Joseph Keawe'aimoku Kaholokula, PhD, A. Aukahi Austin, PhD, K. Beth Yano, PhD, Jill M. Oliveira, PhD, Darryl Salvador, PsyD,
and Robin E.S. Miyamoto, PsyD
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.
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.
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).
I OLA LAHUI: RURAL HAWAI‘I BEHAVIORAL HEALTH PSYCHOLOGY TRAINING PROGRAM
The review thus far of Hawai‘i’s medically underserved and rural populations and the behavioral health care situation have highlighted two overlapping needs: 1) the increasing behavioral health care needs of Native Hawaiians and other medically underserved, rural communities of Hawai‘i and 2) the need for culturally and professionally competent psychologists working in Hawai‘i’s diverse ethnic and rural communities. It is in response to these needs that I Ola Lahui: Rural Hawai‘i Behavioral Health Program was created.
In collaboration with the NHHSP, two CHCs on two different islands, and the NHHCS on the island of Moloka‘i, I Ola Lahui opened its doors in the fall of 2007 to two pre-doctoral psychology interns selected as part of the Argosy University Internship Consortium, a consortium that is listed with the Association of Psychology Postdoctoral and Internship Centers (APPIC). In selecting the psychology interns, a preference is given to those applicants who demonstrated interest and experience in provision of services to Native Hawaiian and other medically underserved communities.
The goal of I Ola Lahui is to increase capacity to address the growing mental and behavioral health care needs of rural Hawai‘i through training in behavioral health care and chronic disease management, psychopharmacology, traditional mental health concerns such as anxiety and mood disorders and substance abuse, and the integration of cultural-and community-based perspectives and approaches in programdevelopment, implementation, and evaluative processes. The aims of I Ola Lahui are:
- To provide training to pre-doctoral psychology interns in assessment and effective, culturally-minded interventions for use in Hawai‘i’s rural and medically underserved communities.
- To provide culturally-minded, evidence-based behavioral health care that is responsive to the needs of medically underserved and predominantly Native Hawaiian rural communities.
Program Format. I Ola Lahui is designed to provide the interns with the opportunity to train in rural behavioral health on two islands (Moloka‘i and O’ahu) and in two types of clinical settings (CHC and NHHCS). The interns receive training in four core clinical areas: 1) Primary Care and Integrated Behavioral Health, 2) Behavioral Medicine and Health Psychology, 3) Adult Outpatient, and 4) Child and Adolescent. The types of training activities offered within these four clinical areas are outlined here:
Primary Care Psychology and Integrated Behavioral Health
- Provision of rapid assessment, diagnostic formulation, and treatment for a wide range of psychological concerns within a primary care clinic setting. The focus of care in this setting is on early identification and brief intervention.
- Consultation and collaboration with primary care physicians.
Behavioral Medicine and Health Psychology
- Provision of assessment and multi-level interventions for health behaviors with particular emphasis on chronic disease conditions and prevention.
- Individual and group formatted interventions for tobacco cessation, chronic pain, diabetes management, and weight management
- Care coordination and consultation with family practice physicians and other providers.
- Provision of assessment and treatment of a wide array of psychological concerns including: depression, anxiety, substance abuse, PTSD, schizophrenia, and bipolar disorder in an integrated behavioral health setting.
- Individual and couples therapy formats.
- Consultation and collaboration with family practice physicians within an integrated behavioral health setting
Child and Adolescent
- Provision of assessment and treatment of psychological concerns affecting children, adolescents, and their parents including anxiety, depression, and disruptive behaviors.
- Individual, parent, family, and group formats.
- Consultation and collaboration with pediatricians and family practice physicians within an integrated behavioral health setting.
As part of their training, interns receive didactic instructions in topics relevant to the four clinical core areas and professional psychology (weekly clinical and professional development supervision, individual and group) and training by program faculty on topics such as cultural competence, cognitive behavioral therapy and other evidence-based interventions and psychopharmacology. The professional development supervision is designed to assist interns in identifying and building skills relevant to their career goals.
In addition, I Ola Lahui interns have the opportunity to select from an array of available community outreach projects designed to expand areas of interest, gain experience in new specialty areas, and participate in research projects with program faculty. Potential research topics include describing service utilization patterns in each setting, examining the effectiveness of group and individual treatment programs in addressing health concerns, and demonstrating the cost-effectiveness of behavioral medicine interventions for chronic diseases. Interns are also encouraged to complete their doctoral projects prior to the end of the internship year. Interns are allotted 4 hours per week for research projects including their doctoral dissertations, research related to their clinical site placement, and other research projects.
Training and Supervision
Six state of Hawai‘i licensed psychologists who co-founded I Ola Lahui and who serve as the I Ola Lahui program faculty supervise the interns. When interns are on the island of Moloka‘i, they are directly supervised by two psychologists, Dr. Jill Oliveira of N? Pu’uwai Native Hawaiian Health Care Systems Clinic and Dr. Darryl Salvador of Molokai ‘Ohana Community Health Center. When on O’ahu, the interns are supervised by Dr. Aukahi Austin of Waimanalo Health Center. Dr. Austin also serves as the Executive Director and Director of Training for I Ola Lahui. The other three psychologists, Drs. Beth Yano, Robin Miyamoto, and J. Keawe‘aimoku Kaholokula assist in providing didactic training and professional development supervision to the interns.
I Ola Lahui is governed by a Board of Directors that ensures that the training program is executed in accordance with our mission to provide culturally-minded evidence-based behavioral health care that is responsive to the needs of medically underserved and predominantly Native Hawaiian rural communities. I Ola Lahui is applying to become a 501(c)(3) non-profit organization.
The training model of I Ola Lahui was based on that of the Rural Hawai‘i Behavioral Health Program (newly named the Rural and Community Health Program) of the Tripler Army Medical Center (TAMC), which was designed to prepare pre-and post-doctoral psychology trainees to work in Hawai‘i’s CHCs and NHHCS clinics (see Oliveira et al., 2006). The training program emphasizes health psychology, child, and neuropsychology rotations in addition to providing time-limited training experiences in CHC and NHHCS clinic sites. Interns and postdoctoral fellows who participate in the TAMC civilian training program receive didactic instruction as well as clinical supervision in the treatment of diabetes, chronic pain, tobacco cessation, obesity, and other more traditional psychological concerns such as anxiety and depression related disorders. The success of this training program is evident in the number of psychology interns and fellows who have graduated from the program and now work with Native Hawaiian communities either through direct service as practitioners or through other health related activities such as research in Native Hawaiian health or health administration. In fact, all six I Ola Lahui faculty either completed their internship and/or fellowship training or are faculty with the TAMC’s Rural and Community Health Program.
Although I Ola Lahui extends the work of TAMC’s psychology training program and contains some similar elements, it is distinct from that organization. The training services that it provides to the community are based exclusively within NHHCS sites and CHCs, emphasizing interventions that are highly compatible with Native Hawaiian conceptions of health and well being, and utilizing research and evaluation strategies to study the effectiveness of those interventions. Moreover, the development of I Ola Lahui was encouraged by the TAMC training program as it is believed that our community-based training model will be an important vehicle for training psychologists in the future.
I Ola Lahui has applied to become an APPIC internship site which would open the application process up to a much broader national audience. With application for APA accreditation in the near future, it is our hope that I Ola Lahui becomes a center of excellence for research and clinical training addressing indigenous issues and rural behavioral health.
The founding psychologists are also entertaining the idea of expanding I Ola Lahui: Rural Hawai‘i Behavioral Health Psychology Training Program to include additional training sites and opportunities in research and clinical practice for three pre-doctoral psychology interns and three post-doctoral fellows each year. It is the hope of I Ola Lahui to help in the building of a healthy and thriving Hawai‘i. I Ola Mau Ka Lahui! For more information regarding our program, contact Dr. Aukahi Austin at firstname.lastname@example.org.
PROGRAM FACULTY AND BOARD OF DIRECTORS
A. Aukahi Austin, Ph.D. -Executive Director, Director of Training, Clinical Supervisor. Dr. Austin received her Ph.D. in clinical psychology from the Clinical Studies Program in the Department of Psychology at the University of Hawai‘i at Manoa in 2004. She completed a pre-doctoral internship at Tripler Army Medical Center (TAMC) with an emphasis in Community and Health Psychology and a post-doctoral fellowship at the University of Hawai`i at Manoa Department of Psychology in Child and Adolescent Evidence Based Practice. She is currently the Licensed Clinical Psychologist at the Waimanalo Health Center. She is interested in conducting ongoing research regarding the prevalence of mental health disorders in rural medically under-served areas specifically, and among Native Hawaiians in general, as well as the effectiveness of treatment programs designed for delivery in rural areas.
Robin E.S. Miyamoto, Psy. D. -Program Consultant, Professional Development Supervisor.
Dr. Miyamoto completed her Psy.D. in clinical psychology at Argosy University, Honolulu campus in 2000. She completed a post-doctoral fellowship in Health Psychology at TAMC, and continues to serve on staff as Director of Training at TAMC. She was a TAMC pre-and post-doctoral clinical supervisor at the Integrated Behavioral Health Program at Waimanalo Health Center for 5 years, and maintains a part-time clinical hospital based practice at St. Francis Medical Center. Her areas of interest include diabetes, renal disease, and cancer. She is current President of the Hawaii Psychological Association, co-chair of the RxP Committee, and a member of the American Psychological Association’s Committee of State Leaders.
Jill M. Oliveira, Ph.D. – Clinical Supervisor -Dr. Oliveira received her Ph.D. in clinical psychology from the Clinical Studies Program in the Department of Psychology at University of Hawai`i at Manoa in 2001. She completed a post-doctoral fellowship in Health Psychology at TAMC, and continues to serve on staff as a supervisor of clinical training for pre-and post-doctoral trainees at TAMC as they complete rotations in rural community health center service delivery. She has served on the APA Committee on Rural Health (2003-2006), the Ron Levant Presidential Task Force on Enhancing Diversity in APA, and is currently a co-chair of the Hawaii Psychological Association’s RxP Committee. She is also the Director of the Behavioral Health Program at Na Pu`uwai Native Hawaiian Health Systems Clinic and is interested in research on effective treatment and service delivery models for medically under-served populations in community health care settings.
Joseph Keawe‘aimoku Kaholokula, Ph.D. – Director of Research, Professional Development Supervisor -Dr. Kaholokula received his Ph.D. in clinical psychology from the Clinical Studies Program in the Department of Psychology at University of Hawai`i at Manoa in 2003. He completed both a pre-doctoral internship and post-doctoral fellowship in Health Psychology at TAMC. He now holds a faculty position in the Department of Native Hawaiian Health, John A. Burns School of Medicine at the University of Hawai`i at Manoa where he examines psychosocial and socio-cultural factors related to the etiology, prognosis, and management of chronic medical conditions among Native Hawaiians and other Pacific Peoples.
Darryl Salvador, Psy.D. – Clinical Supervisor -Dr. Salvador obtained his Psy.D. in clinical psychology from Argosy University/Honolulu in 2004, and completed a 2 year post-doctoral fellowship in Clinical Psychology (Health Psychology/Behavioral Medicine specialty track) at TAMC. He is currently the Behavioral Health Director at Molokai Community Health Center. In addition, he remains on TAMC staff/faculty as the Director of Practicum Training and consultant to the Rural and Community Health Program. Dr. Salvador is also presently serving as the Public Interest Representative for APA’s Committee on Early Career Psychologists (CECP), Maui County Representative to the HPA Board, and Co-Chair for HPA’s Early Career Psychologists Committee. His interests include integrated behavioral health models and their application in community settings.
K. Beth Yano, Ph.D. – Consultant -Dr. Yano earned her Ph.D. in Clinical-Community Psychology from the University of Oregon, Department of Psychology in 1989. She is a Child and Family Psychology Services faculty member at TAMC, and has been actively involved in the provision and supervision of behavioral health services to rural communities on O’ahu, Maui, Kaua`i, and the Big Island for over 10 years. Her interests include community outreach and prevention, organizational and team development and child, adolescent and family interventions.
Na‘alehu K. Anthony, MBA -Works in the multi-media field of film and video, owns a production company, Paliku Documentary Films. He is interested in telling the stories of Hawai‘i and capturing the oral histories of Native People. His entrepreneurial spirit has led him to establish ‘Oiwi Television Network, a Native Hawaiian television station, to help redefine the Hawaiian experience in the 21st century.
Richard Kaipo Lum, MA -Richard Lum is the chief executive of Vision Foresight Strategy LLC, a futures planning and strategy firm. Mr. Lum has training and expertise in futures studies, strategy formulation, and planning process design. He delivers speeches and presentations to organizations ranging from the World Future Society to the University of Hawai‘i at Manoa (UHM) and has been published in the Journal of Futures Studies and the journal Futures. He served for several years as the Strategic Planner for the Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield licensee for the state of Hawai‘i. Mr. Lum currently serves on the boards of the Native Hawaiian Chamber of Commerce, the Merchant Street Hawaiian Civic Club, I Ola Lahui, and KEY Project. He is a graduate of Kamehameha Schools, has earned a Bachelors and a Masters degree in Political Science with a specialization in Alternative Futures from the University of Hawai‘i , and is a PhD candidate in the Political Science department focusing on the issue of designing governance systems.
1On July 9, 1921 the U.S. Congress passed the Hawaiian Homes Commission Act for the stated purpose of enabling Native Hawaiians to return to their lands in an effort to support their self-sufficiency and self-determination, and for the preservation of their values, traditions, and culture. For more information about Hawaiian Homelands visit: http://www.hawaii.gov/dhhl/.
2 For more information about CHCs in Hawai‘i and NHHCS visit: http://www.hawaiipca.net/ and http://nativehawaiianhealth.net/moku/stateWide.cfm.
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