiar with Marshallese culture, Healthcare provider, Exercise physiology/sports medicine, diabetes educator, etc.

Based on a 5-point Likert scale:

Based on current recommendations, how likely is this regimen meet the minimum standards for physical activity?

1 – not at all 2 – unlikely 3 – neutral 4 – somewhat likely 5 – very likely

How likely are you recommend patients/persons to participate in this regimen?


Do you anticipate patients being willing to participate in this type of exercise?


Have you ever tried anything like this before for your patients?

1 – never 2 – once or twice 3 – tried on a few patients 4 – tried for many patients 5 – tried for most patients


How likely are you to recommend this to your patients?


How likely do you think this program would promote increased exercise for this patient population?


Can you think of any barriers to implementation? If so, what?

Can you think of any facilitators to implementation? If so, what?


Appendix H

Cultural Basis for Dance Questionnaire

Consider for the following questions, the Marshallese culture and population:

1. Who in the population dances? Young, old, all ages, no one, etc.

______________________________________________________________________________________________________________________________________________________

2. What types(s) of dance are there in this culture/population?

______________________________________________________________________________________________________________________________________________________

3. What type(s) of music is listened to when dancing?

______________________________________________________________________________________________________________________________________________________

4. What is the significance of dance within this culture?

______________________________________________________________________________________________________________________________________________________

5. What impact do dance have on the community?


Appendix I

Results from Cultural Evaluation

Questions Likert Score 1

Likert Score 2

Likert Score 3

Likert Score 4

Likert Score 5

Mean Rating

How important is dance to you?

0 0 0 1 10 4.91

How important is dance to your culture?

0 0 0 0 11 5

How important is exercise to you?

0 2 0 3 6 4.18

How culturally appropriate is this dance regimen?

0 0 2 1 8 4.55

Based on cultural appropriateness alone, how comfortable would you be participating in this regimen?

0 2 0 0 9 4.45

How familiar are you with these dances?

0 2 0 3 6 4.18

Would you recommend this dance regimen to your friends and/or family?

0 0 2 1 8 4.55

Is this method on implementation a fitting way to help people be active?

0 0 1 1 9 4.73


Appendix J

Results from Exercise Questionnaire

Question Likert Score 1

Likert Score 2

Likert Score 3

Likert Score 4

Likert Score 5

Mean Rating

Based on current recommendations, how likely is this regimen meet the minimum standards for physical activity?

0 0 2 2 3 4.14

How likely are you recommend patients/persons to participate in this regimen?

0 0 1 5 1 4

Do you anticipate patients being willing to participate in this type of exercise?

0 0 1 5 1 4

Have you ever tried anything like this before for your patients?*

3 0 2 1 0 2.17

How likely are you to recommend this to your patients?

0 0 1 5 1 4

How likely do you think this program would promote increased exercise for this patient population?

0 0 1 5 1 4

One evaluator did not respond to this question.