Social justice in medical education: strengths and challenges of a student-driven social justice curriculum.

In the current rapidly evolving healthcare environment of the United States, social justice programs in pre-medical and medical education are needed to cultivate socially conscious and health professionals inclined to interdisciplinary collaborations. To address ongoing healthcare inequalities, medical education must help medical students to become physicians skilled not only in the biomedical management of diseases, but also in identifying and addressing social and structural determinants of the patients' daily lives. Using a longitudinal Problem-Based Learning (PBL) methodology, the medical students and faculty advisers at the University of Hawai'i John A. Burns School of Medicine (JABSOM) developed the Social Justice Curriculum Program (SJCP) to supplement the biomedical curriculum. The SJCP consists of three components: (1) active self-directed learning and didactics, (2) implementation and action, and (3) self-reflection and personal growth. The purpose of introducing a student-driven SJ curriculum is to expose the students to various components of SJ in health and medicine, and maximize engagement by using their own inputs for content and design. It is our hope that the SJCP will serve as a logistic and research-oriented model for future student-driven SJ programs that respond to global health inequalities by cultivating skills and interest in leadership and community service.

Hawai'i Island Health Workforce Assessment 2008.

BACKGROUND: Anecdotal reports of a doctor shortage on the Big Island have been circulating for years, but a detailed assessment of the health care workforce had not previously been accomplished. METHODS: The Hawai'i Island Health Workforce Assessment used licensure data, focus groups, telephone follow up to provider offices, national estimates of average provider supply and analysis of insurance claims data to assess the extent of the existing medical and mental health workforce, approximate how many additional providers might be effectively utilized, develop a population-based estimate of future demand and identify causes and potential solutions for the challenges faced. RESULTS: As of February 2008, the researchers were able to locate 310 practicing physicians, 36 nurse practitioners, 6 physician assistants, 51 psychologists, 57 social workers and 42 other mental health providers. Based on national averages, claims analysis and focus groups, the Island could use approximately 45 additional medical professionals to care for the 85% of the population that is medically insured; a larger number to care for the entire population. Ascertaining a complete roster of mental health professionals was not possible using this methodology. DISCUSSION: The researchers compared the current supply of physicians with the national average of physicians to population and the number of visits to different specialists for the year 2006 and found specific regional shortages of providers. The focus groups concentrated on solutions to the workforce crisis that include the formation of a well-organized, broad collaboration to coordinate recruitment efforts, expand and strengthen retention and renewal activities, and reinvigorate the health profession pipeline and training opportunities. The researchers recommend collaboration between the community, government, business, health center care providers, hospitals and centers to develop a plan before the tenuous state of healthcare on the Big Island worsens. In addition, continued surveillance of the health workforce is vital to tracking the impact of interventions. This could be accomplished through community informants and data collected at the time of professional relicensure to include practice location and practice intensions for future planning estimates.

Health care needs of the homeless of O'ahu.

An interview study of 162 homeless individuals on O'ahu demonstrated that the homeless studied were 3 times more likely than the general population of O'ahu to rate their health as fair to poor, despite the fact that 77% of interviewees had medical insurance and 66% a regular health care provider Better self ratings of health were only associated with younger age and self report of having dental insurance when demographic variables were controlled for. Qualitatively the homeless population interviewed described 'good health' as avoiding illness and being able to make healthy lifestyle choices, finding emotional balance and caring for others. Commonly reported barriers to accessing care included financial factors such as being unable to purchase medications; environmental challenges such as clean drinking water and a safe place to stay; and general discomfort with the health care system. Clinical implications of this study indicate the need for providers caring for the homeless be alert to challenges particular to the homeless, such as barriers to following medical advice (high fiber/low salt diet, exercise, refrigerating medications, etc.). The surprising relationship between knowledge of having dental insurance and better self ratings of health deserves additional research, as does the lack of association between health ratings and having health insurance and a regular provider.

Assessing health disparities in rural Hawaii using the Hoshin facilitation method.

CONTEXT: Health disparities between rural and urban communities are well documented. There are many suggested causes and many proposed solutions but no one-size-fits-all answer. The most successful community interventions have been introduced by communities themselves. However, before communities invest in such interventions, each group must identify and prioritize their needs. PURPOSE: This article describes the Hoshin facilitation method as a practical option assisting communities in assessing their needs and gaining consensus for future steps. METHODS: Thirty-four meetings were held in 11 rural communities in Hawaii using the Hoshin process to identify factors that impact rural health. Themes were identified by constant comparative analysis and thematic frequency described. Commonality of responses between communities was examined. Informal feedback was collected from meeting participants. FINDINGS: There was a great deal of commonality between community responses, with economic factors, drug use, lack of community leadership, lack of health care services and access to services, lack of healthy activities for youth, and poor public education being the most common issues noted. Group involvement in the meetings was high, and the facilitation method received positive feedback from participants. CONCLUSIONS: The Hoshin facilitation method is a very useful tool to help communities rapidly identify and prioritize areas for programmatic attention.

Evaluation of distance learning for health education.

The Hawai'i Unified Telehealth program is a distance learning health education program for rural communities, created with federal grant funding from the U.S. Department of Commerce and the National Institutes of Health. These grant funds helped develop a network of rural community learning centers that employ distance learning technologies to provide community-driven peer education to isolated areas across Hawai'i and Majuro, Republic of the Marshall Islands. In this article, the authors briefly describe the development of the ongoing health education program and the results of outcome evaluation completed at the end of the funding period.