Association of the COVID-19 Pandemic With Women, Infants, and Children (WIC) Receipt Among Pregnant Individuals: United States, 2016-2022.

Objectives. To evaluate the effect of COVID-19 on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receipt among pregnant individuals overall and by race/ethnicity. Methods. We measured changes in WIC receipt among Medicaid-covered births (n = 10 484 697) from the US National Center for Health Statistics Natality Files (2016-2022). Our interrupted time series logistic model included a continuous monthly variable, a binary post-COVID variable, and a continuous slope shift variable. We additionally fit separate models for each race/ethnicity relative to White individuals, using interaction terms between the time series variables and race/ethnicity. Results. We found decreases in WIC receipt (adjusted odds ratio [AOR] = 0.899; P < .001) from before COVID (66.6%) to after COVID (57.9%). There were larger post-COVID decreases for American Indian/Alaska Native (AOR = 0.850; P < .001), Native Hawaiian/Other Pacific Islander (AOR = 0.877; P = .003), Black (AOR = 0.974; P < .001), and Hispanic (AOR = 0.972, P < .001) individuals relative to White individuals. Conclusions. The greater reductions in WIC receipt among minoritized individuals highlights a pathway through which the pandemic may have widened gaps in already disparate maternal and infant health. Public Health Implications. Continued efforts to increase WIC utilization are needed overall and among minoritized populations. (Am J Public Health. 2023;113(S3):S240-S247. https://doi.org/10.2105/AJPH.2023.307525).

Effects of Race and Poverty on Sleep Duration: Analysis of Patterns in the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey and General National Health Interview Survey Data.

BACKGROUND: There are health concerns associated with unhealthy sleep duration. A growing body of evidence indicates that there are disparities in sleep duration based upon race/ethnicity and socioeconomic status. Prior studies have suffered from inadequate measures of poverty and have not included Native Hawaiians and Pacific Islanders (NHPI). METHODS: Using the 2014 National Health Interview Survey (NHIS) and the 2014 NHPI-NHIS, the effect of race/ethnicity and poverty was examined for associations with sleep duration. RESULTS: Significant differences among race/ethnicity groups and sleep duration were found in adjusted associations. Compared with Whites, NHPIs and Blacks were twice as likely to experience very short sleep; NHPI, Hispanic, and Blacks were more likely to experience short sleep; Blacks were also more likely to experience long sleep. Asians were less likely to experience unhealthy sleep (very short, short, or long sleep). Persons living in poverty were significantly more likely to experience very short sleep compared with persons not living in poverty. CONCLUSION: This is the first population-based study that has examined the relationship between sleep duration and poverty with a large sample that included NHPI in relation to other races/ethnicities. The difference in sleep duration between NHPI and Asians provides a strong rationale for not aggregating Asian and NHPI data in population-based studies.

A Community-Based Participatory Approach to Promote Healthy Eating Among Marshallese.

This article describes changes made to the menu served during the 2015 Marshallese May Day celebration in Northwest Arkansas, an annual Marshallese community event. The menu changes were part of a community-based participatory collaborative to improve nutrition and health in the Marshallese community. The 2015 May Day menu significantly reduced the 2014 May Day menu amount of calories, fat, carbohydrates, sodium, and cholesterol of foods offered by incorporating healthier ingredients and reducing portion sizes. Compared to the 2014 May Day menu, the total caloric value of the revised menu was reduced by more than 63%, declining from 1369 calories to 499 calories. The menu change affected an estimated 1,800 Marshallese in attendance for the 2015 May Day celebration. The successful implementation of the menu changes, which resulted in reductions in calories, fat, carbohydrates, sodium, and cholesterol offered to participants demonstrates the effectiveness of community-based participatory approaches in the implementation of policy, systems, and environmental strategies to promote health.

Developing and Launching a Research Participant Registry.

BACKGROUND: A major challenge in clinical research today is the difficulty that studies have in meeting recruitment goals. Up to 48% of studies do not meet accrual goals within the specified timeframe, significantly delaying the progress of projects and the dissemination of findings. This pervasive problem is a recruitment crisis. We developed a representative, ethnically and racially diverse research participant registry in a predominantly rural state with high levels of health care disparities and minority populations. We sought input at each step of development from members of community advisory boards (CABs) across Arkansas. We report how community involvement in the development of the registry was implemented. METHODS: Members of CABs were partners in developing all aspects of the registry website, including the name, content, appearance, educational messages, and testimonials used. Constructs from the Health Belief Model informed the educational messages and supported the intense multimedia campaign used to launch and promote ongoing registrations. Using CAB guidance, community events were held throughout the state of Arkansas at venues with diverse racial and ethnic attendance. RESULTS: From April 1, 2016 to September 1, 2017, 4,002 people registered statewide who match the demographic profile of Arkansas. CONCLUSION: CAB involvement in the registry, multiple cues to action, and face-to-face contact with diverse lay audiences throughout the state were key components of the successful registry launch.

Physical Activity Among Native Hawaiians and Pacific Islanders: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine the proportion of Native Hawaiian and Pacific Islander (NHPI) meeting recommended physical activity guidelines for Americans (PAG) and determine differences in physical activity (PA) by sex and between NHPI and Asians when data are disaggregated. DESIGN: Systematic review and meta-analysis. SETTING: Articles identified in CINAHL, The Cochrane Library, Embase, PsychINFO, PubMed, Scopus, SocINDEX, SPORTDiscus, and Web of Science. PARTICIPANTS: NHPI children and adults, and Asian adults. INTERVENTIONS: Proportion of NHPI meeting PAG and differences in PA involvement by sex and by ethnicity. METHODS: Summary reporting for articles, and meta-analysis using random-effects and inverse-various weighted models. CONCLUSIONS AND IMPLICATIONS: Just over one-third of NHPI children met the PAG (mean = 38.6%, 95% CI [32.43-45.08]), with more males (42.8%) than females (34.7%) meeting the guidelines (t = 6.74, df = 1, P = .02). Less than half met the PAG for combination (mean = 48.7%, 95% CI [34.69-62.97]), moderate (mean = 47.1%, 95% CI [33.62-61.07]), and about one-third met the PAG for vigorous PA (mean = 33.4%, 95% CI [24.55-43.62]). There were no significant differences between Asians and NHPI in PA. Policy, systems, and environmental changes as well as culturally appropriate interventions are needed to increase physical activity among NHPI.

Sleep deficiency among Native Hawaiian/Pacific Islander, Black, and White Americans and the association with cardiometabolic diseases: analysis of the National Health Interview Survey Data.

PURPOSE: Examine sleep deficiency, factors, and associations with cardiometabolic diseases in United States Native Hawaiian/Pacific Islanders (NHPI), Blacks, and Whites. DESIGN: Data from the 2014 National Health Interview Survey and NHPI National Health Interview Survey household interviews of adults were analyzed. PARTICIPANTS: Of 31,724 participants, 7% were NHPI, 14% were Black, and 79% were White. METHODS: Habitual sleep duration and quality, sociodemographic/economic covariates, health behaviors, psychological distress, and chronic diseases were self-reported. Sleep duration was coded as very short (VSS; <5 hours), short (SS; 5-6 hours), long (LS; >8 hours), or healthy (7-8 hours). Using multivariate logistic regressions, the association between sleep duration and diseases was assessed after adjusting for covariates. RESULTS: NHPI were more likely to report sleep <7 hours compared to Whites (40.2% NHPI, 29.3% White) and less LS than Blacks (7% NHPI, 9.2% Black), report poor sleep quality, and use fewer sleep medications. VSS was related to smoking and psychological distress in NHPI men. VSS was associated with hypertension and SS with diabetes in NHPI, even in adjusted models. The relationship between SS and diabetes was higher in NHPI (risk ratio [RR]: 1.40, 95% confidence interval [CI]: 1.03-1.90) than Whites (RR: 1.01, 95% CI: 0.90-1.14, P = .027) and Blacks (RR: 1.02, 95% CI: 0.85-1.23, P = .043) even after adjusting for other covariates. CONCLUSIONS: NHPI reported suboptimal sleep duration that was linked to hypertension and diabetes even after controlling for covariates. Additional prospective studies in NHPI are needed to understand biological, behavioral, and psychological factors of sleep deficiency and its impact on chronic diseases.

Design of a comparative effectiveness randomized controlled trial testing a faith-based Diabetes Prevention Program (WORD DPP) vs. a Pacific culturally adapted Diabetes Prevention Program (PILI DPP) for Marshallese in the United States.

BACKGROUND: Pacific Islander populations, including Marshallese, face a disproportionately high burden of health disparities relative to the general population. OBJECTIVES: A community-based participatory research (CBPR) approach was utilized to engage Marshallese participants in a comparative effectiveness trial testing 2 Diabetes Prevention Program (DPP) interventions designed to reduce participant's weight, lower HbA1c, encourage healthy eating, and increase physical activity. DESIGN: To compare the effectiveness of the faith-based (WORD) DPP to the culturally adapted (Pacific Culturally Adapted Diabetes Prevention Program [PILI]) DPP, a clustered randomized controlled trial (RCT) with 384 Marshallese participants will be implemented in 32 churches located in Arkansas, Kansas, Missouri, and Oklahoma. Churches will be randomly assigned to WORD DPP arm or to PILI DPP arm. METHODS: WORD DPP focuses on connecting faith and health to attain a healthy weight, eat healthy, and be more physically active. In contrast, PILI DPP is a family and community focused DPP curriculum specifically adapted for implementation in Pacific Islander communities. PILI focuses on engaging social support networks to maintain a healthy weight, eat healthy, and be more physically active. All participants are assessed at baseline, immediate post intervention, and 12 months post intervention. SUMMARY: Both interventions aim to cause weight loss through improving physical activity and healthy eating, with the goal of preventing the development of T2D. The clustered RCT will determine which intervention is most effective with the Marshallese population. The utilization of a CBPR approach that involves local stakeholders and engages faith-based institutions in Marshallese communities will increase the potential for success and sustainability. This study is registered at clinicaltrials.gov (NCT03270436).

Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community.

Objectives Pacific Islanders are disproportionately burdened by poorer perinatal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. The aim of this study is to examine Marshallese mothers' beliefs, perceptions, and experiences of prenatal care and to identify potential barriers. Methods Three focus groups were conducted with Marshallese mothers, who were 18 years or older, and living in Arkansas. Focus groups focused on mothers' beliefs, perceptions, and experiences of prenatal care. A thematic qualitative analysis was conducted to identify salient themes within the data. Results The results demonstrated that negotiating health insurance, transportation, and language barriers were all major structural barriers that constrain prenatal care. The social-cultural barriers that emerged included a lack of understanding of the importance of seeking early and consistent prenatal care, as well as how to navigate the healthcare process. The more complicated challenges that emerged were the feelings of shame and embarrassment due to the perception of their age or being unmarried during pregnancy not being acceptable in American culture. Furthermore, the participants described perceived discrimination from prenatal care providers. Lastly, the participants described fear as a barrier to seeking out prenatal care. Conclusions for Practice This study identified both structural and socio-cultural barriers that can be incorporated into suggestions for policy makers to aid in alleviating maternal health disparities among Pacific Islander women. Further research is needed to address the Marshallese mothers' perceived discrimination from maternal health care providers.

Best practices for community-engaged participatory research with Pacific Islander communities in the USA and USAPI: protocol for a scoping review.

INTRODUCTION: Community-based participatory research is a partnership approach to research that seeks to equally involve community members, organisational representatives and academic partners throughout the research process in a coequal and mutually beneficial partnership. To date, no published article has synthesised the best practices for community-based participatory research practices with Pacific Islanders. METHODS AND ANALYSIS: The reviewers will examine studies' titles, abstracts and full text, comparing eligibility to address discrepancies. For each eligible study, data extraction will be executed by two reviewers and one confirmation coder, comparing extracted data to address any discrepancies. Eligible data will be synthesised and reported in a narrative review assessing coverage and gaps in existing literature related to community-based participatory research with Pacific Islanders. DISCUSSION AND DISSEMINATION: The purpose of this review is to identify best practices used when conducting community-based participatory research with Pacific Islanders; it will also extrapolate where the gaps are in the existing literature. This will be the first scoping review on community-based participatory research with Pacific Islanders. To facilitate dissemination, the results of this scoping review will be submitted for publication to a peer-reviewed journal, presented at conferences and shared with community-based participatory research stakeholders.

Integrating Interprofessional Education and Cultural Competency Training to Address Health Disparities.

PROBLEM: Many U.S. medical schools have accreditation requirements for interprofessional education and training in cultural competency, yet few programs have developed programs to meet both of these requirements simultaneously. Furthermore, most training programs to address these requirements are broad in nature and do not focus on addressing health disparities. The lack of integration may reduce the students' ability to apply the knowledge learned. Innovative programs that combine these two learning objectives and focus on disenfranchised communities are needed to train the next generation of health professionals. INTERVENTION: A unique interprofessional education program was developed at the University of Arkansas for Medical Sciences Northwest. The program includes experiential learning, cultural exposure, and competence-building activities for interprofessional teams of medicine, nursing, and pharmacy students. The activities include (a) educational seminars, (b) clinical experiential learning in a student-led clinic, and (c) community-based service-learning through health assessments and survey research events. CONTEXT: The program focuses on interprofessional collaboration to address the health disparities experienced by the Marshallese community in northwest Arkansas. The Marshallese are Pacific Islanders who suffer from significant health disparities related to chronic and infectious diseases. OUTCOME: Comparison tests revealed statistically significant changes in participants' retrospectively reported pre/posttest scores for Subscales 1 and 2 of the Readiness for Interpersonal Learning Scale and for the Caffrey Cultural Competence in Healthcare Scale. However, no significant change was found for Subscale 3 of the Readiness for Interpersonal Learning Scale. Qualitative findings demonstrated a change in students' knowledge, attitudes, and behavior toward working with other professions and the underserved population. LESSONS LEARNED: The program had to be flexible enough to meet the educational requirements and class schedules of the different health professions' education programs. The target community spoke limited English, so providing interpretation services using bilingual Marshallese community health workers was integral to the program's success.

Cultural Adaptation of Diabetes Self-Management Education for Marshallese Residing in the United States: Lessons Learned in Curriculum Development.

BACKGROUND: Type 2 diabetes is a significant public health problem, with U.S. Pacific Islander communities bearing a disproportionate burden. The Marshallese are a Pacific Islander community that has significant inequities in diabetes, yet few evidence-based diabetes interventions have been developed to address this inequity. OBJECTIVES: We used a community-based participatory research (CBPR) approach to adapt an evidence-based diabetes self-management education (DSME) intervention for the Marshallese. METHODS: Our team used the Cultural Adaptation Process Model, in addition to an iterative process consisting of formative data and previous literature review, and engagement with community and academic experts. LESSONS LEARNED: Specific cultural considerations were identified in adapting DSME components, including the dichotomous versus gradient conceptualization of ideas, the importance of engaging the entire family, the use of nature analogies, and the role of spirituality. CONCLUSIONS: We identified key cultural considerations to incorporate into a diabetes self-management program for the Marshallese. The insights gained can inform others' work with Pacific Islanders.

Community Health Warriors: Marshallese Community Health Workers' Perceptions and Experiences with CBPR and Community Engagement.

Our manuscript highlights the viewpoints and reflections of the native Marshallese community health workers (CHWs) engaged in research with the local Marshallese community in Northwest Arkansas. In particular, this paper documents the vital role Marshallese CHWs play in the success of programs and research efforts. The negative health effects of nuclear testing in the Marshall Islands has been passed down through many generations, along with unfavorable attitudes toward the U.S. government and researchers. However, the community-based participatory research (CBPR) approach used by the University of Arkansas for Medical Sciences (UAMS) has allowed the native Marshallese CHWs to become advocates for the Marshallese community. The use of native CHWs has also leveled the power dynamics that can be a barrier to community-based research, and has strengthened trust with community stakeholders. Our paper shows how using Marshallese CHWs can produce positive health outcomes for the Marshallese community.

Qualitative study of participants' perceptions and preferences regarding research dissemination.

BACKGROUND: The study identifies the experiences, preferences, and perceptions of research participants regarding dissemination of research findings at the participant level and community level. METHODS: The qualitative study utilized focus-group methodology to explore research participants' experiences and preferences for the dissemination of research findings. Five focus groups were held with 53 participants who were recruited through existing community advisory boards in Arkansas. RESULTS: Participants stated that researchers should always offer to share research findings. Participants explained that disseminating findings is appropriate because of their sense of ownership of results, it encourages participation facilitating higher quality research, and it may foster greater trust between researchers and participants. Participants also provided insights on how research findings should be shared, including recommendations for appropriate mode, timing, and context, as well as ways to share sensitive findings and the role of community partners in dissemination. CONCLUSIONS: This study is consistent with other studies that document participants' desire to receive research findings and expands our knowledge by documenting participants' rationale for why they think it is important and their recommendations for how to share results. Further research is needed to understand why researchers are not disseminating study findings to participants and to test the best ways to share results.

Improving Culturally Appropriate Care Using a Community-Based Participatory Research Approach: Evaluation of a Multicomponent Cultural Competency Training Program, Arkansas, 2015-2016.

INTRODUCTION: The United States continues to become more racially and ethnically diverse, and racial/ethnic minority communities encounter sociocultural barriers to quality health care, including implicit racial/ethnic bias among health care providers. In response, health care organizations are developing and implementing cultural competency curricula. Using a community-based participatory research (CBPR) approach, we developed and evaluated a cultural competency training program to improve the delivery of culturally appropriate care in Marshallese and Hispanic communities. METHODS: We used a mixed-methods evaluation approach based on the Kirkpatrick model of training evaluation. We collected quantitative evaluation data immediately after each training session (March 19, 2015-November 30, 2016) and qualitative data about implementation at 2 points: immediately after each session and 6 months after training. Individuals and organizational units provided qualitative data. RESULTS: We delivered 1,250 units of in-person training at 25 organizations. Participants reported high levels of changes in knowledge (91.2%), competence (86.6%), and performance (87.2%) as a result of the cultural competency training. Organizations reported making policy and environmental changes. CONCLUSION: Initial outcomes demonstrate the value of developing and implementing cultural competency training programs using a CBPR approach. Additional research is needed to determine the effect on long-term patient outcomes.

Design of a randomized, controlled, comparative-effectiveness trial testing a Family Model of Diabetes Self-Management Education (DSME) vs. Standard DSME for Marshallese in the United States.

BACKGROUND: Type 2 diabetes (T2D) is a significant public health problem, with U.S. Pacific Islander communities-such as the Marshallese-bearing a disproportionate burden. Using a community-based participatory approach (CBPR) that engages the strong family-based social infrastructure characteristic of Marshallese communities is a promising way to manage T2D. OBJECTIVES: Led by a collaborative community-academic partnership, the Family Model of Diabetes Self-Management Education (DSME) aimed to change diabetes management behaviors to improve glycemic control in Marshallese adults with T2D by engaging the entire family. DESIGN: To test the Family Model of DSME, a randomized, controlled, comparative effectiveness trial with 240 primary participants was implemented. Half of the primary participants were randomly assigned to the Standard DSME and half were randomly assigned to the Family Model DSME. Both arms received ten hours of content comprised of 6-8 sessions delivered over a 6-8 week period. METHODS: The Family Model DSME was a cultural adaptation of DSME, whereby the intervention focused on engaging family support for the primary participant with T2D. The Standard DSME was delivered to the primary participant in a community-based group format. Primary participants and participating family members were assessed at baseline and immediate post-intervention, and will also be assessed at 6 and 12 months. SUMMARY: The Family Model of DSME aimed to improve glycemic control in Marshallese with T2D. The utilization of a CBPR approach that involves the local stakeholders and the engagement of the family-based social infrastructure of Marshallese communities increase potential for the intervention's success and sustainability.

Engagement practices that join scientific methods with community wisdom: designing a patient-centered, randomized control trial with a Pacific Islander community.

This article illustrates how a collaborative research process can successfully engage an underserved minority community to address health disparities. Pacific Islanders, including the Marshallese, are one of the fastest growing US populations. They face significant health disparities, including extremely high rates of type 2 diabetes. This article describes the engagement process of designing patient-centered outcomes research with Marshallese stakeholders, highlighting the specific influences of their input on a randomized control trial to address diabetes. Over 18 months, an interdisciplinary research team used community-based participatory principles to conduct patient-engaged outcomes research that involved 31 stakeholders in all aspects of research design, from defining the research question to making decisions about budgets and staffing. This required academic researcher flexibility, but yielded a design linking scientific methodology with community wisdom.

Diabetes and Hypertension in Marshallese Adults: Results from Faith-Based Health Screenings.

BACKGROUND: The Pacific Islander population in the USA is growing rapidly. However, research on Pacific Islanders in the USA is limited, or sometimes misleading due to aggregation with Asian Americans. This project seeks to add to the dearth of health literature by conducting a health assessment of Marshallese in northwest Arkansas. METHODS: Using a community-based participatory research approach, nine health screening events were conducted at local Marshallese churches. Participants completed the Behavioral Risk Factors Surveillance Survey core questionnaire and diabetes module if applicable. Biometric data, including Hemoglobin A1c, blood pressure, and body mass index, were gathered by an interprofessional team. RESULTS: Four hundred one participants completed health screenings. High proportions of diabetes, obesity, and hypertension were found. A high percentage of participants were uninsured, and multiple barriers to health care were found within the sample. DISCUSSION: This project represents one of the first broad health assessments of Pacific Islanders in the USA. Proportions of diabetes, hypertension, obesity, and uninsured found in the sample are much higher than national proportions.

The National Children's Study: Recruitment Outcomes Using the Provider-Based Recruitment Approach.

OBJECTIVE: In 2009, the National Children's Study (NCS) Vanguard Study tested the feasibility of household-based recruitment and participant enrollment using a birth-rate probability sample. In 2010, the NCS Program Office launched 3 additional recruitment approaches. We tested whether provider-based recruitment could improve recruitment outcomes compared with household-based recruitment. METHODS: The NCS aimed to recruit 18- to 49-year-old women who were pregnant or at risk for becoming pregnant who lived in designated geographic segments within primary sampling units, generally counties. Using provider-based recruitment, 10 study centers engaged providers to enroll eligible participants at their practice. Recruitment models used different levels of provider engagement (full, intermediate, information-only). RESULTS: The percentage of eligible women per county ranged from 1.5% to 57.3%. Across the centers, 3371 potential participants were approached for screening, 3459 (92%) were screened and 1479 were eligible (43%). Of those 1181 (80.0%) gave consent and 1008 (94%) were retained until delivery. Recruited participants were generally representative of the county population. CONCLUSIONS: Provider-based recruitment was successful in recruiting NCS participants. Challenges included time-intensity of engaging the clinical practices, differential willingness of providers to participate, and necessary reliance on providers for participant identification. The vast majority of practices cooperated to some degree. Recruitment from obstetric practices is an effective means of obtaining a representative sample.

Interpretive policy analysis: Marshallese COFA migrants and the Affordable Care Act.

BACKGROUND: Since the enactment of the Affordable Care Act (ACA), the rate of uninsured in the United States has declined significantly. However, not all legal residents have benefited equally. As part of a community-based participatory research (CBPR) partnership with the Marshallese community, an interpretative policy analysis research project was conducted to document Marshallese Compact of Free Association (COFA) migrants' understanding and experiences regarding the ACA and related health policies. This article is structured to allow the voice of Marshallese COFA migrants to explain their understanding and interpretation of the ACA and related polices on their health in their own words. METHODS: Qualitative data was collected from 48 participants in five focus groups conducted at the local community center and three individual interviews for those unable to attend the focus groups. Marshallese community co-investigators participated throughout the research and writing process to ensure that cultural context and nuances in meaning were accurately captured and presented. Community co-investigators assisted with the development of the semi-structured interview guide, facilitated focus groups, and participated in qualitative data analysis. RESULTS: Content analysis revealed six consistent themes across all focus groups and individual interviews that include: understanding, experiences, effect on health, relational/historical lenses, economic contribution, and pleas. Working with Marshallese community co-investigators, we selected quotations that most represented the participants' collective experiences. The Marshallese view the ACA and their lack of coverage as part of the broader relationship between the Republic of the Marshall Islands (RMI) and the United States. The Marshallese state that they have honored the COFA relationship, and they believe the United States is failing to meet its obligations of care and support outlined in the COFA. CONCLUSION: While the ACA and Medicaid Expansion have reduced the national uninsured rate, Marshallese COFA migrants have not benefited equally from this policy. The lack of healthcare coverage for the Marshallese COFA migrants exacerbates the health disparities this underserved population faces. This article is an important contribution to researchers because it presents the Marshallese's interpretation of the policy, which will help inform policy makers that are working to improve Marshallese COFA migrant health.

Marshallese COFA Migrants in Arkansas.

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