Johns Hopkins University Press
Summary

This report describes one community health center's response to COVID-19 by integrating Pacific Island (PI) values—which prioritize dignity, agency, and ancestral philosophies—within the context of deep relationship building. We share impacts and insights with the hope this work will resonate with other PI and Indigenous communities.

Key words

Health equity, Indigenous and Pacific Islander health, COVID-19, community health

Pacific Island (PI) cultures have long valued the intricate balance between human and environmental health.1 Colonial medical perspectives can often disrupt this ancestral relationship to time and place, leading to inappropriate and ineffective treatment of Pacific Islanders by mainstream health care.2,3 Kokua Kalihi Valley Comprehensive Family Services (KKV), a federally qualified health center (FQHC) in Hawaii, believes engagement in the health care system can become healing for a wider group of people when we foster community health experiences that prioritize Pacific values, including deep relationships, dignity, agency, and ancestral philosophies.

For the past 50 years, KKV has been a hub of cultural connections and health equity initiatives while providing a broad spectrum of clinical and community care. Situated between the two largest public housing complexes on the island, we serve a high population of low-income and newly immigrated Asian and Pacific Islanders. In 2014, searching for metrics that reflected our values, KKV and Islander Institute conducted focus groups with Native Hawaiian leaders and Kalihi community members. Based on this work our team created Pilinahā, the Four Connections Framework.4 Pilinahā emphasizes that connections to place, community, best self (the healthiest version of a person), and past-present-future (generational connection over time) are critical to [End Page 471] health and healing. This framework represents how Kalihi, like other culturally diverse communities, defines health through relationships.5

When COVID-19 gripped the world, KKV applied our longstanding cultural and relationship-based approaches to address the pandemic. This method was effective, since although unprecedented, COVID-19 highlighted inequities our community has faced for generations.6,7 While continuing to provide essential care, in April 2020, KKV created Hui Hoaka (HH), a new arm of the organization focusing on increasing community resilience.8 With resources from newly-acquired and redirected federal and private funding sources, HH uses both new employees as well as redeployed existing staff which prevented the need for furloughs due to lockdown measures. Hui Hoaka's immediate goal is to keep our community safe through equitable access to culturally grounded care, information, and resources. At the same time, we strive for long-term systems change by uplifting personal agency and community abundance. This connection between the intimate and systemic is a practice our community health workers (CHWs) and health professionals have been engaged in for decades—investing in relationships to co-navigate the health system with every patient.

Below, we provide stories and outcomes from our experiences of prioritizing Pilinahā during COVID-19. These data was collected during program activities including outreach calls to community members, intake and exit interviews with patients, and debriefing sessions with KKV staff reflecting on thier experiences. Our report aims to celebrate the many layers of relationships among our providers, CHWs, and community. We believe these relationships enabled us to serve hard-to-reach patients and address complicated issues such as stigma, discrimination, and inequity.

Relationships as Resources

Right when I said "Hi," our patient recognized my voice and started crying. She said she was so relieved we called because she was worried she'd be forgotten.

—CHW during outreach

Hui Hoaka took inspiration from our Elder Care Director, Merlita Compton, who reached out to our elders as soon as stay-at-home orders were implemented. Her phone check-ins became the blueprint for our COVID-19 outreach system. Community health workers supported patients by building relationships. This means, rather than cycling through a list of questions, staff are trained to listen deeply and elicit stories with simple prompts such as "How are you?". One CHW shared, "I stopped asking any questions because the patient just kept talking. She was telling us all the answers without us needing to ask anything." This style of data collection supports meaningful interactions between staff and community members. It also helps patients feel heard rather than extracted from, which can easily happen when callers are primarily focused on filling out forms.

From March 2020 to July 2020, our team conducted over 3,000 outreach check-ins in Kalihi's major languages, including Chuukese, Samoan, and Ilocano. These interactions focused on our most vulnerable patients, including elders, public housing residents, [End Page 472]

Figure 1. Hui Hoaka Food Security.
Click for larger view
View full resolution
Figure 1.

Hui Hoaka Food Security.

and families with chronic illness. We learned that many households were struggling with isolation and food security. In response, HH delivered over 15,300 prevention care packages from April 2020 to April 2022. These packages included locally grown culturally relevant produce, dry goods, personal protective equipment, public health information, and social support.

In August 2020, our community switched from focusing on the prevention of COVID-19 to dealing with one of the worst outbreaks in Hawaii.11 The pandemic spread quickly, in large part due to our community's high exposure rates from essential front-line employment and crowded housing situations with heavily trafficked elevators. Hui Hoaka began to provide wrap-around household care to help ease the stress, fear, and confusion of positive households as well as prevent the spread of the disease. This included connecting families to information and resources they needed to safely isolate and quarantine, such as cleaning supplies, culturally revelant food, and economic support. From July 2020 to April 2022, HH conducted 1,785 COVID-19-positive intakes, and made 1,148 COVID-19-positive household deliveries (representing 5,481 individuals).

During a time of stigma and mistrust, our relationship building efforts encouraged patients to feel safe and talk about their struggles and sacrifices. By sharing their experiences, community members guided KKV's leadership. For example, we learned about complex, unstable, and multi-household living situations, barriers to patients accessing state-run isolation hotels, and renters facing illegal eviction. In turn, HH directed resources to address these issues including providing household-based care, advocating to Hawaii's Department of Health, and securing legal assistance for renters. (Figure 1) [End Page 473]

Building Community

I was calling a patient to let her know her quarantine was over and so I wouldn't be checking in on her everyday anymore. Then the auntie asked me to turn on my video so that we could see each other's faces, so that when we saw each other after the pandemic was over, she could thank me, and we could give each other a hug. After I turned on my camera the auntie showed me all the pictures on her wall and told me about her family. And she is not the only one, there are so many people who are now a part of our 'ohana (family).

—HH CHW

Building connections to community, one's best self, place, and past-present-future is critical to this work. Our goal is for staff to treat every patient interaction as a sacred opportunity to build relationships. These trusting relationships are especially important when fear and seclusion are pervasive. One patient shared, "I'm so happy to see KKV because my husband is in the nursing home and I can't see him, so seeing you all has made my heart." While staff were canvasing our neighborhood with public health posters, another patient shouted, "I love KKV! You guys always help me. Can I put one of your signs on my car?" Others were excited to see their dentist outside the clinic, "Hey doc! Remember me?"

This sense of membership in community, of belonging to something larger than oneself, can inspire people to be thier best selves and share their resources, skills, and compassion. This generative giving in turn increases community abundance. For example, some patients planted cuttings from the KKV produce they received and distributed their harvest to staff and neighbors. This reciprocal giving, rather than institutionalized forms of charity, helps people reconnect to a shape of healing that is more familiar to PI cultures.11 A CHW who lives in public housing described, "After KKV's deliveries, all my neighbors now knock on each other's doors to share what we have with one another." We believe our methods of focusing on relationship-building, collecting data through deep listening, and linking people to the four connections of Pilinahā, helped to transform our work from a public health "service" to membership in community.

Outcomes

This is good not just for them, but for me too. There was this woman in the program who I think she doesn't like me but when I called her, as soon as she heard my voice, I could tell she was happy and was crying. She misses us. And I know when we see each other again we are going to get along. We are learning a lot from this different time. We will change our behaviors, we will respect people more and we won't waste anything—not time, not budgeting, not people.

—Elder care CHW

This work has reminded KKV of our values and has been healing for both our community and staff. For example, between July 2020 and May 2022 there were 1,747 confirmed cases of individuals who tested at KKV or for whom KKV was notified [End Page 474] of their postive result. Despite serving a high-risk population with high rates of comorbidities and economic instability compared with the rest of the state,12 with KKV having 17 deaths officially attributed to COVID, we had a case fatality rate that is close to the state average.13

In addition, patients recovering from COVID reported that HH's support enabled them to stay home, potentially preventing COVID spread. Seeing that many people needed additional support when exiting isolation/quarantine, we began conducting exit interviews with households who were referred to HH for COVID-19 positive wraparound care. From September 2020 to April 2022, we interviewed 394 households. Many (93%) felt supported during their isolation/quarantine. One household member added, "I felt loved and supported from KKV, my team always call me with words of encouragement. KKV was the only one to help us and the food delivered helped." One CHW reported that he received over 100 requests to join KKV's medical services because "KKV was different." This suggests KKV's culture-based approach is desired by our community and may be essential to sustaining our patient volume.

Although stressful, the work we completed during the pandemic liberated our staff from many oppressive and extractive systemic practices. One CHW shared, "Now, when other organizations want to partner but they want us to go back to the old way—of only being so worried about counting and getting information from people—I'm not afraid to say, 'No that's not how we do it anymore.'" Instead, we have reconnected to KKV's origin story of staff knocking on doors to ask neighbors what they needed. One young CHW reflected, "In the true essence of why KKV started, people are being reminded that we are descendants of those super aunties [CHWs] that went door to door. This is our genealogy."

Sustaining Resilience

I know what it feels like when everyone is handing you things, but you don't have a gift to give people. This work reminded me that we all have things to give, even if it's just a hug or compassion … these are the memories that will be passed to the next generation.

—HH CHW

Kokua Kalihi Valley Comprehensive Family Services continues to invest in relationship and cultural-based work. For example, we are growing our community outreach capacity by securing funding for CHWs, training all staff in Pilinahā, and strengthening integration of SDOH and clinical activities. We are also expanding our capacity to honor relationships in our data system. This work is shifting the process of data collection from robotically attaching diseases to names, to making data-sharing an essential part of the healing process. For example, our database matches staff and patients who have strong relationships with each other, increasing our effectiveness during outreach. Our forms also prompt staff to record stories and ask deeper questions over time, inviting patients into more intensive care and service as trusting relationships are developed.

As KKV continues to build relationships and share resources grounded in Pacific values, we are becoming a more connected community. The collective knowledge gained during the pandemic lives within our staff, stakeholders, patients, and community [End Page 475] members. In a time of confusion and fear, we continue to witness increases in patient agency and community abundance. Our convictions are now stronger than ever, that for health equity, we must support people and foster systems that value and grow connections to community, land, best-selves, and past-present-future (Pilinahā).

Megan Inada, Puni Jackson, Ku'ulei Freed, Michael Epp, and David Derauf

All the Authors are affiliated with the Kokua Kalihi Valley Comprehensive Family Services.

Please address all correspondence to Megan Inada, 2239 North School Street, Honolulu, HI, 96819; Phone: 808.791.9400; Email: minada@kkv.net.

References

1. Spencer MS, Fentress T, Touch A, et al. Environmental justice, indigenous knowledge systems, and Native Hawaiians and other Pacific Islanders. Hum Biol. 2020 Nov 17;92(1):45–57. https://doi.org/10.13110/humanbiology.92.1.06 PMid:33231026
2. Kaholokula JK, Miyamoto RES, Hermosura AH, et al. Prejudice, stigma, and oppression on the behavioral health of Native Hawaiians and Pacific Islanders. In: Benuto L, Duckworth M, Masuda A, et al, eds. Prejudice, Stigma, Privilege, and Oppression. New York, NY: Springer, Cham., 2020:107–34. https://doi.org/10.1007/978-3-030-35517-3_7
3. Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020 Jun;44(3):193–200. https://doi.org/10.1111/1753-6405.12971 PMid:32311187
4. Odom SK, Jackson P, Derauf D, et al. Pilinahā: an indigenous framework for health. Curr Dev Nutr. 2019 Feb 22;3(Suppl 2):32–8. https://doi.org/10.1093/cdn/nzz001 PMid:31453426 PMCid:PMC6700459
5. Wright R. Social support and health outcomes in a multicultural urban population. Soc Work Health Care. 2006;43(4):15–28. https://doi.org/10.1300/J010v43n04_02 PMid:16966307
6. Ndumbe-Eyoh S, Muzumdar P, Betker C, et al. 'Back to better': amplifying health equity, and determinants of health perspectives during the COVID-19 pandemic. Glob Health Promot. 2021 Jun;28(2):7–16. https://doi.org/10.1177/17579759211000975 PMid:33761795 PMCid:PMC7994919
7. Hawai'i Advisory Committee to the U.S. Commission on Civil Rights. COVID-19 and Pacific Islander communities in Hawai'i. Honolulu, HI: Hawai'i Advisory Committee, 2021. Available at: 05-19-HI-SAC-COVID-19-and-Pacific-Islanders-Report.pdf (usccr.gov).
8. White GM, Robillard AB. Doctor talk and Hawaiian 'talk story': the conversational organization of a clinical encounter. Amsterdam: John Benjamins Publishing Company, 1989 Jan 1:197–211. https://doi.org/10.1075/pbns.4.11whi
9. Office of Disease Prevention and Health Promotion. Social determinants of health. Washington, DC: U.S. Department of Health and Human Services, 2022. Available at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health.
10. Hofschneider A. Kalihi has the worst COVID-19 outbreak in Hawai'i. Here's how the community is responding. Honolulu, HI: Honolulu Civil Beat, 2020 Sept 9.
11. Mahi D. The children of Kalihi. Reclaiming Children and Youth. 2013;22(1):50–4.
12. Research Economic Analysis Division (READ). Census data highlights: 2019 American Community Survey, 1-year estimates. Honolulu, HI: Hawaii State Data Center, 2020. Available at: https://census.hawaii.gov/wp-content/uploads/2020/10/acs2019_1-yr_DBEDT-highlights.pdf.
13. State of Hawaii Department of Health, Disease Outbreak Control Division. Hawai'i COVID-19 data. Honolulu HI: State of Hawaii, Department of Health, 2019. Available at: https://health.hawaii.gov/coronavirusdisease2019/current-situation-in-hawaii/.

Share