The Register Report, Fall 2007 Working Together: Integrated Health Care I Ola Lahui: Rural Hawaii Behavioral Health Program by Joseph Keawe'aimoku Kaholokula, Ph.D., A. Aukahi Austin, Ph.D., K. Beth Yano, Ph.D., Jill M. Oliveira, Ph.D., Darryl Salvador, Psy.D. and Robin E.S. Miyamoto, Psy.D. Return to Table of Contents

Over coffee six psychologists entertained the idea of starting a psychology training program that would increase the number of psychologists practicing in rural communities of Hawai‘i. With nothing more than vision and a shared enthusiasm, I Ola Lahui: Rural Hawai‘i Behavioral Health Psychology Training Program took shape over a year’s time. I Ola Lahui is a Hawaiian phrase that translates into the English language as, “So that the people will live and thrive.” With this in mind, Drs. Aukahi Austin, Jill Oliveira, Robin Miyamoto, Darryl Salvador, Beth Yano, and J. Keawe‘aimoku Kaholokula began I Ola Lahui.

HEALTH DISPARITIES AND UNIQUE CHALLENGES IN HAWAI‘I

The idea of creating a psychology training program like I Ola Lahui arose from the growing behavioral and mental health care needs of the medically underserved and people who reside in the rural communities of Hawai‘i. These individuals face challenges in receiving quality medical and psychological services, similar to many medially underserved and rural communitites across the US (Oliveira, Austin, Miyamoto, Kaholokula, Yano, & Lunasco, 2006). Often people do not access care, are offered limited care, or are referred to specialty health care services in urban areas that are miles away and, in Hawai‘i, such services may be an island away. These specialty referrals often lead to failure to follow up and seek needed services.

Geography. The state of Hawai‘i is comprised of seven islands spanning 400 miles from the island of Hawai‘i to the island of Kaua‘i. About 1.3 million people reside in the state of Hawai‘i, with more than 70% of these people residing on the island of O’ahu alone (U.S. Census Bureau, 2006). The majority of physicians, mental health professionals, state-ofthe-art hospitals, and health care resources are located on O’ahu. As a result, people in rural communities on other islands either do not receive adequate care, must wait for limited professional services by fly-in providers, or are made to travel long distances for their health care services.

Cultural and Economic Diversity. Not only is the geography of Hawai‘i a challenge to providing quality medical and psychological services to people of rural communities, but the level of complexity in effectively delivering quality health care services is further impacted by the cultural diversity and the economic and health conditions of many rural residents. Hawai‘i is perhaps the most ethnically and culturally diverse state in the U.S. Native Hawaiians, the descendents of the indigenous people of Hawai‘i, make up about 22% of the population while the other are 16.5% Japanese, 25.3% Caucasian,11.3% Filipino, 3.6% Chinese, and 21.3% various other ethnic groups (e.g., Samoan, Chuukese, and Southeast Asians; Hawai‘i State Department of Health, 2005). Although Native Hawaiians make up 22% of the state’s total population, they make up an even greater percentage of the people residing in rural communities because most of the Hawaiian Homelands are located in rural areas.1

To add to this ethnic heterogeneity, Hawai‘i is made up of people with varying acculturation statuses, such as native people (e.g., Native Hawaiians), immigrants, (e.g., Chuukese), and refugees (e.g., Hmong). As a result, many people are of multiple ethnic admixtures in which an individual might have, for example, a combined Native Hawaiian, Portuguese, and Chinese ancestry. A diversity of ethnic admixtures in the people of Hawai‘i contributes to the large variations in their ethnic identifications and affiliations. Such ethnic and cultural diversity requires that behavioral health care providers have a high degree of cultural and linguistic competency to meet Hawai‘i’s need.

Hawai‘i’s rural communities are as economically diverse as they are ethnically and culturally diverse. Residents of rural Hawai‘i include the wealthiest to the most economically challenged people in Hawai‘i. Many of them, however, fall closer to the latter rather than the former end of the economic spectrum. Compared to people living in urban areas, people who live in rural areas of the U.S. tend to have less formal education, higher unemployment rates, and more poverty (Campbell, Richie, & Hargrove, 2003). Native Hawaiians as a group, who make up a large number of the rural population, are among the most economically and socially disadvantaged ethnic group in Hawai‘i. Compared to other ethnic groups, they are less likely to have adequate health care coverage and receive routine health care services (Oliveira et al., 2006).

Health Status in Rural Communities. The overall health status of the medically undeserved and other people in rural Hawai‘i is poorer than that of the general population of Hawai‘i. Native Hawaiians, for example, have a higher prevalence of depression (11.4%) compared to Filipinos (8.6%), Japanese (4.2%), and Caucasians (7.3%); (Hawai‘i State Department of Health, 2007). A study of Native Hawaiians living in a rural community found the prevalence of depression to be as high as 15% for this ethnic group (Kaholokula, Grandinetti, Crabbe, Chang, & Kenui, 1999). Moreover, people who reside in rural communities perceive their health status as being poorer than people residing in urban areas (United States Department of Agriculture, 2006). A study in a rural community of Hawai‘i found the prevalence of diabetes to be higher among NativeHawaiians (19%), Filipinos (19.4%), and Japanese (21%) when compared to Caucasians (4.4%); (Grandinetti, Kaholokula, Theriault, Mor, Chang, & Waslien, 2007).

Overall, Native Hawaiians have the highest rate of untreated medical and psychological concerns as compared to other ethnic groups, and those who do seek services rely on state and federally sponsored programs for their health care (Office of Hawaiian Affairs, 2006). Greater medical and psychological concerns coupled both with disparities in income and education and the cultural distress experienced by Native Hawaiians have created an unprecedented demand for health services. Further exacerbating the dire need for mental health treatment is the reluctance of patients to seek treatment due to the stigma of mental health problems.

Behavioral Health Service Needs. Oliveira et al. (2006) highlighted many behavioral health care needs of Native Hawaiians, the medically underserved, and rural communities of Hawai‘i. They report that behavioral health care services are needed for a wide range of medical and psychological concerns. For example, mood and anxiety related disorders, substance abuse, and substance-induced psychotic disorders are commonly seen in community health centers throughout Hawai‘i. Often, presentations of depression and anxiety are a result of poorly managed medical conditions, such as diabetes or heart disease. Consequently, intervention programs that address the risk factors (e.g., smoking cessation and obesity management) of chronic diseases and their management (e.g., diabetes behavioral management) are needed in addition to traditional psychological services. Moreover, behavioral health care providers need to be trained in psychopharmacology to serve as consultants to primary care physicians because of the absence of regular psychiatric services in many of the rural areas of Hawai‘i. Such diverse behavioral health care needs of Hawai‘i’s medically underserved and rural communities require providers to be competent in a wide range of assessment and intervention strategies.

Behavioral Health Service Delivery. A majority of the behavioral health care services for the medically underserved and people of rural communities of Hawai‘i are currently provided by Community Health Centers (CHCs) and the Native Hawaiian Health Care Systems (NHHCS). There are currently thirteen CHCs and five NHHCS on five (i.e., Hawai‘i, Maui, Molokai, O’ahu, and Kaua’i) of the seven islands within the State of Hawai‘i. Most of these CHCs receive federal section 330 grants to support their fiscal operations and their health care services (e.g., medical, psychological, social, and educational services) for people with and without health care coverage. The five NHHCS were formed out of the Native Hawaiian Health Care Act and the Native Hawaiian Health Care Improvement Act enacted by Congress to address the health disparities of Native Hawaiians. The NHHCS often refer their clients to CHCs to help them gain access to primary care services. Therefore, both the CHCs and NHHCS play a vital role in providing health care services to Hawai‘i’s medically underserved and rural communities.2

Health Provider Shortage. Despite the presence of CHCs and NHHCS in rural Hawai‘i, there remains a shortage of trained professionals to provide specialty medical and behavioral health services. In recognition of this shortage of trained health professionals in rural areas, the Native Hawaiian Health Scholarship Program (NHHSP) was created to increase the number of health care providers in medicine, dental health, mental health, social work, and public health who provide culturally-competent services for Native Hawaiians (Birnie, 1998; Santiago, Shimizu, & Vaioleti, 2001). Graduate students in these health professions receive NHHSP scholarships to support their education and, in return, commit to work in rural communities throughout Hawai‘i for a period of time following completion of their professional education and training. For NHHSP recipients in psychology, there are few opportunities for them to receive pre-and post-doctoral training that focuses specifically on preparing psychologists to practice in rural, predominantly Native Hawaiian settings.

Generalist Practitioner. A provider of rural behavioral health services in Hawai‘i requires special training to acquire the needed cultural and professional competencies. The specific training needed to acquire these necessary competencies is described in a report from the Ad Hoc Rural Mental Health Provider Work Group (1997). In their report they noted that mental health providers of rural communities must be generalist in the provision of services and that rural communities have sufficiently distinct needs from urban communities. However, they also noted that the trend for training programs and credentialing bodies has been toward specialization and that most training programs are modeled after service delivery systems of urban settings. As a result one of the recommendations made by the Work Group was that, “The mental health profession should actively encourage innovative training strategies (both didactic and experiential training) that are explicitly targeted at expanding the competencies required to practice effectively in rural settings” (p. 3). continued

 

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