To improve patients’ health outcomes, Cyndy Endrizal thinks beyond the lab coat.
“In the U. S., our typical way that we provide care is we put on our white coats…and we have all our initials after our name, and we’d like to be called doctor,” said Endrizal. “Local people here have a hard time with that.”
Endrizal heads up the community outreach department at Wahiawa Center for Community Health in Wahiawa, Hawaii—an isolated community near Oahu’s North Shore. The town used to be an agricultural mecca. Sugar and pineapple plantations drew thousands of workers from across Asia and the Pacific throughout the early 20th century. Workers received housing, education, and health care through their employers.
But then, in the mid- 1900s, these companies moved overseas to cheaper labor markets, leaving little infrastructure in their place.
Today, a significant portion of Wahiawa’s population lacks access to basic goods including medical care, adequate housing, and electricity. “This community is kind of stuck in time,” said Pua Akana, the health center’s director of pharmacy.
Due to low rates of insurance, the hospital’s emergency department is often used as a clinic for primary care needs. Endrizal says this is particularly common among those experiencing homelessness: “They go there because they’re hungry, they go there because they’re having pain and they need opioids, or maybe they need to use the bathroom.”
When this happens, the hospital calls Endrizal. “The nurse manager and I talk a lot. She’ll call me, ‘Oh, so-and-so’s back in the ER’ and I’ll tell her, ‘Okay, send them down to us.’”
To help reach these patients, BD, together with Direct Relief, provided a $150,000 grant to help Wahiawa Health incorporate community health workers into their medication management program. This investment is part of the broader BD Helping Build Healthy Communities initiative. With this funding, community health workers will help patients overcome barriers preventing them from adhering to their medication regimens, including housing and food insecurity, a lack of electricity, or a language barrier.
In order to establish trust with these patients, many of whom are wary of the medical establishment, the health center practices what’s called “cultural safety.” The approach focuses on ensuring patients feel respected and heard, which can be difficult given the variety of cultural backgrounds. Many patients are first generation Pacific Islander and often speak languages that providers don’t know.
At Wahiawa Health, a diverse staff helps bridge this gap. “When patients see someone that looks like them and talks like them and has the same mannerisms and whatnot, they’re much more likely to communicate and share what their concerns might be,” said Endrizal.
But cultural safety not only applies to interactions within the health center. It’s an integral part of their outreach. Staff frequently provide care at the local homeless encampment, but they’re sensitive in their approach. “There’s a protocol…and the protocol would be for me to be invited,” said Endrizal.
This invitation usually comes from the leader of the encampment, known as the Governor. “For me to understand that protocol and follow that protocol, that’s cultural safety,” she said. This approach has helped the health center reach communities cut off from the health care system, expanding access to care.
In addition to establishing trust with their patients, the health center works to understand what their lives are like.
“Is there electricity? Is there food insecurity? [Are] there financial constraints where patients are not able to adhere to their medication?” said Dr. Akana.
These factors, known as social determinants of health, make it difficult for patients to prioritize their health, often resulting in worse health outcomes.
Most patients at Wahiawa Health have a chronic condition; the most common are diabetes and hypertension. Managing these diseases requires adhering to a strict medication regimen, such as daily injections of insulin, a temperature-sensitive medication used to manage high blood sugar in those with diabetes.
“It’s so classic for someone to maybe scold the patient, ‘Why aren’t you taking your insulin? You keep forgetting or, or what’s going on?’ when we haven’t asked if they have a refrigerator,” said Endrizal.
These barriers, such as not having electricity or being unable to afford a certain medication, can cause patients to modify their treatment plan or skip it altogether. “A lot of patients here will take their medication every other day or every couple of days to stretch it out,” said Dr. Akana.
This can lead to overprescribing. Providers might not know a patient is skipping doses and may prescribe an additional medication if they see their condition is not improving. “That is very, very common, where we think that [the] medication wasn’t enough or isn’t working for a patient so we add on,” said Dr. Akana. “In actuality it could be something basic: a language barrier–they didn’t understand, it could be finances.”
Fear or distrust of medical professionals only compounds the issue, according to Dr. Akana. “They could be afraid to tell me…’Hey, I just, I couldn’t afford it. I never picked it up,’”
But building trust with patients is not only about improving their own their health. The effects have the potential to be generational. “In my family, dying from complications of diabetes was just accepted,” she said. “We just thought that’s the way it is.”
As a medical professional, Dr. Akana has broken that cycle. Now, she wants the same for her patients. “I think that would be a change long-term,” she said.
For more information about Wahiawa Health, a federally qualified community health center that treats patients, regardless of ability to pay, visit their page here. More information on BD’s Helping Build Healthy Communities program can be found here.