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"Neighborhood – The Smallest Unit of Health: A Health Center Model for Pacific Islander and Asian Health,"

by Jamila Jarmon July/August 2011 issue of Poverty & Race

“Neighbors being Neighborly to Neighbors.” This is how Kokua Kalihi Valley Comprehensive Family Services (KKV) approaches neighborhood health in Kalihi Valley, a mostly immigrant community of 30,000 residents on the edge of urban Honolulu. KKV is a federally-qualified community health center, serving about 10,000 residents, primarily Pacific Islander and Asian-American, a year, fostering neighborly values to ensure health for all. Through the years, KKV has grown and currently operates at seven separate locations in the community, including the largest public housing complex in the State of Hawai`i. With growth, KKV retains an original grassroots vision of health and well-being developed together with the community.

KKV has humble roots, beginning in 1972 with four outreach workers operating out of a trailer, going door- to-door getting to know their neighbors: their immediate needs, their hopes, dreams and individual talents, too. The four spoke three different languages and were able to assist community members with agency resources. From their trailer-offices, workers interacted with the community. Soon, medical and dental physicians volunteered their time, broadening KKV’s community participation. Standing by its motto, KKV continues to expand, maintaining an active and ongoing conversation with the growing community that includes Hawaiians, Filipinos, Samoans and Micronesians, to name a few. The traditional services associated with community health centers are present at KKV, including primary care physicians, dental, nutrition, behavioral health, elderly care, and maternal-child health services. These services help KKV to retain its identity as a traditional community health center. In addition, KKV staff speak 21 different languages, supporting language access and cultural competency for limited-English-proficient speakers. KKV staff diversity enables it to develop innovative programs that support neighborhood health in culturally competent ways.

Adapting a community-based health model pioneered by Dr. Jack Geiger and others on the mainland U.S., KKV understands that communities want to be active participants in developing solutions and strategies that benefit neighborhood health. KKV addresses ongoing human resource needs by hiring from the community, building lasting relationships and thinking programmatically. Hiring workers from the community allows KKV to have a continued connection with the community. The employee is able to listen and work to develop programs within the community that are sustainable. The policy also provides paying jobs to the community, yielding not only health impacts, but also economic impact. By building relationships and working on an equalized plane, KKV is able to not only recognize strength and leadership within the community, it also builds trust as an institution in the community. This helps KKV fulfill its mission of “serving communities, families and individuals through strong relationships that foster health and harmony.”

KKV focuses on its internal capacity to continue providing services to the community. The bottom line for KKV is the neighborhood’s health and well-being; all programs that begin out of this community dialogue are designed for sustainability. As a community participant, KKV seeks to develop the internal capacity of its partners and clients so that programs can last beyond individual project funding. The neighborhood is an integral part driving programming based on need. For KKV, it is important to keep up the organization’s side of the partnership and retain continuity of the programs offered, regardless of funding challenges.

KKV embraces an expanded meaning of “health care” by having a broad view of neighborhood health. It has developed a variety of innovative neighborhood health partnerships that serve its diverse ethnic community, which includes many new Pacific-Islander and Asian-American immigrant communities. This commentary highlights four programs at KKV: Lei Hipu`u o Kalihi; Kalihi Valley Instructional Bike Exchange; Medical-Legal Partnership for Children in Hawai`i; and Ho`oulu `Aina. Focusing on culture and family, these programs are guided and led by the community.

Lei Hipu`u o Kalihi

KKV’s Lei Hipu`u o Kalihi (Lei Hipu`u) is a grantee of the Health Through Action Grant from the Asian & Pacific Islander American Health Forum sponsored by the W.K. Kellogg Foundation. Lei Hipu`u’s purpose it to work on capacity-building in the area of early childhood health within the Kalihi Valley community. Because KKV serves various ethnic groups, Lei Hipu`u conducts focus groups with each around early childhood health issues, identifying cultural similarities and differences. These focus groups produce qualitative data that help Lei Hipu`u, as a representative of KKV, understand how the community raises their children. Many of these focus groups are assembled by the community outreach specialist for Lei Hipu`u, who is a leader in the Chuukese (Micronesian) community. Hiring from the community for this position provides Lei Hipu`u continuous opportunities to work in partnership with the community and understand neighborhood priorities. The Micronesian community is the newest and fastest growing immigrant community in Hawai`i and a large consumer of KKV services. Hiring from the community not only created the opportunity to build a relationship with a new and growing immigrant population, it built the community outreach specialists’ capacity and provided economic opportunity for work previously done without pay.

Relationships are built through Lei Hipu`u, which serves as a connector in the neighborhood. Lei Hipu`u created a “Leadership Council” that comes together monthly as a cohort of Kalihi-based service providers, including social workers, librarians, school staff and officials, community leaders, doctors, lawyers and more. The relationships developed have resulted in increased trust, support and collaboration among the community of service providers. The prevailing culture of the Leadership Council remains focused on the ever-shifting needs and hopes of the communities served.

Lei Hipu`u fosters a notable community relationship with the Kuhio Park Terrace Residents Association (KPTRA). Kuhio Park Terrace (KPT) is the largest public housing complex in the State of Hawai`i, and many residents receive services from KKV. KPTRA, in partnership with Lei Hipu`u, created monthly “talk story” meetings. “Talking story” is a custom of dialoguing about community and family issues or events. These talk stories have resulted in committees forming to address issues within the community, such as tackling fire safety with the Honolulu Fire Department and discussion of traditional health practices amongst the different cultures in housing led by residents of KPT. Lei Hipu`u builds the capacity and confidence of the KPTRA to continue a dialogue in the community in order to recognize needs of their neighbors. Lei Hipu`u contributes greatly to neighborhood health and the equalization of resources to benefit all participants in the Kalihi Valley community. Lei Hipu`u’s goal is for community residents to take ownership of their neighborhood’s health.

Kalihi Valley Instructional Bike Exchange

The Kalihi Valley Instructional Bike Exchange (KVIBE) is a program of KKV that lives by the motto “If you build it they will come.” KVIBE is a non-profit bicycle shop that began in 2005 and promotes bicycle-related activities for at-risk youth in Kalihi Valley. KVIBE stocks about 100 bikes at a time and relies on steady donations. Two neighborhood residents who previously volunteered with the program currently staff KVIBE. One had previous bicycle repair expertise and the other was a youth participant who developed skills over time. Personal relationships help to foster trust in KVIBE. This trust engages Kalihi Valley youth to come and either buy, build or repair bikes there. Those who choose to build do so with the help of KVIBE staff and other youth who have gained skills from their time at KVIBE. This program exists because it recognizes that a bike shop is one method to affect or understand community health.

KKV acknowledges that through knowledge of building a bike, KVIBE is able to build the capacity of the Kalihi Valley youth. Not only do they redeem a bike after building it, they learn responsibility, hard work, and gain mentors to help guide them. KVIBE staff are trained to discuss healthy relationships and foster a safe environment where no gang colors are allowed, targeting youth to build a sustained neighborhood health capacity for the future of Kalihi Valley. KVIBE is a true innovation in neighborhood health, providing youth a viable alternative to learn, grow and make healthy choices from positive experiences.

Medical-Legal Partnership for Children in Hawai`i

The Medical-Legal Partnership for Children in Hawai`i (MLPC Hawai`i) is a project of the Health Law Policy Center of the William S. Richardson School of Law (University of Hawai`i at Manoa). Medical-Legal Partnerships follow a model established by Dr. Barry Zuckerman of the Boston Medical Clinic, who hired an attorney to “address the social determinants that negatively impact the health of vulnerable populations.” Recognizing KKV’s unique relationship with the Kalihi Valley community, the co-director of the Health Law Policy Center partnered with a pediatrician at KKV to construct a program that allowed legal interventions and advocacy to improve health care and access. This particular doctor and lawyer saw that there were instances when medical conditions could be alleviated through legal intervention, such as when a child with chronic asthma and eye infections needs a landlord to fix a leaky pipe that has caused mold to develop in his bedroom. MLPC Hawai`i approached its partnership with KKV by engaging with the community first. To begin, the MLPC Hawai`i legal director and law student interns accompanied KKV public housing outreach workers on a door-to-door survey to introduce KKV services and to hear about public housing residents’ needs, including the lack of accessible legal services. After listening to the neighborhood, MLPC Hawai`i built on the trust families have with their children’s doctors and began providing direct legal services to families at KKV to address the social/legal problems that negatively impact their health. MLPC Hawai`i runs its legal clinics to coincide with the KKV Pediatric Clinics, allowing legal advocates to meet with families alongside pediatricians in the exam rooms during well-child medical visits. KKV generously provided office space to MLPC Hawai`i in their office located in the KPT Resource Center, giving MLPC Hawai`i a central and constant presence in the neighborhood to continue garnering trust.

MLPC Hawai`i also works to build the capacity of the community to advocate for themselves. Clients are taught about their legal rights, recognize the effect on health, and are empowered with the understanding that those rights are enforceable. For example, the right to have habitable housing is reinforced with law for clients because many health ailments are exacerbated or persist from uninhabitable living conditions.

Also, MLPC Hawai`i has engaged in language access advocacy on both individual and systemic levels. They enlist the help of interpreters from KKV staff to ensure open dialogue with their many limited-English-proficient clients. They even look to the community for translation services to produce legal resources and information in native languages. In addition, MLPC Hawai`i advocates provide clients with “language access rights” cards so they can enforce their state and federal right to an interpreter at state agencies, federal agencies and hospitals. Knowledge is power and can galvanize people to act; providing these resources gives the community this power and experience to effectively advocate for themselves. Working closely with the community, service providers and health professionals foster the goals of MLPC Hawai`i to value and respect collaboration in real-life settings. Taking the time to build and foster these valuable relationships also helps legal advocates to stay in touch with the ever-shifting needs and hopes of the neighborhood. MLPC Hawaii’s partnership with KKV has contributed to building resources and advocacy opportunities for the neighborhood.

Ho`oulu `Aina

Ho`oulu `Aina is a part of KKV located on a 99-acre land preserve in Kalihi Valley to engage communities in nurturing their land. Hawaiians for generations and until today honor this area as sacred to the creation gods, and this land in the past was very fertile, providing sustenance for the people of Kalihi Valley and beyond. Ho`oulu `Aina recognizes land as a community member. In partnership with the community, Ho`oulu `Aina uses a land-based program to improve overall neighborhood health. When people come to Ho`oulu `Aina to work, they nurture the land, which in turn nurtures them: “O ka ha o ka `aina ke ola o ka po`e: the breath of the land is the life of the people.”

Most of the staff at Ho`oulu `Aina live in Kalihi Valley and bring valuable relationships to enrich accessibility to this unique neighborhood experience. These opportunities are, like other KKV programs, fostered through community dialogue. For example, KKV’s Nutrition Program’s diabetes group has utilized this access for exercise and nutrition purposes. For a year, the nutrition program was unable to influence members of the Chuukese diabetes group to exercise. In a meeting, the interpreter explained that there was no word for “exercise” in Chuukese. They tried “Take a walk”—to which the participants said —“To where?” It is not in their culture to “take a walk” or “exercise” without a purpose or destination. Also, highly urban areas like Kalihi are sometimes difficult or dangerous for walking. Farming was mentioned as an option and hands shot up! This led to weekly trips to Ho`oulu `Aina, to begin clearing land so that gardens could be planted, harvested, cooked and shared with family and neighbors, for their “exercise.” In addition, other programs at Ho`oulu `Aina enforce health through story-telling, native reforestation and learning the history of Kalihi Valley.

Ho`oulu `Aina recognizes the community as experts in their health and values their expertise in understanding the social forces that affect neighborhood health. During an open dialogue with the community, they discussed how difficult it was to find or afford healthy food in Kalihi Valley. In addition, the large immigrant population is unfamiliar with Western foods and their nutritional value. Ho`oulu `Aina and partners are now embarking on the “Roots Project,” with the goal of building community capital by providing more education and opportunity to enjoy and prepare healthy foods as neighbors. Ho`oulu `Aina will increase food production with the neighborhood and utilize the new commercial kitchen being built at KKV’s main clinic. Neighbors will have the opportunity to work the land, grow food, learn how to prepare that food in new ways, and then share the fruits of their labor, coming together as neighbors. Ho`oulu `Aina, in partnership with the community, is directly impacting neighborhood health through food production and consumption.

“Neighbors being Neighborly to Neighbors”

KKV is an innovative community health center because it understands that the community is a neighbor and collaborator. Direct services are grounded in the various cultural traditions of patients and residents working together to provide resources necessary for health access. KKV understands that language access goes hand-in-hand with cultural competency, creating a trusting environment. Language access and cultural competency does not stop there however; hiring from the community creates more cultural context and gives economic incentive to retain language and culture. KKV recognizes that when working with a diverse community of new immigrants, Pacific Islanders and Asian Americans, community dialogue and support create sustainable programs to serve the neighborhood. KKV is a community health center with place-based focus and a health justice mission. This neighborhood health model’s use has broad application for any institution or individual working to affect neighborhood health. Health is not only medical health; it is holistic. Health is community. Health is legal advocacy. Health is self-advocacy. Health is a bike shop. Health is reconnecting with culture and land. By being a neighbor, KKV creates programs that foster a healthy community. Institutions and individuals have the ability to be neighborly. As a neighbor, KKV is a vital part of revitalizing and sustaining the Kalihi Valley community now and for future generations.

Jamila Jarmon is a Post-Graduate Legal Fellow with the William S. Richardson School of Law’s Health Policy Center Medical-Legal Partnership for Children Hawai`i and Kokua Kalihi Valley Comprehensive Family Services’ Lei Hipu`u o Kalihi Program.

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