Problem: Health care clinicians are trained to treat illness and injury but not the social determinants of health, such as poverty, discrimination and violence. As a result, many root causes of poor health go unaddressed by health care providers, and low-income and other vulnerable people suffer disproportionately.
Background: To fully understand the meaning of kuleana, look no further than Jamie Kamailani Boyd, PhD, a pioneering nurse practitioner and educator in Hawaii who made a long and arduous climb out of poverty and is now helping others do the same. She lives and breathes kuleana, a Hawaiian word that means that individuals have the right to be able to sustain themselves and their families and, in turn, have a responsibility to sustain their communities.
Boyd spent her early childhood with her grandmother, an indigenous nurse in rural Hawaii who bartered her services and knowledge for food and other goods. When Boyd’s grandmother died, Boyd was taken in by a foster family. During this period, she became a single mother at 13.
While in foster care, Boyd was forced to separate from her child because no foster parents were willing to care for both a teenager and her infant. When she reached the age of 15, she was released from the foster care system. She then faced the staggering responsibility of recovering from years of abuse, learning how to live independently, and supporting a child without the benefit of a high school diploma or the support of a partner. By 17, she was the mother of two.
At the time, the only job she could find was as a nurse’s aide at a mental health institution. She was grateful for the job but, like much of the rest of the nation’s working poor, was unable to get by on a low-wage salary. She earned too much to qualify for government assistance but not enough to support her family or access quality health care.
Her childhood social worker encouraged her to get her general educational development (GED) degree and apply to vocational school. So, at age 27, and by then the mother of three children, Boyd applied to get her associate’s degree in nursing. She was accepted on the condition that she enroll in remedial math classes on a nearby military base. “The drill sergeant yelled at me,” she recalls. “But I finished that first Intro-to-Algebra class with an ‘A.’ It really planted in me the idea that I could succeed in college…That was good.”
After earning her associate’s degree, she enrolled at Hardin-Simmons University in Abilene, Texas, to get her bachelor’s degree. During that period, she lost custody of her three children in a lawsuit against her now ex-husband. Her legal ordeal left her broke and on the brink of suicide. She confided in a teacher, who told her that it “would be a crime to let someone like me, who was determined to succeed, fall through the cracks.” The teacher brought Boyd’s case to the attention of the college president, who agreed to give her free room and board on the condition that she attend every class—no exceptions.
She did. And, as her mentors had predicted, she triumphed.
Boyd graduated with her bachelor’s degree in nursing and went on to earn her master’s degree as a nurse practitioner, and then her doctorate degree in nursing. Two school officials also testified on her behalf in her battle for custody of her children, and she won the case. It was these constant struggles to pay for college, housing and child care, and the overwhelming gratitude for the help she received along the way, that brought to light the true meaning of kuleana: the value of pulling yourself up and then pulling up others in need.
She is now finding ways to pull up others around her. “I have sat in the middle of the bed in the darkness of night rocking back and forth begging for mercy, and I am now working to answer that call for other mothers,” she says.
Solution: Once on the receiving end of kuleana, Boyd is now on the giving end.
A professor of nursing at Windward Community College in Hawaii, she has created an academic program that helps native Hawaiians and other disadvantaged students become registered nurses. Called Pathway Out of Poverty, the program aims to help disadvantaged Hawaiians rise out of poverty, a key root cause of poor health. As a nurse practitioner she found that people who can’t afford food and shelter certainly can’t pay for prescription drugs and office visits, she says. “When you only have $15 left, you use it for gas and Pampers, not for a co-pay for hypertension. Health isn’t going to improve until people have enough to pay the rent and buy the Pampers and meet the basic necessities of life.”
Boyd’s program helps disadvantaged people equip themselves to earn enough to afford those basic necessities and improve their health and the health of others along the way. The program helps about 50 native Hawaiians and other at-risk students—mainly low-income mothers—become nurse’s aides, which is comparatively more secure than other low-wage jobs in the food and sanitation sectors. About three quarters go on to higher education courses to become registered nurses. Boyd also spends time writing grants and helping her students find creative ways to cover the cost of tuition and non-tuition needs such as child care and transportation. From CNA to RN, students in the program are preparing to be nurses while addressing community needs.
In addition to alleviating poverty and improving health, the program increases diversity in nursing and improves the quality of care. Native Hawaiians represent about 29 percent of the local population but are vastly underrepresented in the Hawaiian nursing workforce, Boyd says. To address this disparity, she persuaded officials at nearby Kapi`olani Community College to hold 10 of 80 nursing school seats for indigenous students in the Pathway. Boyd calls it her biggest accomplishment, and says these native nurses will go on to care for elders and others in native Hawaiian communities.
Boyd’s program is only four years old, so the final outcomes are still unclear. What is clear is that her students and their families are making healthier decisions as a result of the program, she says. They’re eating smaller portions, walking instead of driving, and watching less television. “If we don’t get anything other than that out of the program, I’ll consider it a success.”
RWJF Perspective: Jamie Kamailani Boyd was named one of 10 recipients of the 2011 Robert Wood Johnson Foundation Community Health Leaders Award. The award honors exceptional men and women who have overcome significant obstacles to tackle some of the most challenging health and health care problems facing their communities.
Now in its 18th year, the Community Health Leaders Award elevates the work of the leaders by raising awareness of their extraordinary contributions through national visibility, a $125,000 award, and networking opportunities.
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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