HomeMy WebLinkAboutHealthcare Assoc of HI - Hawaii County Community Health Needs Assessment 2015
Hawaii County
Community Health Needs Assessment
North Hawaii Community Hospital
— November 2015 —
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Table of Contents
Executive Summary ............................................................................................... 4
Introduction ....................................................................................................... 4
Summary of Findings ......................................................................................... 4
Selected Priority Areas ...................................................................................... 6
1 Introduction ..................................................................................................... 6
1.1 Summary of CHNA Report Objectives and Context ..................................... 6
1.1.1 Healthcare Association of Hawaii ........................................................... 7
1.1.2 Member Hospitals.................................................................................. 7
1.1.3 Advisory Committee............................................................................... 7
1.1.4 Consultants ........................................................................................... 9
1.2 About the Hospital ................................................................................ 9
1.2.1 Hospital Community Benefit Team and Goals ...................................... 10
1.2.2 Definition of Community + Map ......................................................... 10
2 Selected Priority Areas ................................................................................... 10
3 Evaluation of Progress since Prior CHNA ....................................................... 11
3.1 Impact since Prior CHNA .......................................................................... 11
3.2 Community Feedback on Prior CHNA or Implementation Strategy ........... 15
4 Methods .......................................................................................................... 15
4.1 Quantitative Data Sources and Analysis..................................................... 15
4.1.1 Race/Ethnicity Disparities ....................................................................... 16
4.1.2 Preventable Hospitalization Rates .......................................................... 16
4.1.3 Shortage Area Maps ................................................................................ 17
4.1.4 External Data Reports .............................................................................. 17
4.2 Qualitative Data Collection and Analysis ................................................... 17
4.3 Prioritization ............................................................................................ 18
4.4 Data Considerations .................................................................................. 18
5 Demographics ................................................................................................. 18
5.1 Population ................................................................................................. 19
5.1.1 Age ....................................................................................................... 19
5.1.2 Racial/Ethnic Diversity ........................................................................ 19
5.2 Social and Economic Determinants of Health ........................................... 22
5.2.1 Income ................................................................................................ 22
5.2.2 Poverty ................................................................................................ 22
5.2.3 Education ............................................................................................ 22
5.2.4 SocioNeeds Index® .............................................................................. 23
6 Findings ......................................................................................................... 24
Note to the Reader ............................................................................................. 27
6.1 Access to Care ........................................................................................... 29
6.1.1 Access to Health Services .................................................................... 29
6.1.2 Mental Health ...................................................................................... 31
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6.1.3 Oral Health .......................................................................................... 32
6.1.4 Economy ............................................................................................. 33
6.1.5 Transportation .................................................................................... 33
6.2 Chronic Diseases ...................................................................................... 34
6.2.1 Exercise, Nutrition & Weight .............................................................. 34
6.2.2 Diabetes and Kidney Disease .............................................................. 35
6.2.3 Heart Disease & Stroke ...................................................................... 36
6.2.4 Arthritis .............................................................................................. 37
6.2.5 Cancer ................................................................................................ 38
6.3 Environmental Health & Respiratory Diseases ......................................... 39
6.3.1 Environment ...................................................................................... 39
6.3.2 Respiratory Diseases .......................................................................... 39
6.4 Mental Health & Health Risk Behaviors .................................................... 41
6.4.1 Mental Health & Mental Disorders ...................................................... 41
6.4.2 Substance Abuse ................................................................................ 42
6.4.3 Wellness & Lifestyle ........................................................................... 44
6.4.4 Prevention & Safety ........................................................................... 44
6.4.5 Immunizations & Infectious Diseases ................................................ 46
6.5 Women’s, Infant, & Reproductive Health .................................................. 47
6.5.1 Maternal, Fetal, & Infant Health .......................................................... 47
6.5.2 Family Planning and Teen Sexual Health ........................................... 48
6.5.3 Women’s Health ................................................................................. 49
7 A Closer Look at Highly Impacted Populations ............................................... 49
7.1 Children, Teens, & Adolescents ................................................................. 50
7.1.1 Access to Care ..................................................................................... 50
7.1.2 Oral Health ......................................................................................... 50
7.1.3 Disabilities .......................................................................................... 50
7.1.4 Nutrition & Physical Activity ............................................................... 50
7.1.5 Asthma ................................................................................................ 51
7.1.6 Mental Health & Substance Abuse ....................................................... 51
7.1.7 Prevention and Safety .......................................................................... 51
7.1.8 Teen Pregnancy and Sexual Health ...................................................... 51
7.2 Older Adults .............................................................................................. 51
7.2.1 Access to Care ...................................................................................... 51
7.2.2 Chronic Diseases ................................................................................. 52
7.2.3 Safety .................................................................................................. 52
7.2.4 Social Environment ............................................................................. 52
7.3 Low-Income Population ............................................................................ 52
7.4 Rural Communities ................................................................................... 53
7.5 People with Disabilities ............................................................................. 53
7.6 Homeless Population................................................................................. 54
7.7 People from Micronesian Regions ............................................................. 55
7.8 Disparities by Race/Ethnic Groups ............................................................ 55
8 Conclusion ...................................................................................................... 59
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Tables
Table 5.1: Population Density and Change ...............................................................................19
Table 6.1: Secondary Data Scoring for Health Topic Areas.......................................................26
Table 6.2: Secondary Data Scoring for Quality of Life Topic Areas ...........................................26
Table 6.3: Providers per 100,000 Residents .............................................................................29
Table 6.4: Adult Oral Health ......................................................................................................32
Table 6.5: People and Families Living Under Poverty Level ......................................................33
Table 6.6: Physical Activity Among Teens .................................................................................35
Table 6.7: Diabetes Management .............................................................................................36
Table 6.8: Prevalence of High Blood Pressure and High Cholesterol ........................................36
Table 6.9: Prevalence of Cardiovascular Diseases ...................................................................36
Table 6.10: Awareness of Symptoms and Response to Stroke or Heart Attack.........................37
Table 6.11: Outpatient Rehabilitation for Heart Attack of Stroke Survivors ................................37
Table 6.12: Limitations due to Arthritis ......................................................................................37
Table 6.13: Cancer Incidence and Death Rates ........................................................................38
Table 6.14: Highly Impacted Populations, Cancer .....................................................................38
Table 6.15: ED Visits due to Asthma .........................................................................................39
Table 6.16: Hospitalizations due to Mental Health .....................................................................41
Table 6.17: Teen Mental Health ................................................................................................42
Table 6.18: Highly Impacted Populations, Suicide Death Rate ..................................................42
Table 6.19: Adults who Attempted to or Successfully Quit Smoking ..........................................42
Table 6.20: Substance Abuse among Teens .............................................................................43
Table 6.21: Highly Impacted Populations, Drug-Induced Deaths ...............................................44
Table 6.22: Highly Impacted Populations, Prevention and Safety .............................................46
Table 6.23: Vaccination Rates among Adults ............................................................................46
Table 6.24: Preterm Births ........................................................................................................47
Table 6.25: Infant Deaths ..........................................................................................................47
Table 6.26: Highly Impacted Populations, Maternal Smoking and Early Preterm Births ............48
Table 6.27: Births to Teens and Mothers without High School Diplomas ...................................48
Table 6.28: Highly Impacted Populations, Births to Teens and Mothers without High School
Diplomas ...................................................................................................................................49
Table 7.1: ED Visits and Deaths due to Asthma Among Seniors ...............................................52
Table 7.2: Number of Homeless Served by Program Type .......................................................54
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Figures
Figure 1.1: Service Area Map to be Added by Hospital ............... Error! Bookmark not defined.
Figure 4.1: Secondary Data Methods ........................................................................................16
Figure 5.1 Population by Age, 2013 ..........................................................................................19
Figure 5.2: Population by Race/Ethnicity, 2013 .........................................................................20
Figure 5.3: Population by One Race Alone or in Combination ...................................................20
Figure 5.4: Population by Race in Hawaii County: Breakdown of Asian Population, 2013 .........21
Figure 5.5: Population by Race in Hawaii County, 2013: Breakdown of Native Hawaiian and
Other Pacific Islander Population, 2013 ....................................................................................21
Figure 5.6: Persons Below Poverty Level by Race/Ethnicity, 2009-2013 ...................................22
Figure 5.7: 2015 SocioNeeds Index® for Hawaii County ............................................................23
Figure 6.1: Strength of Evidence of Need..................................................................................24
Figure 6.2: Topic Areas Demonstrating Strong Evidence of Need .............................................25
Figure 6.3: Word Cloud of Themes Discussed by Key Informants .............................................27
Figure 6.4: Layout of Topic Area Summary ...............................................................................28
Figure 6.5: Health Professional Shortage Areas ........................................................................30
Figure 6.6: Mental Health ..........................................................................................................31
Figure 7.1: Disparities by Race/Ethnicity ...................................................................................57
Figure 7.2: Key Informant-Identified Health Issues Impacting Racial/Ethnic Groups .................58
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Executive Summary
Introduction
The Healthcare Association of Hawaii and its member hospitals are pleased to present the
2015-2016 Hawaii County Community Health Needs Assessment (CHNA). This CHNA report
was developed through a collaborative process and provides an overview of the health needs in
Hawaii County. The Healthcare Association of Hawaii partnered with Healthy Communities
Institute to conduct the CHNA for Hawaii County.
The goal of this report is to offer a meaningful understanding of the health needs in Hawaii
County, as well as to guide the hospitals in their community benefit planning efforts and
development of implementation strategies to address prioritized needs. Special attention has
been given to identify health disparities, needs of vulnerable populations, unmet health needs or
gaps in services, and input from the community. Although this report focuses on needs,
community assets and the aloha spirit support expanded community health improvement.
Summary of Findings
The CHNA findings are drawn from an analysis of an extensive set of quantitative data (over
300 secondary data indicators) and in-depth qualitative data from key community health leaders
and experts from the Hawaii Department of Public Health and other organizations that serve
and represent vulnerable populations and/or populations with unmet health needs.
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The most severe health needs, based on the overlap between quantitative data (indicators) and
qualitative data (interviews), include Access to Health Services; Children’s Health; Disabilities;
Immunizations & Infectious Diseases; Mental Health & Mental Disorders; Respiratory Diseases;
and Substance Abuse. Other significant health needs are based on strong evidence from either
quantitative or qualitative data, and span a range of topic areas.
Though Hawaii County fares well in many health, wellbeing, and economic vitality indicators
compared to other counties in the U.S., major themes emerged from the needs identified in this
report:
• Access to Care: Hawaii County has significant unmet healthcare access needs due to
provider shortages, limited oral health services and coverage, and inadequate
coordination in mental health care. Residents also face substantial rates of poverty and
challenges in transportation, further exacerbating access issues.
• Chronic Diseases: Many Hawaii County residents are at greater risk of chronic
diseases due to relatively low access to healthy foods and exercise opportunities and
high rates of food insecurity. There are many issues associated with diabetes: a high
rate of prediabetes, inadequate diabetes management and education, and a
correspondingly high rate of complications. Hawaii County also has a high prevalence of
cardiovascular risk factors and diseases. Sub-optimal early responses to stroke and
heart attack symptoms increase the likelihood of disability. Other areas of need include
arthritis and cancer.
• Environmental Health & Respiratory Diseases: Volcano activity negatively impacts air
quality and lava flow may threaten infrastructure and services on the Big Island. Asthma
impacts much of the population, from children to older adults.
• Mental Health & Health Risk Behaviors: Access to mental health services and
substance abuse treatment is limited. Rates of both suicide deaths and substance abuse
are high across Hawaii County, but disproportionately impact residents of Native
Hawaiian descent. Substance abuse is also an area of concern for teens and pregnant
women. Risky behaviors lead to high rates of avoidable injuries and motor vehicle
collisions. Intimate partner violence and abuse are also issues in Hawaii County.
• Women’s, Infant, & Reproductive Health: There are high rates late or no prenatal care
and substance abuse among mothers in Hawaii County, as well as high rates of poor
birth outcomes. Rates of condom usage are low among teen girls, and teen birth rate is
high, especially among Native Hawaiian and Other Pacific Islander teens.
• Highly Impacted Populations: The cross-cutting major themes are even more acute in
certain geographical areas and subpopulation groups. These highly impacted
populations tend to experience poorer health status, higher socioeconomic need, and/or
cultural and linguistic barriers. For the highly
impacted populations, a focus on the core
determinants of health in addition to topic specific
needs is likely to lead to the most improvement in
health status.
Geographies with High
Socioeconomic Need
Kau
Puna South Hilo
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Subpopulation Groups of High Need
Native Hawaiian Pacific Islander Filipino Hispanic/Latino Children, teens, and
adolescents Older adults People with
disabilities Rural communities
Low-income population People from Micronesian regions* Homeless population
*This is intended to be a respectful reference that includes, but is not limited to, individuals from Micronesian states,
Marshall Islands, Palau, Nauru, and other islands in the region. These individuals may have come to Hawaii through
a Compact of Free Association agreement and may be provided healthcare benefits.
The isolation of many subpopulations and geographies presents spatial and/or cultural/social
challenges leading to the recommendations to increase the continuity of care and leverage
telemedicine. Opportunities to prevent and intervene early with mental health issues, substance
abuse, and the development of chronic disease are needed.
Upstream interventions to address the determinants of health are important for all health
improvement approaches, but especially crucial for the highest-need geographies and
populations that experience the greatest health inequities. Together, Hawaii County hospitals
and health stakeholders are working towards a community where safety, wellness, and
community support exist for all residents.
Selected Priority Areas
In the 2012 study, the CHNA identified 20 areas of community health needs. The Queen’s Health
Systems recognizes the importance of these needs and has supported efforts to address many
of them. One of the major themes presented in the 2015-2016 report is access to care. Hawaii
County has significant unmet healthcare access needs due to provider shortages, limited oral
health services and coverage, and inadequate coordination in mental health care. Residents also
face substantial rates of poverty and challenges in transportation, further exacerbating access
issues.
To promote and improve access to care for the people of Hawai’i Island, North Hawaii Community
Hospital will focus on access through outreach, education, technology, and physician recruitment.
1 Introduction
1.1 Summary of CHNA Report Objectives and Context
In 2013, Hawaii community hospitals and hospital systems joined efforts to fulfill the new
requirements of the Affordable Care Act, with guidelines from the IRS. Three years later, the
group came together to repeat this process, in accordance with the final IRS regulations issued
December 31, 2014, and re-assess the needs of their communities. The Healthcare Association
of Hawaii (HAH) led both of these collaborations to conduct state- and county-level
assessments for its members.
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1.1.1 Healthcare Association of Hawaii
HAH is the unifying voice of Hawaii’s healthcare providers and an authoritative and respected
leader in shaping Hawaii’s healthcare policy. Founded in 1939, HAH represents the state’s
hospitals, nursing facilities, home health agencies, hospices, durable medical equipment
suppliers, and other healthcare providers who employ about 20,000 people in Hawaii. HAH
works with committed partners and stakeholders to establish a more equitable, sustainable
healthcare system driven to improve quality, efficiency, and effectiveness for patients and
communities.
1.1.2 Member Hospitals
Fifteen Hawaii hospitals,1 located across the state, participated in the CHNA project:
Castle Medical Center
Sutter Health Kahi Mohala Behavioral Health
Kaiser Permanente Medical Center Kapiolani Medical Center for Women & Children
Kuakini Medical Center Molokai General Hospital North Hawaii Community Hospital*
Pali Momi Medical Center Rehabilitation Hospital of the Pacific
Shriners Hospitals for Children - Honolulu
Straub Clinic & Hospital The Queen’s Medical Center
The Queen’s Medical Center – West Oahu
Wahiawa General Hospital Wilcox Memorial Hospital
*located in and serves Hawaii County
1.1.3 Advisory Committee
The CHNA process has been defined and informed by hospital leaders and other key
stakeholders from the community who constitute the Advisory Committee. The following
individuals shared their insights and knowledge about healthcare, public health, and their
respective communities as part of this group.
Kurt Akamine, Garden Isle Rehabilitation & Healthcare Center
Marc Alexander, Hawaii Community Foundation Gino Amar, Kohala Hospital Maile Ballesteros, Stay At Home Healthcare Services
Joy Barua, Kaiser Permanente Hawaii Dan Brinkman, Hawaii Health System Corporation, East Hawaii Region
Rose Choy, Sutter Health Kahi Mohala Behavioral Health
Kathy Clark, Wilcox Memorial Hospital R. Scott Daniels, State Department of Health
Thomas Driskill, Spark M. Matsunaga VA Medical Center
1Tripler Army Medical Center, the Hawaii State Hospital, and the public hospital system of Hawaii Health
Systems Corporation (HHSC) are not subject to the IRS CHNA requirement and were not a part of this initiative.
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Tom Duran, CMS Laurie Edmondson, North Hawaii Community Hospital
Lynn Fallin, State Department of Health
Brenda Fong, Kohala Home Health Care of North Hawaii Community Andrew Garrett, Healthcare Association of Hawaii
Beth Giesting, State of Hawai, Office of the Governor Kenneth Graham, North Hawaii Community Hospital George Greene, Healthcare Association of Hawaii
Robert Hirokawa, Hawaii Primary Care Association Mari Horike, Hilo Medical Center Janice Kalanihuia, Molokai General Hospital
Lori Karan, MD; State Department of Public Safety Darren Kasai, Kula and Lanai Hospitals
Nicole Kerr, Castle Medical Center
Peter Klune, Hawaii Health Systems Corporation, Hawaii Region Tammy Kohrer, Wahiawa General Hospital
Jay Kreuzer, Kona Community Hospital
Tony Krieg, Hale Makua Eva LaBarge, Wilcox Memorial Hospital
Greg LaGoy, Hospice Hawaii, Inc. Leonard Licina, Sutter Health Kahi Mohala Behavioral Health Wesley Lo, Hawaii Health Systems Corporation, Hawaii Region
Lorraine Lunow-Luke, Hawaii Pacific Health Sherry Menor-McNamara, Chamber of Commerce of Hawaii Lori Miller, Hawaii Hospice
Pat Miyasawa, Shriners Hospitals for Children – Honolulu Ramona Mullahey, U.S. Department of Housing and Urban Development Jeffrey Nye, Castle Medical Center
Quin Ogawa, Kuakini Medical Center Don Olden, Wahiawa General Hospital
Ginny Pressler, MD, State Department of Health
Sue Radcliffe, State Department of Health, State Health Planning and Development Agency
Michael Robinson, Hawaii Pacific Health
Linda Rosen, MD, Hawaii Health Systems Corporation Nadine Smith, Ohana Pacific Management Company
Corinne Suzuka, CareResource Hawaii Brandon Tomita, Rehabilitation Hospital of the Pacific Sharlene Tsuda, The Queen’s Medical Centers
Stephany Vaioleti, Kahuku Medical Center Laura Varney, Hospice of Kona Cristina Vocalan, Hawaii Primary Care Association
John White, Shriners Hospitals for Children – Honolulu Rachael Wong, State Department of Human Services Betty J. Wood, Department of Health
Barbara Yamashita, City and County of Honolulu, Department of Community Services Ken Zeri, Hospice Hawaii
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1.1.4 Consultants
Healthy Communities Institute
Based in Berkeley, California, Healthy Communities Institute was retained by HAH as
consultants to conduct foundational community health needs assessments for HAH’s member
hospitals. The Institute, now part of Midas+, a Xerox Company, also created the community
health needs assessments for HAH member hospitals in 2013, to support hospitals in meeting
the first cycle of IRS 990 CHNA reports.
The organization provides customizable, web-based information systems that offer a full range
of tools and content to improve community health, and developed
www.HawaiiHealthMatters.org in partnership with the Hawaii Department of Health. The
organization is composed of public health professionals and health IT experts committed to
meeting clients’ health improvement goals. To learn more about Healthy Communities Institute
please visit www.HealthyCommunitiesInstitute.com.
Report authors from Healthy Communities Institute:
Muniba Ahmad Jenny Belforte, MPH
Florence Reinisch, MPH Jennifer M. Thompson, MPH
Rebecca Yae
Diana Zheng, MPH
Storyline Consulting
Dedicated to serving and enhancing Hawaii’s nonprofit and public sectors, Storyline Consulting
assisted with collecting community input in the form of key informant interviews. Storyline is
based in Hawaii and provides planning, research, evaluation, grant writing, and other
organizational development support and guidance. By gathering and presenting data and
testimonies in a clear and effective way, Storyline helps organizations to improve decision-
making, illustrate impact, and increase resources.
To learn more about Storyline Consulting please visit www.StorylineConsulting.com.
Key informant interviewers from Storyline Consulting:
Lily Bloom Domingo, MS
Kilikina Mahi, MBA
1.2 About the Hospital
North Hawaii Community Hospital is a 35 bed, full-service, acute-care hospital located in the heart of Kamuela on Hawaii Island, at an altitude of 2,600 feet and at the base of the often
snow-topped Mauna Kea. As a non-profit hospital, North Hawaii Community Hospital serves more than 30,000 residents in North Hawaii, as well as the many visitors to the island.
North Hawaii Community Hospital opened in 1996. Our mission is to improve the health of the people of North Hawaii by improving access to care. In January 2014, North Hawaii Community
Hospital became part of The Queen’s Health Systems. Our focus is on the patient, the family
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and the culture of healing the whole person. North Hawaii Community Hospital delivers excellent quality health care service within a total healing environment. North Hawaii Community
Hospital’s physical environment includes:
• Amply sized single patient rooms
• Natural lighting and garden views in all rooms • Operable lanai doors in all rooms • Skylights and windows in common areas
• Landscaped gardens • Courtyards with water features • Interior design with warm colors and art
North Hawaii Community Hospital offers a spectrum of high quality services, including
emergency services, general surgical services, critical care, obstetrics, gastroenterology,
orthopedic services, cardiology, diabetes counseling, home health care, holistic services and more. We also offer in-patient and out-patient laboratory, imaging, cardiopulmonary,
rehabilitation, and dialysis services.
1.2.1 Hospital Community Benefit Team and Goals
North Hawaii Community Hospital will be focusing on “Access to Care” as it was selected by
Queen’s Health System as a system-wide priority.
1.2.2 Definition of Community + Map
The county serves as the unit of analysis for the Community Health Needs Assessment and the
health needs in this assessment pertain to individuals living within this geographic boundary.
The specific area served by North Hawaii Community Hospital is indicated in Figure 1.1.
2 Selected Priority Areas
In the 2012 study, the CHNA identified 20 areas of community health needs. The Queen’s Health
Systems recognizes the importance of these needs and has supported efforts to address many
of them. One of the major themes presented in the 2015-2016 report is access to care. North
Hawaii Community Hospital will be focusing on “Access to Care” as it was selected by Queen’s
Health System as a system-wide priority.
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Hawaii County has significant unmet healthcare access needs due to provider shortages, limited
oral health services and coverage, and inadequate coordination in mental health care. Residents
also face substantial rates of poverty and challenges in transportation, further exacerbating
access issues.
To promote and improve access to care for the people of Hawai’i Island, North Hawaii Community
Hospital will focus on access through outreach, education, technology, and physician recruitment.
• Improve access to underserved populations by increasing the number of new patients and decreasing wait time for first appointments.
• Increase physician recruiting, specifically for primary care, OBGYN and general surgery.
• Shorten the length of time between diagnosis of cancer and initiation of treatment.
• Increase translation services to improve cultural competency and to strengthen care.
3 Evaluation of Progress since Prior CHNA
3.1 Impact since Prior CHNA
Priority
Area
Strategy: Objectives Activity Outcome (Metrics of Success)
Exercise Community outreach/education
Support for and creation of
opportunities
Keiki
Promote increasing
physical activity
Served as catalyst for
community exercise activities [buddy
systems, exercise contracts, walking
groups, etc.]
Helped schools empower students with
the knowledge, skills and attitudes that
support and maintain healthy exercise
behavior by providing educational materials.
. Supported integration of
school-based activity programs with family
and community life by providing family oriented
activities.
Utilized community/school
Provided one or more community exercise promoting activities per year.
Created and provided educational materials to multiple schools.
Created and provided at least one family
based interactive activity.
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organized sporting
events as an opportunity for education
Adults/Seniors
Promote increasing
physical activity
Radio PSAs with varying focused messages
Served as catalyst for community exercise
activities.
Participated in efforts to improve activity among
the NHCH employee community.
Attended and provided educational
materials at at least one keiki event.
Aired radio spots focused on promoting
exercise.
Provided one or more community exercise
promoting activities per year.
Promoted and provided access to NHCH gym
Weight Community outreach/education
Support for and Creation of
opportunities
Keiki
Educate and promote
healthy weight
Educated keiki about
healthy weight
Supported community efforts to assess healthy
weight indices among students and to align
any intervention activities
(not done due to privacy)
Providers to educate patients about the effect
of weight on chronic disease.
Adult / Senior
Educate and promote
healthy weight
Radio PSAs with varying focused messages
Supported community
efforts to assess healthy weight indices among
target populations, and
Created and provide educational material relating to healthy weight at at least one
school.
Provided educational materials at at least one keiki event.
Provided education material that communicates the effect of weight on
chronic disease.
Aired radio spots promoting exercise and health.
Attended and provide educational
materials at community classes.
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to align any intervention
activities
Participate in efforts to improve healthy BMI
among the NHCH employee community.
Providers to educate
patients about the effect of weight on chronic
disease.
Employee nurse educated employees
about healthy weight.
Provided education materials that
communicates the effect of weight on chronic disease
Nutrition Community outreach/education
Support for and Creation of
opportunities
Keiki
Educate and promote
healthy eating
Provided healthy cooking demonstrations.
Supported schools to
provide students with opportunities to engage
in healthy eating
Helped schools empower students with
the knowledge, skills and attitudes that
support and maintain healthy eating behavior
by providing educational materials
Supported integration of school-based activity
programs with family and community life by
providing family oriented activities.
Promoted fruit and
vegetable consumption.
Medical and community-based providers
provided opportunity to
Developed and shared at least one
cooking demonstration to keiki.
Created and provided healthy eating ideas
to at least one school.
Created and provided educational
materials to at least one school.
Provided at least one family based interactive activity.
Created and provided materials to at least one school/community reflecting the
benefit of consuming fruits and vegetables.
Provided education material that
communicates the effect of weight on chronic disease.
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educate patients and
families re: healthy nutrition through
handouts and referral opportunities
Identification of and interventions with
diabetics in the community who require
support for healthy food
purchases
Adult/Senior
Educate and promote
healthy eating
Radio PSAs with varying
focused messages.
Promotion of breastfeeding
Promotion of Community Supported Agriculture
Promote fruit and vegetable consumption.
NHMG & community-
based providers provide opportunity to educate
patients & families re: healthy nutrition through
handouts and referral opportunities.
Create opportunities for
education with partners’
Provider to educate patients who cannot afford fruits/vegetables with referral
sources to acquire these items. (did not complete due to limited resources and lack
of community interest)
Aired radio spot focused on eating healthy
Provided educational materials to
expectant and new mothers of the nutritional importance of breast feeding.
Became Baby Friendly designated.
Provide educational materials for farmers
to hand out at the markets and to include in the CSA boxes distributed throughout
the community. (did not complete due to limited resources
and lack of community interest)
Provided materials to at least one school/community activity reflecting the
benefit of consuming fruits and vegetables.
Provided educational materials to communicate the effect of weight on
chronic disease to patients.
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community support
activities.
Identification of &
interventions with diabetics in the community who require support for healthy food
purchases.
Participate in efforts to
improve healthy eating among the NHCH
employee community.
Provided educational flyer to be included in
the CSA boxes distributed throughout the community by the Food Basket.
Provider to educate patients who cannot afford fruits/vegetables with referrals to resources so they acquire these items. (did not complete due to limited resources and
lack of community interest)
NHCH Café provided healthy eating
options to employees.
3.2 Community Feedback on Prior CHNA or Implementation
Strategy
North Hawaii Community Hospital did not receive any written comments or feedback on the
prior CHNA process however, North Hawaii Community Hospital has received positive feedback
with increased attendance at community activities and demand for additional community
outreach, particularly in the schools.
4 Methods
Two types of data were analyzed for this Community Health Needs Assessment: quantitative
data (indicators) and qualitative data (interviews). Each type of data was analyzed using a
unique methodology, and findings were organized by health or quality of life topic areas. These
findings were then synthesized for a comprehensive overview of the health needs in Hawaii
County.
4.1 Quantitative Data Sources and Analysis
All quantitative data used for this needs assessment are secondary data, or data that have
previously been collected. The main source for the secondary data is Hawaii Health Matters,2 a
publicly available data platform that is maintained by the Hawaii Department of Health, the
Hawaii Health Data Warehouse, and Healthy Communities Institute. As of March 31, 2015,
when the data were queried, there were 327 health and health-related indicators on the Hawaii
Health Matters dashboard for which the analysis outlined below could be conducted. For each
indicator, the online platform includes several ways (or comparisons) by which to assess Hawaii
County’s status, including comparing to other Hawaii counties, all U.S. counties, the Hawaii
state value, the U.S. value, the trend over time, and Healthy People 2020 targets.
2 http://www.hawaiihealthmatters.org
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For this analysis, we have summarized the many types of comparisons with a secondary data
score for each indicator. The indicator scores are then averaged for broader health topics. The
score ranges from 0 to 3, with 0
meaning the best possible score
and 3 the worst possible score,
and summarizes how Hawaii
County compares to the other
counties in Hawaii and in the
U.S., the state value and the U.S.
value, Healthy People 2020
targets, and the trend over the
four most recent time periods of
measure.
Please see Appendix A for further
details on the quantitative data
scoring methodology.
4.1.1 Race/Ethnicity
Disparities
Indicator data were included for
race/ethnicity groups when
available from the source. The
race/ethnicity groups used in this
report are defined by the data sources, which may differ in their approaches. For example,
some sources present data for the Native Hawaiian group alone, while other sources include
this group in the larger Native Hawaiian or Other Pacific Islander population.
The health needs disparity by race/ethnicity was quantified by calculating the Index of Disparity3
for all indicators with at least two race/ethnic-specific values available. This index represents a
standardized measure of how different each subpopulation value is compared to the overall
population value. Indicators for which there is a higher Index of Disparity value are those where
there is evidence of a large health disparity.
4.1.2 Preventable Hospitalization Rates
In addition to indicators available on Hawaii Health Matters, indicators of preventable
hospitalization rates were provided by Hawaii Health Information Corporation (HHIC). These
Prevention Quality Indicators (PQI),4 defined by the Agency for Healthcare Research and
Quality (AHRQ) to assess the quality of outpatient care, were included in secondary data
scoring. Unadjusted rates of admission due to any mental health condition are also presented
as an assessment of the relative utilization of services among subpopulations due to mental
health conditions.
3 Pearcy JN, Keppel KG. A summary measure of health disparity. Public Health Reports.
2002;117(3):273-280.
4 For more about PQIs, see http://qualityindicators.ahrq.gov/Modules/pqi_resources.aspx
Figure 4.1: Secondary Data Methods
17
4.1.3 Shortage Area Maps
Access to care findings are supplemented with maps illustrating the following types of federally-
designated shortage areas and medically underserved populations5:
• Primary care health professional shortage areas
• Mental health professional shortage areas and/or populations
4.1.4 External Data Reports
Finally, several health topic areas were supplemented with quantitative data collected from
previously published reports. This additional content was not incorporated in secondary data
scoring due to the limited number of comparisons possible, but is included in the narrative of
this report for context.
4.2 Qualitative Data Collection and Analysis
The qualitative data used in this assessment consist of key informant interviews collected by
Storyline Consulting. Key informants are individuals recognized for their knowledge of
community health in one or more health areas, and were nominated and selected by the HAH
Advisory Committee in September 2014. Fifteen key informants were interviewed for their
knowledge about community health needs, barriers, strengths, and opportunities (including the
needs for vulnerable and underserved populations as required by IRS regulations). In many
cases, the vulnerable populations are defined by race/ethnic groups, and this assessment will
place a special emphasis on these findings. Interview topics were not restricted to the health
area for which a key informant was nominated.
Key Informants from:
County of Hawaii, Dept. of
Research & Development Hui Mālama Ola Nā ʿŌiwi Puna Community Medical
Center
Department of Health Ka'u Community Rural Health
Association
UH-Hilo, Daniel K. Inouye
College of Pharmacy Department of Health, Office of
Rural Health
North Hawaii Community
Hospital
West Hawaii Community Health
Center Hamakua Health Center North Hawaii Hospice
Hilo Medical Center North Hawaii Outcomes Project
Excerpts from the interview transcripts were coded by relevant topic areas and other key terms
using the qualitative analytic tool Dedoose.6 The frequency with which a topic area was
discussed in key informant interviews was one factor used to assess the relative urgency of that
topic area’s health and social needs.
5 Criteria for medically underserved areas and populations can be found at: http://www.hrsa.gov/shortage/
Data included in this report were accessed June 9, 2015.
6 Dedoose Version 6.0.24, web application for managing, analyzing, and presenting qualitative and mixed
method research data (2015). Los Angeles, CA: SocioCultural Research Consultants, LLC (www.dedoose.com).
18
Please see Appendix A for a list of interview questions.
4.3 Prioritization
In the 2012 study, the CHNA identified 20 areas of community health needs. The Queen’s Health
Systems recognizes the importance of these needs and has supported efforts to address many
of them. One of the major themes presented in the 2015-2016 report is access to care and this
was selected for North Hawaii Community Hospital. Hawaii County has significant unmet
healthcare access needs due to provider shortages, limited oral health services and coverage,
and inadequate coordination in mental health care. Residents also face substantial rates of
poverty and challenges in transportation, further exacerbating access issues.
To promote and improve access to care for the people of Hawai’i Island, North Hawaii Community
Hospital will focus on access through outreach, education, technology, and physician recruitment.
4.4 Data Considerations
Several limitations of the data should be considered when reviewing the findings presented in
this report. Although the topics by which data are organized cover a wide range of health and
health-related areas, within each topic there is a varying scope and depth of quantitative data
indicators and qualitative findings. In some topics there is a robust set of quantitative data
indicators, but in others there may be a limited number of indicators for which data is collected,
or limited subpopulations covered by the indicators. The breadth of qualitative data findings is
dependent on who was nominated and selected to be a key informant, as well as the availability
of selected key informants to be interviewed during the time period of qualitative data collection.
Since the interviews were conducted, some policies may have changed and new programs may
have been implemented. The Index of Disparity is also limited by data availability: for some
indicators, there is no subpopulation data, and for others, there are only values for a select
number of race/ethnic groups. For both quantitative and qualitative data, efforts were made to
include as wide a range of secondary data indicators and key informant expertise areas as
possible.
Finally, there are limitations for particular measures and topics that should be acknowledged.
Measures of income and poverty, sourced from the U.S. Census American Community Survey,
do not account for the higher cost of living in Hawaii and may underestimate the proportion of
residents who are struggling financially. Additionally, many of the quantitative indicators
included in the findings are collected by survey, and though methods are used to best represent
the population at large, these measures are subject to instability—especially among smaller
populations.
5 Demographics
The demographics of a community significantly impact its health profile. Different race/ethnic,
age, and socioeconomic groups may have unique needs and require varied approaches to
health improvement efforts. All estimates are sourced from the U.S. Census Bureau’s American
Community Survey unless otherwise indicated.
19
5.1 Population
In 2013, Hawaii County had a population of 190,821. As measured by the decennial Census,7
its population density is lower than the U.S. average and is the lowest among counties in
Hawaii. Between 2010 and 2013, Hawaii County’s population grew more quickly than the
national average, as shown in Table 5.1.
U.S. Hawaii Hawaii
County
Population, 2013 316,128,839 1,404,054 190,821 Pop. density, persons/sq mi, 2010* 87 212 46
Population change, 2010-2013 2.4% 3.2% 3.1%
*2010 U.S. Census
5.1.1 Age
Hawaii County’s
population is older on
average than the rest of
the state and the country,
with a median age of 41.0
in 2013, compared to
38.1 and 37.5,
respectively. As shown in
Figure 5.1, children under
18 made up 22.3% of the
county’s population
(compared to 22.0% in
the state and 23.3% in
the U.S.), and adults over
65 made up 16.8% of the
population (compared to
15.7% in Hawaii and
14.2% in the U.S.).
5.1.2 Racial/Ethnic Diversity
The race/ethnicity breakdown of Hawaii County is significantly different from the rest of the
country. In Figure 5.2, racial identity is displayed to the left of the line, while Hispanic/Latino
ethnicity (of any race) is shown to the right. Over one in four residents identifies as two or more
races, a proportion higher than both Hawaii and the nation as a whole.
7 United States Census Bureau. (2010). 2010 Census Demographic Profiles. Available from http://www.census.gov/2010census/data/
Table 5.1: Population Density and Change
Figure 5.1 Population by Age, 2013
20
A closer examination
of the multiracial
population in Figure
5.3, in addition to the
single-race
populations, sheds
more light on the
diversity of the
county. Within
Hawaii County,
35.1% of the
population identified
as any part Native
Hawaiian or Pacific
Islander, 43.0% as
any part Asian, and
55.1% as any part White.
Figure 5.2: Population by Race/Ethnicity, 2013
Figure 5.3: Population by One Race Alone or in Combination with Other Races in Hawaii County, 2013
21
Of county residents identifying as one race only in 2013, 34.9% (the largest group) were White
only, compared to 25.6% of the state and 73.7% of the nation. Similar to Hawaii overall,
Black/African American and Other race/ethnic groups were smaller compared to the national
average. While the Hispanic/Latino population was also smaller than the U.S. average, this
group made up a larger share of the population in the county than in the state overall. The
second-largest single race group in the county was Asian, of which the majority comprised
Japanese (11.3%) and Filipino (7.6%) populations (Figure 5.4).
Among the Native Hawaiian and Other Pacific Islander group, the majority identify as Native
Hawaiian (Figure 5.5).
Figure 5.4: Population by Race in Hawaii County: Breakdown of Asian Population, 2013
Figure 5.5: Population by Race in Hawaii County, 2013: Breakdown of Native Hawaiian
and Other Pacific Islander Population, 2013
22
In 2009-2013, 10.9% of Hawaii County was foreign-born, compared to 17.9% of the state and
12.9% of the U.S. In addition, fewer county residents speak a foreign language compared to
Hawaii and the U.S.: in 2009-2013, 18.7% of Hawaii County’s population aged 5 and older
spoke a language other than English at home, lower than Hawaii’s 25.4% and the U.S.’s 20.7%.
5.2 Social and Economic Determinants of Health
5.2.1 Income
The overall income in Hawaii County is low relative to both the state and the nation. The
county’s median household income in 2009-2013 was $51,250, compared to $67,402 in the
state and $53,046 in the nation. At $24,635, per capita income was also lower in Hawaii County
than the U.S. ($28,155) and Hawaii overall ($29,305).
5.2.2 Poverty
Hawaii County experiences a high rate of poverty overall, and Figure 5.6 shows that certain
race/ethnic groups are even more acutely affected. 18.3% of Hawaii County’s population lived
below poverty level in 2009-2013, substantially higher than both the State of Hawaii (11.2%)
and the U.S. average (15.4%). Even given these high rates of poverty, however, it is important
to note that federal definitions of poverty are not geographically adjusted, so the data may not
adequately reflect the proportion of Hawaii County residents who struggle to provide for
themselves due to the high cost of living across the State of Hawaii. For instance, the 2013
median gross monthly rent was $905 in the U.S. but $1,414 in the State of Hawaii.
Note: Populations making up <1% of the total population are not included in this graph
5.2.3 Education
In 2009-2013, 91.0% of the county’s residents aged 25 and older had at least a high school
Figure 5.6: Persons Below Poverty Level by Race/Ethnicity, 2009-2013
23
degree, higher than the Hawaii average of 90.4% and the U.S. average of 86.0%. At the same
time, however, a smaller proportion of Hawaii County residents aged 25 and older had at least a
bachelor’s degree (25.6%) than the state (30.1%) and the nation (28.8%).
5.2.4 SocioNeeds Index®
Healthy Communities Institute developed the SocioNeeds Index® to easily compare multiple
socioeconomic factors across geographies. This index incorporates estimates for six different
social and economic determinants of health that are associated with health outcomes. The data,
which cover income, poverty, unemployment, occupation, educational attainment, and linguistic
barriers, are then standardized and averaged to create one composite index value for every zip
code in the United States with a population of at least 300. Zip codes have index values ranging
from 0 to 100, where zip codes with higher values are estimated to have the highest
socioeconomic need and are correlated with poor health outcomes, including preventable
hospitalizations and premature death. Within Hawaii County, zip codes are ranked based on
their index value to identify the relative level of need within the state, as illustrated by the map in
Figure 5.7. Index values were not calculated for those areas missing on the map below due to
low population count.
The zip codes with the highest levels of socioeconomic need are found in Puna, Kau, and North
and South Hilo. These areas are more likely to experience poor health outcomes.
Figure 5.7: 2015 SocioNeeds Index® for Hawaii County
24
6 Findings
Together, qualitative and quantitative data provided a breadth of information on the health
needs of Hawaii County residents. Figure 6.1 shows where there is strong evidence of need in
qualitative data (in the upper half of the graph); in quantitative data (towards the right side of the
graph); or in both qualitative and quantitative data (in the upper right quadrant).
Figure 6.1: Strength of Evidence of Need
25
Across both data types, there is high evidence of need in the areas of Access to Health
Services and Mental Health & Mental Disorders. Although key informants gave Oral Health a
high level of importance, the topic did not score high in quantitative data, which is likely due to
the poor data availability in this area. Several indicators in the topics Environmental &
Occupational Health and Family Planning contributed to a high quantitative score, but were not
mentioned by key informants due to the specific nature of the health topics.
Each type of data contributes to the findings. Typically, there is either a strong set of secondary
data indicators revealing the most dire health needs, or powerful qualitative data from key
informant interviews providing great insight to the health needs of the community. On rare
occasion, because quantitative data and qualitative data have their respective strengths and
weaknesses, there can be both a strong set of secondary data indicators and qualitative data
from interviews enhancing and corroborating the quantitative data. Findings are discussed in
detail in the report by theme.
Figure 6.2: Topic Areas Demonstrating Strong Evidence of Need
26
Below are tables that list the results of the secondary data scoring, for both Health and Quality
of Life topic areas. Topics with higher scores indicate poor comparisons or greater need.
Health Topic Secondary
Data Score
Disabilities 1.89
Children's Health 1.85
Family Planning 1.80
Access to Health Services 1.77
Environmental & Occupational Health 1.71
Mental Health & Mental Disorders 1.68
Substance Abuse 1.63
Women's Health 1.63
Heart Disease & Stroke 1.62
Respiratory Diseases 1.61
Teen & Adolescent Health 1.60
Immunizations & Infectious Diseases 1.60
Other Chronic Diseases 1.58
Oral Health 1.53
Disabilities 1.89
Children's Health 1.85
Maternal, Fetal & Infant Health 1.49
Prevention & Safety 1.48
Cancer 1.48
Other Conditions 1.48
Exercise, Nutrition, & Weight 1.42
Older Adults & Aging 1.37
Wellness & Lifestyle 1.34
Diabetes 1.27
Men’s Health 1.22
Please see Appendix A for additional details on indicators within these
Health and Quality of Life topic areas.
Table 6.1: Secondary Data Scoring for Health Topic Areas
Table 6.2: Secondary Data Scoring for
Quality of Life Topic Areas Quality of Life Topic
Secondary
Data Score
Economy 2.11
Transportation 1.82
Education 1.79
Environment 1.62
Social Environment 1.62
Public Safety 1.62
27
Below is a word cloud, created using the tool Wordle.8 The word cloud illustrates the themes
that were most prominent in the community input. Themes that were mentioned more frequently
are displayed in larger font. Key informants discussed the areas of Access to Health Services,
Mental Health and Mental Disorders, Transportation, Low-Income/Underserved, and Cultural
Barriers most often.
“People from Micronesian regions” is used throughout this report and intended to be a respectful
reference that includes, but is not limited to, individuals from Micronesian states, Marshall
Islands, Palau, Nauru, and other islands in the region. These individuals may have come to
Hawaii through a Compact of Free Association agreement and may be provided healthcare
benefits.
Note to the Reader
Readers may choose to study the entire report or alternatively focus on a specific major theme.
Each section reviews the qualitative and quantitative data for each major theme and explores
the key issues and underlying drivers within the theme. Due to the abundance of quantitative
data, only the most pertinent and impactful pieces are discussed in the report. For a complete
list of quantitative data included in the analysis and considered in the report, see Appendix A.
Navigation within the themes
At the beginning of each thematic section, key issues are summarized and opportunities and
strengths of the community are highlighted. The reader can jump to subthemes, which
correspond with the topic area categories, or to the key issues within each subtheme, as
illustrated in Figure 6.4.
8 Wordle [online word cloud applet]. (2014). Retrieved from http://www.wordle.net
Figure 6.3: Word Cloud of Themes Discussed by Key Informants
28
Figures, tables, and extracts from qualitative and quantitative data substantiate findings
throughout. Within each subtheme, special emphasis is also placed on populations that are
highly impacted, such as the low-income population or people with disabilities.
Figure 6.4: Layout of Topic Area Summary
29
6.1 Access to Care
Key issues
• High rates of poverty impede access to care
• Shortage of primary and specialty physicians
• Transportation is challenging, on- and off-island
• Lack of mental health integration
• Oral health services are extremely limited for low-income children and adults
Opportunities and Strengths
Need for more translation services Improved cultural competency and translation services could strengthen care
Opportunity to integrate primary care and
mental/behavioral health services
Preventing unnecessary and expensive
travel to receive care off-island could save time and reduce anxiety
6.1.1 Access to Health Services
Health professional shortages
Hawaii County compares poorly to the state on most measures of
provider availability. As seen in Table 6.3, there are fewer medical
doctors, primary care providers, physician assistants, and nurse
practitioners in the county than in Hawaii overall.
Providers per 100,000 residents Hawaii County Hawaii
Practicing Medical Doctors, 2012 67.7 79.7
Primary Care Providers, 2011 74 85 Non-Physician Primary Care Providers, 2013 29 39
Practicing Physician Assistants, 2013 7.9 18.8
Practicing Nurse Practitioners, 2013 24.6 30.4
Many key informants discussed the problem of primary and specialty physician shortages in
Hawaii County. Oncology was identified as an area of particular need by multiple informants,
with one noting that only two oncologists serve the island’s population. This leads to long wait
times for patients’ first appointments and delayed initiation of cancer treatments. A 2010 study
also identified a shortage of obstetrics/gynecology physicians in Hawaii County.9
Other issues discussed by informants were the high cost of liability insurance, lack of
opportunities for physicians-in-training to log clinical hours with appropriate oversight, and the
difficulty of providers staying economically viable. One informant observed that limited access to
care snowballs into other health, social environment, and economic issues. Specifically, delays
9 Family Health Services Division, Department of Health, State of Hawaii. (2010). State of Hawaii
Maternal and Child Health Needs Assessment. Retrieved from: https://mchdata.hrsa.gov/tvisreports/Documents/NeedsAssessments/2011/HI-NeedsAssessment.pdf
Table 6.3: Providers per 100,000 Residents
The statewide physician
shortage is a
public health emergency on
Hawaii Island
30
in care result in more expensive
healthcare utilization because of the
increased severity of potentially
preventable medical issues.
The Health Resources and Services
Administration (HRSA) has designated
areas where there are 3,500 or more
individuals per primary care physician as
Primary Care Health Professional
Shortage Areas (HPSAs).10 By these
criteria, the South Kohala, Kau, and Puna
districts of Hawaii County emerge as
Primary Care HPSAs.
In addition to provider shortages, a key
informant discussed the shortage of
healthcare data accessible to the public,
which prohibits analysis of healthcare
trends.
Health insurance and preventive services
A higher share of adults and children in Hawaii County did not have health insurance compared
to the state: 13.1% of adults in 2013 and 5.4% of children in 2012 were uninsured in the county,
compared to 10.0% and 3.8% in the state, respectively. A key informant noted that coverage for
medications is insufficient.
Among adults, only 83.7% had a usual source of care and only 65.7% had a routine checkup in
2013, both of which compare unfavorably to the state. The Healthy People 2020 target for
percentage of adolescents who receive a physical is 75.6%, which Hawaii County failed to meet
in both its young teen (44.6%) and teen (60.5%) populations in 2013. Only 38.4% of men ages
65 and older in Hawaii County utilized certain preventive services in 2013, below the Healthy
People 2020 target of 44.6%. The services include a flu shot in the past year, a pneumonia
vaccination, and either a colonoscopy/sigmoidoscopy in the past 10 years or a fecal occult
blood test in the past year.
Cultural and linguistic barriers
Key informants called for improved cultural competency
and more translation and interpretation services,
especially in ambulatory care settings. Some cultures
were observed to encourage reliance on traditional
medicine before accessing Western health services.
10 Health Resources and Services Administration Data Warehouse. (Accessed June 9, 2015). HPSA Find. Retrieved from http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx
Figure 6.5: Health Professional Shortage Areas
Patient “noncompliance” is really
a symptom of something we don’t yet know about the patient’s
culture, values, etc.
31
Highly impacted populations
Rural communities: A key informant noted that rural communities typically have lower wages,
lower incomes, and other social factors that lead to poor health. Because access to care is
especially difficult in remote areas, rural residents delay seeking care until their conditions
worsen, leading to fewer healthy days overall. The informant also warned that the closing of
rural hospitals would compound access issues and lead to healthcare deserts.
Race/ethnic groups: One key informant observed that the Hispanic/Latino population is rapidly
growing, and many are seasonal workers on coffee and macadamia nut farms in Hawaii County.
Linguistic barriers, low socioeconomic status, some concerns about deportation, and social
stigma impede this population’s access to health services.
While the uninsured adult population in Hawaii County is already large, the uninsured proportion
is even higher among Filipino (17.8%) and Native Hawaiian (21.5%) adults.
6.1.2 Mental Health
Access to services
Many key informants highlighted mental health as an area of need in
Hawaii County. The resource shortage affects a continuum of care,
from inpatient settings to case management and follow-up supports.
One key informant observed that some individuals with mental health
issues are in the emergency room anywhere from two to six days a
week, often self-referred or brought in by a medic or police officer.
Also discussed was the issue of Medicaid not paying for behavioral
health issues.
HRSA has designated areas where there
are 30,000 or more individuals per
psychiatrist as Mental Health Professional
Shortage Areas (Mental Health HPSAs).11 By these
criteria, much of the Big Island is identified as a Mental
Health HPSA, as seen in Figure 6.6. In addition, the
population living in Puna is identified as facing
substantial barriers in accessing care.
High hospitalization rates in mental health, as further
discussed in Section 6.4.1, further corroborate
insufficient access to mental health services.
Coordination of mental health services
Qualitative data show insufficient coordination of mental
health care. One key informant noted that primary care
physicians cannot adequately address mental health
11 Health Resources and Services Administration Data Warehouse. (Accessed June 9, 2015). HPSA Find. Retrieved from http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx
Figure 6.6: Mental Health
Professional Shortage Areas
There is inadequate
access to high-quality, integrated
mental health
services for all ages
32
issues on their own; they are not equipped to stay current on methods of assessing and treating
depression, anxiety, and substance abuse. Similarly, other key informants called for better
integration of primary care and mental/behavioral health services.
Highly impacted populations
Race/ethnic groups: A key informant shared that there is a particular dearth of mental health
providers who are savvy in addressing cultural issues, especially for the Native Hawaiian
population.
6.1.3 Oral Health
Access to services
In 2011, there were 56 licensed dentists per 100,000 population in Hawaii County, fewer than
both Honolulu County (86) and Maui County (61).12 The Big Island ranked the worst of all
counties in Hawaii on three indicators of adult oral health access; there is also substantial
variation across the county, as seen in Table 6.4.13
Adult Oral Health,
2006, 2008, 2010
Adults with No
Dental Visit
Adults with No
Teeth Cleaning
Adults with
Permanent Teeth Removed
State of Hawaii 26.1% 28.7% 39.9%
Hawaii County 32.7% 38.0% 43.6%
Hilo 30.9% 36.3% 42.3% Puna 35.9% 43.8% 42.5%
Kau 43.3% 49.3% 51.8%
South Kona 37.9% 39.4% 47.8% North Kona 27.0% 29.5% 42.1%
South Kohala 29.0% 36.8% 38.8% North Kohala 26.7% 40.0% 37.5% Hamakua 35.0% 35.7% 48.9%
A large share of the population does not have dental coverage, and even individuals who have
coverage run into insurance limits on scope of services. Furthermore, a key informant observed
a lack of understanding among residents of how oral health impacts overall health.
12 North Hawaii Outcomes Project. (Accessed August 4, 2015). Community Health Profile, Hawaii County.
Retrieved from http://nhop.org/wp-content/uploads/2012/06/R.Master06.06.12.pdf 13 The Hawaii Department of Health. (Accessed August 4, 2015). State of Hawaii Primary Care Needs
Assessment Data Book, 2012. Retrieved from http://health.hawaii.gov/about/files/2013/06/pcna2012databook.pdf
Table 6.4: Adult Oral Health
33
Highly impacted populations
Children, teens, and adolescents: Qualitative evidence
demonstrated the difficulty of accessing oral health
services for children in Hawaii County. The challenges
are compounded for children in low-income
households.
Low-income population: Multiple key informants described the severe lack of oral health care
available to low-income residents of Hawaii County. Many dentists reportedly do not accept
Medicaid. This coverage gap, in combination with a large population of uninsured, low-income
individuals, results in “terrible” oral health for many adults in the county, noted a key informant.
People with disabilities: One key informant noted that the Department of Health provides oral
health services to people with disabilities and mental illness, but that these services are only
available on Oahu and thus require off-island travel to utilize.
6.1.4 Economy
As mentioned in Section 5.2.2, living in Hawaii is costly compared to the rest of the U.S. Even
when using federal guidelines, however, poverty is observed to be highly prevalent in Hawaii
County and impacts all age groups, as seen in Table 6.5.
% Living Below Poverty
Level, 2009- 2013 Hawaii County Hawaii U.S.
Families 13.5% 7.9% 11.3%
People (All Ages) 18.3% 11.2% 15.4% Children (<18 Years) 27.0% 15.4% 21.6%
Adults Ages 65 and Over 9.6% 7.4% 9.4%
Poverty is one of several social and economic determinants of
health, and correlates with limited access to care and poor health
outcomes. In 2013, 12.6% of Hawaii County adults did not visit a
doctor due to cost, compared to 8.6% across the state. Key
informants described the many factors impacting the health of the
low-income population. These individuals must choose between
food, housing, and medication. In addition, many low-income
individuals have lower levels of health literacy and are unable to
self-advocate for healthcare access when needed.
6.1.5 Transportation
Traveling to receive healthcare is a challenge, whether on- or off-island. Key informants
identified the Big Island’s size, geography, lack of public transportation, and limited road
infrastructure as barriers to access. One key informant observed that traffic is a growing
concern that impacts not only cars and buses, but also ambulances in cases of emergency.
Many healthcare services require travel to Honolulu, necessitating time away from work.
Table 6.5: People and Families Living Under Poverty Level
Oral health for many children
raised in poverty is abysmal
The social
determinants of health—
transportation,
education, economic opportunity—all
affect access to
healthcare
34
Highly impacted populations
Low-income population: A key informant noted that people with lower incomes often find lower-
cost housing in more rural areas, where there are fewer services and require longer travel to
healthcare.
Rural communities: Another key informant shared that while transportation issues are
widespread in Hawaii County, the challenges are particularly acute in West Hawaii, Kau, and
Ocean View.
6.2 Chronic Diseases
Key issues
• Limited access to healthy foods and exercise opportunities
• Poor physical activity behaviors among teens
• Poor diabetes management and education, and high hospitalization rates
• High prevalence of heart disease and insufficient early response rates to stroke and heart attack symptoms
• Other areas of need include arthritis and cancer
Opportunities and Strengths
Increase awareness that Electronic Benefit Transfer (EBT) cards are accepted at farmers’
markets
6.2.1 Exercise, Nutrition & Weight
Physical activity
In 2009-2013, Hawaii County had the smallest percentage of workers who walk to work (2.6%)
in the state and failed to meet the Healthy People 2020 target of 3.1%. Hawaii County residents
also have the most limited access to exercise opportunities in the state: only 73.4% of
individuals lived reasonably close to a park or recreational facility in 2013.
Nutrition and access to healthy foods
Within the state, Hawaii County had highest percentage of households that did not have a car
and had low access to a grocery store (2.6% in 2010). In addition, higher percentages of
children, older adults, and low-income individuals in Hawaii County had low access to a grocery
store compared to other U.S. counties. Hawaii County residents experienced the most food
insecurity out of all counties in the state. In 2012, 26.9% of children and 15.0% of the general
population experienced food insecurity at some point in the past
year (compared to the state at 23.9% and 14.2%, respectively). A
key informant observed that lack of education about nutritious food
and limited access and transportation are concerns.
At 33.8% in 2013, Hawaii County had the highest percentage of
overweight adults in the state.
Nutrition is the
underlying basis
of other health problems
35
Highly impacted populations
Children, teens, and adolescents: Physical activity behaviors need to be improved in youth in
Hawaii County. Many teens in the county failed to meet physical activity guidelines (Table 6.6).
The U.S. Department of Health and Human Services recommends at least 60 minutes of
aerobic physical activity every day for children and adolescents. Daily physical education is
extremely low (6.9%) among teens in Hawaii County and across the state compared to the U.S.
and Healthy People 2020 targets.
In addition, many young teens reported spending more than the maximum two hours of screen
time recommended by the American Academy of Pediatrics, an indicator associated with low
physical activity levels. In 2013, 65.3% of young teens (grades 6-8) reported 2 hours or less of
TV time, and 61.5% reported 2 hours or less of computer and video game time; both indicators
failed to meet Healthy People 2020 targets. The percentage of teens (grades 9-12) reporting 2
hours or less of computer and video game time also failed to meet the Healthy People 2020
target (59.6% vs. 82.6%).
Physical Activity indicators,
2013
Hawaii
County Hawaii US Healthy
People 2020
Teens who attend daily physical education 6.9% 7.3% 29.4% 36.6%
Teens who meet aerobic
physical activity guidelines 24.8% 22.0% 27.1% 31.6%
Low-income population: More Hawaii residents who were low-
income had low access to a grocery store compared to other
U.S. counties in 2010. A key informant commented that low-
income people are often working multiple jobs and have longer
commute times because they live in more rural areas, so fast
foods that are quick and inexpensive are very appealing.
6.2.2 Diabetes and Kidney Disease
Diabetes is a cause for concern in Hawaii County; more residents in the county were prediabetic
(13.1%) compared to the state (12.9%) in 2013. In 2011, Hawaii County had the highest rate in
the state for hospitalization due to uncontrolled diabetes at 9.8 per 100,000 population,
compared to the state’s 6.8 hospitalizations per 100,000 population.
Several metrics for diabetes management failed to meet the Healthy People 2020 targets in
2013, including annual foot examination. Foot examination helps prevent diabetes-related
amputation.
Kidney disease is more prevalent in Hawaii County than in the U.S. As of 2013, 2.9% of adults
had been told they had kidney disease (not including kidney stones, bladder infection, or
incontinence), compared to 2.5% of U.S. adults.
Table 6.6: Physical Activity Among Teens
Hawaii Island leads the
state in diabetes and chronic disease – a direct
reflection of leading the
state in poverty.
36
Highly impacted populations
Race/ethnic groups: The age-adjusted
death rate due to diabetes was nearly
five times higher in 2011-2013 among
Native Hawaiians and other Pacific
Islanders than the county overall (73.3
vs. 14.8 deaths per 100,000
population).
6.2.3 Heart Disease & Stroke
High blood pressure and high cholesterol
High blood pressure and high cholesterol are major modifiable risk factors for heart disease and
stroke. As shown in Table 6.8, prevalence among adults in Hawaii County fail to meet Healthy
People 2020 targets. Furthermore, only 75.0% of Hawaii County adults in 2013 had their blood
cholesterol checked within the past five years, failing to meet the Healthy People 2020 target of
82.1%.
In 2011, 37.6 adults per 100,000 in Hawaii County were hospitalized for hypertension, which
was higher than the rate for Hawaii overall, 26.7 hospitalizations per 100,000 population.
Cardiovascular disease
In 2013, Hawaii County had the highest rates in the state for heart attacks and coronary heart
disease (Table 6.9).
Hawaii County Hawaii
Heart Attacks, 2013 4.2% 3.2%
Coronary Heart Disease, 2013 3.9% 2.7%
Recognizing the early signs and symptoms of a heart attack or stroke and responding quickly is
imperative to preventing disability and death. Quantitative data suggest that this is an area of
need. Table 6.10 presents indicators gauging awareness of symptoms and importance of
response among Hawaii County residents; these fall below state averages and do not meet
Healthy People 2020 targets. In addition, Hawaii County had the highest death rates in the state
for stroke (38.6 deaths per 100,000 population) and congestive heart failure (15.0 deaths per
100,000 population) in 2011-2013.
Percentage of adults with diabetes in 2013
who:
Hawaii County Hawaii Healthy People
2020
Have received formal diabetes education 48.3% 46.9% 62.5%
Have their feet checked 69.3% 71.6% 74.8%
Table 6.7: Diabetes Management
Table 6.8: Prevalence of High Blood Pressure and High Cholesterol
Hawaii County Hawaii HP2020
High Blood Pressure Prevalence, 2013 29.1% 28.5% 26.9%
High Cholesterol Prevalence, 2013 36.9% 34.9% 13.5%
Table 6.9: Prevalence of Cardiovascular Diseases
37
Among survivors of heart attack or stroke in Hawaii County, the rates of referral to any kind of
outpatient rehabilitation— to help regain lost skills and independence—were relatively low when
compared to the state and nation (Table 6.11).
Highly impacted populations
Race/ethnic groups: Native Hawaiians and Other Pacific Islanders have the highest death rates
due to stroke and heart disease.
*per 100,000 population
6.2.4 Arthritis
In 2013, Hawaii County had the highest percentages in the state for adults reporting various
limitations due to arthritis (Table 6.12).
Awareness of Symptoms, 2009 Hawaii County Hawaii U.S. Healthy People 2020
Stroke
Early symptoms 39.2% 41.8% 43.6% 59.3%
Early symptoms and calling 911 37.0% 37.5% 38.1% 56.4% Heart attack
Early symptoms 28.5% 30.4% 30.6% 43.6%
Early symptoms and calling 911 26.8% 27.7% 26.9% 40.9%
Table 6.10: Awareness of Symptoms and Response to Stroke or Heart Attack
Outpatient Rehabilitation Rates, 2013 Hawaii County Hawaii U.S.
Heart Attack 12.4% 19.1% 34.7% Stroke 21.7% 23.5% 30.7%
Table 6.11: Outpatient Rehabilitation for Heart Attack of Stroke Survivors
Death rate* Hawaii County Asian Nat. Hawaiian/ Pac. Islander. White
Heart disease, 2013 79.8 85.8 249.2 62.2
Stroke, 2011-2013 38.6 42.6 103.7 32.8
Table 6.12: Highly Impacted Populations, Heart Disease and Stroke Death Rates
Limitations due to Arthritis, 2013 Hawaii County Hawaii
Work Limitations 38.3% 31.1%
Activity Limitations 40.3% 37.8%
Social Limitations 36.4% 35.3%
Table 6.12: Limitations due to Arthritis
38
6.2.5 Cancer
Quantitative data indicate that oropharyngeal cancer, liver and bile duct cancer, and melanoma
are areas of concern in the general population, as shown in Table 6.13, with rates for Kauai
County higher than state or national rates. Among women, cervical cancer and preventive
services (mammograms, Pap smears, and HPV vaccination) emerge as areas of need (further
discussed in Section 6.5.3).
Hawaii
County Hawaii U.S. HP2020
Cervical Cancer Incidence Rate, 2007-2011* 8.4 7.3 7.8 7.1
Cervical Cancer Death Rate, 2009-2013** 2.5 2.3 2.3 2.2 Oropharyngeal Cancer Death Rate, 2011-2013** 3.6 2.6 2.5 2.3
Liver and Bile Duct Cancer Incidence Rate, 2007-2011* 9.0 10.6 7.1 -
Melanoma Incidence Rate, 2007-2011* 25.3 25.0 19.7 -
Melanoma Death Rate, 2011-2013** 2.3 1.5 2.7 2.4
*cases per 100,000 population **deaths per 100,000 population
The U.S. Preventive Services Task Force advises that adults ages 50 to 75 have a blood stool
test every year, a sigmoidoscopy every five years with a blood stool test every three years, or a
colonoscopy every 10 years. Colon cancer detection is low in Hawaii County: only 63.7% of
adults ages 50 to 75 met the recommendations for colorectal cancer screening in 2013, falling
below the state average (66.4%) and the Healthy People 2020 target (70.5%).
Highly impacted populations
Race/ethnic groups: The Native Hawaiian and Other Pacific Islander group experienced the
highest mortality from breast and prostate cancer in 2011-2013. White residents of Hawaii
County have the highest incidence rate for melanoma.
Hawaii County Highly impacted groups
Melanoma Incidence Rate,
2007-2011* 25.3 White: 52.6
Breast Cancer Death Rate,
2011-2013** 15.9 Native Hawaiian/Other Pac. Islander: 56.6
Prostate Cancer Death Rate, 2011-2013** 15.2 Native Hawaiian/Other Pac. Islander: 36.1 White: 17.0
*cases per 100,000 population
**deaths per 100,000 population
Table 6.13: Cancer Incidence and Death Rates
Table 6.14: Highly Impacted Populations, Cancer
39
6.3 Environmental Health & Respiratory Diseases
Key issues
• Poor air quality
• High rates of ED visits due to asthma
6.3.1 Environment
Active volcanoes in the county produce sulfur dioxide and negatively impact air quality, which in
turn affects respiratory health. The American Lung Association gave Hawaii County an F grade
for the number of days that exceeded US standards for particle pollution in 2010-2012. In
addition, there were 254 days in 2013 of unsatisfactory air quality, defined as days in which the
Air Quality Index (AQI) is over 100. The AQI is a scale from 0 to 500; a value of 300 or greater
indicates emergency conditions. Furthermore, a key informant noted that lava flow threatens
infrastructure and services.
In 2006-2010, 27.3% of households in Hawaii County experienced severe housing problems.
These problems include overcrowding, high housing costs, lack of kitchen, or lack of plumbing
facilities. Compared to the state, a larger share of adults in Hawaii County did not smoke but
were exposed to secondhand smoke in a car or at home (15.7% vs. 13.8%).
6.3.2 Respiratory Diseases
Asthma
Asthma prevalence is high among both adults and children in Hawaii County. As of 2013, 10.1%
of adults and 16.8% of children had asthma, compared to 9.4% and 12.8% in the state overall.
Rates of emergency room visits for asthma are high across many segments of the Hawaii
County population, suggesting poor management of the disease.
Hawaii County Hawaii
Healthy
People 2020 Target
ED Visits for Asthma Among Children <5
Years Old per 10,000 children, 2011 150.0 119.4 95.7
ED Visits for Asthma Among Population Ages 5-64, 2011 70.6 44.6 49.6
ED Visits for Asthma Among Population
Ages 65 Years and Over, 2011 52.0 30.0 13.7
COPD
In 2013, 6.8% of adults aged 45 and older in Hawaii County had been told that they had chronic
obstructive pulmonary disease (COPD), emphysema, or chronic bronchitis, which is slightly
higher than both the state (6.3%) and the nation (6.5%) overall.
Table 6.15: ED Visits due to Asthma
40
Highly impacted populations
Race/ethnic groups: Prevalence of asthma is even higher among adults of Native Hawaiian
descent. In 2013, 17.5% of Native Hawaiian adults were told by a healthcare provider that they
currently have asthma, compared to 10.1% of all adults in Hawaii County.
41
6.4 Mental Health & Health Risk Behaviors
Key Issues
• Limited access to mental health and substance abuse resources
• High rates of preventable injuries
• Heavy drinking and smoking
• Substance abuse among teens
• High rates of intimate partner violence
Opportunities and Strengths
Need to address the connections between
mental health, domestic violence, and
substance abuse
High rates of injury could be reduced by
addressing mental health and substance
abuse needs
More substance abuse resources are needed
6.4.1 Mental Health & Mental Disorders
As noted in Section 6.1.2, multiple key informants highlighted the lack
of mental health resources as a major issue in Hawaii County.
According to data provided by Hawaii Health Information Corporation,
there were 756 hospitalizations due to mental health per 100,000
hospitalizations in Hawaii County in 2011; this was the highest rate in
the state, suggesting a need for more preventive services in this area.
Table 6.16 shows the percentage of total hospital admissions due to
various mental illnesses and disorders in 2006-2010.
Percent of Hospital Admissions in
2006-2010 due to:
Hawaii
County
Schizophrenia 2.7%
Mood Disorder 8.0% Delirium/Dementia 7.1%
Anxiety 3.3%
In addition, Hawaii County has the highest rate of suicide in the state: at 19.6 deaths per
100,000 population in 2011-2013, the county compared very poorly to the state and national
rates of 10.9 and 12.6 deaths per 100,000 population, respectively.
Highly impacted populations
Children, teens, and adolescents: Concerns for teens include bullying, cyber-bullying, and
suicide. As seen in Table 6.17, Hawaii County performs poorly on these indicators when
compared to national values or Healthy People 2020 targets.
14 The Hawaii Department of Health. (Accessed August 4, 2015). State of Hawaii Primary Care Needs
Assessment Data Book, 2012. Retrieved from http://health.hawaii.gov/about/files/2013/06/pcna2012databook.pdf
Table 6.16: Hospitalizations due to Mental Health14
There are huge
substance abuse
and mental health challenges
42
Race/ethnic groups: The 2011-2013 suicide death rate among residents aged 15 and older was
also much higher among residents of Native Hawaiian or Other Pacific Islander descent, as
seen in Table 6.18. Suicide rates in the White population were also higher than the county
average.
Hawaii
County Asian Nat. Hawaiian/
Other Pac. Islander White
Suicide Death Rate per 100,000
population, 2011-2013 19.6 9.4 53.3 25.6
6.4.2 Substance Abuse
Qualitative data emphasized the close ties between substance
abuse and mental health issues in Hawaii County. A key
informant linked the lack of accessible, high-quality mental
health care to chemical dependency and problematic chemical
use. Another key informant observed that poverty makes it
difficult for people to make responsible choices, leading to
substance abuse problems and mental health challenges.
In 2013, 17.6% of adults in the county reported smoking cigarettes, compared to 13.3% of
adults in Hawaii. The percentages of adult smokers have attempted to or successfully quit
smoking are lower than state averages, as seen in Table 6.19. A key informant observed that
the rates of marijuana use are high.
Hawaii
County Hawaii U.S. HP2020
Target
Adults who Attempted to Quit Smoking, 2013 53.4% 61.6% 51.8% 80.0%
Adults who Recently Quit
Smoking, 2013 8.2% 15.3% 6.3% 8.0%
2013 Mental Health Indicators Hawaii County Hawaii US HP2020
Young teens (grades 6-8) who are
bullied 50.6% 44.6% - -
Teens (grades 9-12) who are bullied 23.5% 18.7% 19.6% 17.9%
Teens who are cyber-bullied 15.7% 15.6% 14.8% -
Teens who attempted suicide 3.9% 3.2% 2.7% 1.7%
Table 6.17: Teen Mental Health
Table 6.18: Highly Impacted Populations, Suicide Death Rate
Table 6.19: Adults who Attempted to or Successfully Quit Smoking
People who feel they don't
have a future are more likely to engage in
substance abuse, including
alcohol and cigarettes.
43
However, the State of Hawaii recently took action to deter smoking by increasing the smoking
age to 21 in June 2015, becoming the first U.S. state to do so.15
Excess alcohol consumption has major health impacts on Hawaii County adults. In 2013, 7.4%
of adults reported drinking heavily, defined as having more than one drink per day on average
for women and having more than two drinks per day on average for men. This compared
unfavorably to the national average of 6.2%. Alcohol was involved in 47.0% of all motor vehicle
crash deaths in 2008-2012, placing Hawaii County in the worst quartile of all U.S. counties. The
death rate due to cirrhosis, a liver disease often linked to heavy alcohol use, was 10.8 deaths
per 100,000 population in 2011-2013—also higher than the state (6.7) and the nation (10.2)
overall. Indicators of alcohol use among pregnant women show that this is an area for
improvement (Section 6.5.1).
The rate of deaths due to drug poisoning, which is often linked to prescription drugs, is higher in
Hawaii County than any other county in the state. In 2004-2010, there were 12.1 deaths per
100,000 population in the county, compared to 9.3 in the state overall.
Access to treatment
In 2006-2010, 11.4% of hospital admissions in Hawaii County
were due to a substance-related disorder, comparing unfavorably
to Hawaii’s average of 8.9%.16 This suggests a need for more
resources to address substance abuse issues before they
become acute. Key informants noted the lack of treatment
resources on the island, including no detoxification services at all.
Highly impacted populations
Children, Teens, and Adolescents: A key informant observed that youth in Hawaii County are
experimenting with using alcohol and smoking, especially vapor cigarettes. The quantitative
data corroborate high rates of substance use among teens when compared to the state and/or
nation.
Hawaii
County Hawaii U.S. HP 2020
Target
Teens Who Never Used Illicit Drugs, 2013 50.1% 56.4% 50.1% 58.6%
Teens who Use
Marijuana, 2013 23.6% 18.9% 23.4% 6.0%
Young Teens who Use
Marijuana, 2013 14.6% 7.5% - 6.0%
15 Skinner, C. (2015, June 20). Hawaii becomes first U.S. state to raise smoking age to 21. Reuters. Retrieved from: http://www.reuters.com/article/2015/06/20/us-usa-hawaii-tobacco-
idUSKBN0P006V20150620
16 The Hawaii Department of Health. (Accessed August 4, 2015). State of Hawaii Primary Care Needs
Assessment Data Book, 2012. Retrieved from http://health.hawaii.gov/about/files/2013/06/pcna2012databook.pdf
Table 6.20: Substance Abuse among Teens
Access to and availability of providers
for substance abuse
services is abysmal
44
Hawaii County Hawaii U.S. HP 2020 Target
Illegal Drugs on School
Property, 2013 31.6% 31.2% 22.1% 20.4%
Young Teens who
Smoke Cigarettes, 2013 7.7% 5.2% - -
Teens who Use Alcohol, 2013 31.7% 25.2% 34.9% -
Teens who have Used
Methamphetamines, 2013 4.8% 4.3% 10.6% -
Binge Drinking Among
Teen Girls, 2013 14.5% 12.9% 19.6% 8.6%
Binge Drinking Among
Teen Boys, 2013 11.4% 10.6% 22.0% 8.6%
Race/ethnic groups: Substance use disproportionately impacts Hawaii County residents of
Native Hawaiian descent.
Hawaii
County Highly Impacted Groups
Adults who Smoke Cigarettes, 2013 17.6% Native Hawaiian: 36.6%
Heavy Drinking, 2013 7.4% Native Hawaiian: 13.3%
Drug-Induced Deaths, 2011-
2013
10.7 deaths per 100,000
population
Nat. Hawaiian or Other Pac. Islander: 20.5%
White: 18.7%
Teens who have Used Methamphetamines, 2013 4.8% Native Hawaiian: 5.7%
6.4.3 Wellness & Lifestyle
In 2013, a smaller proportion of adults in Hawaii County reported having good health (85.0%)
than in the state overall (86.2%). In addition, only 62.1% of adults in the county reported that
they got sufficient sleep—defined as seven or more hours of sleep on average—compared to
69.3% in the U.S. As a result of insufficient sleep, these residents may be at higher risk of
chronic disease and depression. Many young teens in Hawaii County watch more than the
recommended daily amount of TV compared to the state, which is associated with physical
inactivity and health problems like obesity and irregular sleep patterns.
6.4.4 Prevention & Safety
Many accidental deaths could be averted through behavioral change or improved safety
education in Hawaii County. The injury death rate, 62.4 deaths per 100,000 population in 2011-
2013, was the highest of any county in the state. The rate of hospitalizations due to
unintentional injuries (398 per 100,000 population in 2009) was also the highest in the state, as
Table 6.21: Highly Impacted Populations, Drug-Induced Deaths
45
was the 2007-2011 rate of emergency department visits for nonfatal injuries due to assault (450
per 100,000 population).
The 2009-2013 drowning death rate in Hawaii County was more than
double the state rate, at 4.4 deaths vs. 2.0 deaths per 100,000
population. A key informant observed that spinal injuries are
increasing due to cliff jumping.
Between 2011-2013, there were 27.1 deaths per 100,000 adults ages
35-54 due to poisoning, higher than the state rate of 20.6.
Motor vehicle and pedestrian safety
The rate of motor vehicle collision deaths is much higher in Hawaii County than the rest of the
state: in 2010-2012, there were 16.6 deaths per 100,000 population in the county, compared to
8.6 in Hawaii overall. The rate of hospitalizations due to motor vehicle collisions was also higher
in the county.
In 2007-2011, there were 934 nonfatal injuries due to motor vehicle
collisions per 100,000 Hawaii County residents; this was more than
double the state rate of 433 injuries per 100,000 population. The
rate of pedestrians suffering nonfatal injuries in the same time
period (45.5 per 100,000 population) was also higher than the state
average (37.3) and much higher than the national average (24.3).
A key informant attributed the high rates of motor vehicle injuries
and deaths to limited mental health and substance abuse services
on the island.
Sexual and physical abuse
In 2013, 1.5% of adults reported that someone exposed them to unwanted sexual situations that
did not involve physical touching within the past year, the highest percentage of any county in
Hawaii. Indicators of intimate partner violence show that both sexual and physical violence are
issues in Hawaii County. In 2013, 11.5% of adults in the county reported experiencing physical
violence at the hands of a current or former intimate partner (vs. 9.5% in the state), while 4.5%
reported experiencing sexual violence (vs. 3.6% in the state).
Highly impacted populations
Race/ethnic groups: Large disparities by race/ethnicity are evident for many injury-related
indicators. The rate of mortality due to injury is highest among the Native Hawaiian or Other
Pacific Islanders group.
There are more head
injuries that result from high-velocity
crashes: people text
while driving and don’t decrease speed
prior to crashing
There is a lack of
first responders; public safety is
very limited
46
6.4.5 Immunizations & Infectious Diseases
In Hawaii County, a number of vaccination rates fall short of state and national comparisons, as
seen in Table 6.23:
Vaccination Rates, 2013 Hawaii County Hawaii U.S.
Influenza Vaccination Rate Ages 18-64 33.0% 40.3% 33.1%
Influenza Vaccination Rate Ages 65+ 62.4% 69.9% 62.8%
HPV Vaccination 7.3% 11.9% 10.6%
HIV/AIDS
Among adults ages 18-44 in Hawaii County, 42.0% had ever been tested for HIV as of 2013,
which compared unfavorably to the national average of 50.0% and failed to meet the Healthy
People 2020 target of 73.6%.
Table 6.22: Highly Impacted Populations, Prevention and Safety
Death Rates per 100,000 population
Hawaii
County Highly Impacted Groups
Drowning Death Rate, 2009-2013 4.4 Native Hawaiian or Other Pacific Islander: 15.3 Asian: 5.1
Injury Death Rate, 2011-
2013 62.4
Native Alaskan/American Indian: 171.7
Native Hawaiian or Other Pacific Islander: 170.1 White: 73.6
Motor Vehicle Collision
Death Rate, 2010-2012 16.6 Native Hawaiian or Other Pacific Islander: 43.9 Asian: 19.6 White: 17.0
Poisoning Death Rate, 2011-2013 12.3 Native Hawaiian or Other Pacific Islander: 22.5 White: 21.7
Unintentional Injury Death
Rate, 2011-2013 34.3 Native Hawaiian or Other Pacific Islander: 88.9
White: 37.7 Firearm-Related Death
Rate, 2011-2013 5.7 Native Hawaiian or Other Pacific Islander: 16.5
White: 8.2
Table 6.23: Vaccination Rates among Adults
47
6.5 Women’s, Infant, & Reproductive Health
Key issues
• Poor birth outcomes including preterm births and infant deaths
• Substance use among pregnant women
• High rates of pregnancy among Native Hawaiian and Pacific Islander teens
• High rates of cervical cancer incidence and death
6.5.1 Maternal, Fetal, & Infant Health
Prenatal care & poor birth outcomes
In 2013, 30.0% of mothers received late or no prenatal care in Hawaii County – over twice the
state value (14.1%), and failed to meet the Healthy People 2020 Target (22.1%).
32.8% of Hawaii County births in 2013 were delivered by Cesarean section, which was higher
than Hawaii (25.6%) and the U.S. (26.9%). At 15.8%, Hawaii County had the highest
percentage of Cesarean section births to low-risk mothers with no prior Cesarean section in the
state (“low risk” is defined as a full-term singleton pregnancy with vertex presentation).
Recovery from a Cesarean section takes longer than a vaginal birth, and also carries a higher
risk of complications.
Hawaii County had the highest percentages in the state for preterm births (less than 37 weeks
of gestation) and very early preterm births (less than 32 weeks of gestation).
The rates of death due to birth defects and sudden unexpected infant deaths were higher in the
county than the state, and failed to meet Healthy People 2020 targets.
Infant deaths due to: Hawaii
County Hawaii HP2020
Sudden Infant Death Syndrome (SIDS), 2007-2011* 0.6 0.2 0.5 Sudden Unexpected Infant Deaths, 2006-2008* 1.1 0.9 0.8
All Birth Defects, 2009-2013* 1.2 0.7 1.3
*deaths per 1,000 live births
In 2011, Hawaii County had the lowest percentage in the state for breastfed infants who were
still receiving breast milk eight weeks after birth (74.7%).
Substance abuse
Smoking and drinking during pregnancy are areas of concern for Hawaii County. A high
percentage of pregnant mothers (7.0%) smoked compared to Hawaii overall (4.3%) in 2013. In
Preterm Births, 2011-2013 Hawaii County Hawaii
Preterm Births 10.4% 10.1%
Very Early Preterm Births 2.5% 2.3%
Table 6.24: Preterm Births
Table 6.25: Infant Deaths
48
2011, a greater percentage of women in Hawaii County (28.1%) reported binge drinking during
the three months prior to pregnancy than in the state overall (24.0%).
Highly impacted populations
Race/ethnic groups: Indicators of maternal smoking and preterm births show Pacific Islanders
and Native Hawaiians are faring the most poorly.
Hawaii
County Highly Impacted Groups
Mothers who Smoked During Pregnancy, 2013 7.0% Native Hawaiian: 12.0% Native Alaskan/American Indian: 10.3%
Early Preterm Births, 2011-2013* 0.8% Other Pacific Islander: 2.2%
*32-33 weeks of gestation
6.5.2 Family Planning and Teen Sexual Health
Delayed sexual initiation among teen boys and girls, as measured by abstinence from sex, fails
to meet Healthy People 2020 targets. In 2013, 60.0% of teenage girls and 58.8% of teenage
boys reported abstinence compared to the respective Healthy People 2020 targets of 80.2%
and 79.2%. In addition, condom usage is lower among teen girls in Hawaii County than
nationwide. Among adolescent females in public school grades 9-12 who had sex in the past
month, only 41.1% used a condom, compared to 53.1% nationally; this percentage also fails to
meet the Healthy People 2020 target of 55.6%. At 31.0 births per 1,000 women aged 15-19
years, Hawaii County had the highest teen birth rate out of all counties in the state in 2013.
Hawaii County Hawaii
Teen Birth Rate, 2013* 31.0 25.0
Infants Born to Mothers with <12 Years Education, 2013 12.7% 6.6%
*births per 1,000 women ages 15-19
The percentage of intended pregnancies, 52.8% in 2011, fell short of the Healthy People 2020
target of 56.0%.
Highly impacted populations
Race/ethnic groups: Births to teen mothers of Native Hawaiian and Other Pacific Islander
descent occur at five times the average county rate, as shown in Table 6.28. The percentage of
births to Pacific Islander mothers with fewer than 12 years of education was over double the
Hawaii County average of 7.6%.
Table 6.26: Highly Impacted Populations, Maternal Smoking and Early Preterm Births
Table 6.27: Births to Teens and Mothers without High School Diplomas
49
*births per 1,000 women ages 15-19
6.5.3 Women’s Health
Preventive Services
In 2013, the percentage of women ages 40 and over who received a mammogram in the past
two years (77.9%) fell below the state average (80.4%). At 81.0%, the percentage of women
aged 18 years and older who had a Pap test in the past three years failed to meet the Healthy
People 2020 target (93.0%) in 2013. Hawaii County had the lowest percentage (7.3%) in the
state for adults aged 18 to 49 years who have received at least one dose of the human
papillomavirus (HPV) vaccine in 2013.
Cancer
Compared to both the state and nation, cervical cancer incidence and death rates are high in
Hawaii County. In 2007-2011, the incidence rate was 8.4 cases per 100,000 women, and there
were 2.5 deaths per 100,000 women in 2009-2013. Both incidence and death rates failed to
meet their respective Healthy People 2020 targets of 7.1 cases per 100,000 women and 2.2
deaths per 100,000 women.
Highly impacted populations
Race/ethnic groups: In 2011-2013, there were 15.9 deaths per 100,000 females due to breast
cancer in Hawaii County overall. The rate was highest among Native Hawaiian and Pacific
Islander women, at 56.6 deaths per 100,000 females.
7 A Closer Look at Highly Impacted Populations
Several subpopulations emerged from the qualitative and quantitative data for their disparities in
access to care, risk factors, and health outcomes. This section focuses on these subpopulations
and their unique needs.
Hawaii
County Highly Impacted Groups
Teen Birth Rate, 2013* 31.0 Native Hawaiian/Pacific Islander: 150.1 Asian: 31.5
Infants Born to Mothers with <12 Years Education, 2013 12.7%
Other Pacific Islander: 31.0%
Other: 22.7% Native Hawaiian: 14.3%
Native Alaskan/American Indian: 13.0%
Table 6.28: Highly Impacted Populations, Births to Teens and Mothers without High School Diplomas
50
7.1 Children, Teens, & Adolescents
Key issues
• Low access to care and poor oral health
• Low access to healthy foods and poor physical activity behaviors
• High burden of asthma
• Teen mental health and substance use
• High rates of teen birth and low condom use among teen girls
Opportunities and strengths
Dental base at the WIC site in Kona does assessments for children
Hawaii County experiences higher mortality rates among its
children and adolescent populations than the state, at 13.9 deaths
per 100,000 children ages 5-9 in 2009-2013 (vs. 9.8), 19.5 deaths
per 100,000 adolescents ages 10-14 in 2009-2013 (vs. 13.5), and
72.5 per 100,000 teens ages 15-19 in 2011-2013 (vs. 39.8). In
addition, multiple key informants observed that the social
environment is insufficient: Hawaii County lacks a vibrant
community and educational opportunities for children, and needs
integrated, stimulating childcare and after-school programs.
7.1.1 Access to Care
As discussed in Section 6.1, health insurance coverage is low among children under 18 and few
teens and young teens receive a routine physical, failing to meet the Healthy People 2020
target. A key informant remarked that the lack of healthcare among children may be a
manifestation of a combination of remote location, no transportation, and low-income status.
7.1.2 Oral Health
Studies show that children on Hawaii Island experience twice as much tooth decay than the
national average, cited a key informant. Oral health is especially challenging for children raised
in poverty.
7.1.3 Disabilities
A key informant described the lack of assessments available for children with learning
challenges and the belief that children with disabilities cannot learn or improve as challenges for
this population.
7.1.4 Nutrition & Physical Activity
Children in Hawaii County have limited access to grocery stores and experienced high rates of
food insecurity compared to the state as discussed in Section 6.2.1. Qualitative data corroborate
this: according to a key informant, children have inadequate access to food and nutrition and
must arrive to school early to eat breakfast. In addition, teenagers failed to meet physical activity
Hawaii Island doesn't have a vibrant
community or
education for our children
51
guidelines, and also had excessive screen time.
7.1.5 Asthma
Asthma prevalence among children is higher in Hawaii County compared to the state, and high
rates of emergency room visits for asthma among children under 5 years of age (as shown in
Section 6.3.2) indicate poor management of the condition.
7.1.6 Mental Health & Substance Abuse
As seen in Section 6.4.1, cyber-bullying, bullying, and attempted suicide are concerns for teens
in Hawaii County. Use of alcohol, tobacco, and illicit drugs among Hawaii County adolescents is
also an area for improvement, as shown in Section 6.4.2.
7.1.7 Prevention and Safety
Usage of child safety seats in cars is low in the county compared to the state, and the proportion
of teens using sunscreen in Hawaii County fails to meet the Healthy People 2020 target.
7.1.8 Teen Pregnancy and Sexual Health
Delayed sexual initiation, as measured through abstinence from sex among teen boys and girls,
compares unfavorably to the Healthy People 2020 target. In addition, condom use among teen
girls is low compared to the national average, and Hawaii County has the highest teen birth rate
compared to other Hawaii counties (Section 6.5.2).
7.2 Older Adults
Key Issues
• Lack of care services, infrastructure, and support systems
• Low utilization of preventive services among older men and women
• High percentages of seniors living alone or in poverty
Opportunities and Strengths
Need long-term beds, home health care, and community-based services
7.2.1 Access to Care
According to a key informant, the elderly population in Hawaii County is growing and struggles
with transportation and thus accessing care. Another key informant observed that lack of access
to medical care results in people becoming so ill that they become hospice eligible without ever
having received appropriate treatment.
Multiple key informants expressed concern over the lack of long-term care facilities. The lack of
long-term beds causes a backup in acute care; acute beds are filled with long-term patients, and
acute patients are held in the ER until acute beds become available. Moreover, another key
informant observed that seniors who live alone without a significant other and have limited
financial resources are not Medicaid eligible, but cannot afford private long-term care.
52
Another key informant commented that services for the elderly are
inadequate – there is no skilled nursing facility, and no home and
community-based services. Another key informant expressed
concern over the lack of infrastructure and support systems that
allow the elderly to age in place, such as home care services, home
telehealth, assisted living options, and sidewalks in rural areas.
Quantitative data suggest that preventive services are accessed insufficiently. In 2013, only
38.4% of men and 42.9% of women ages 65 and over reported receiving preventive services (a
flu shot in the past year, a pneumonia vaccination ever, and either a colonoscopy/
sigmoidoscopy in the past 10 years or a fecal occult blood test in the past year; and for women,
a mammogram in the past 2 years as well).
7.2.2 Chronic Diseases
The Medicare population in Hawaii County experiences high rates of hyperlipidemia (47.7% in
2012) and asthma (5.3% in 2012). Hawaii County had the highest rate for emergency
department visits due to asthma in the state (Table 7.1).
*visits per 10,000 population 65+ **deaths per 1,000,000 population 65+
7.2.3 Safety
A key informant observed many comorbidities with falls; fall patients usually do not die from the
fall itself, but from associated complications like infections and pneumonia.
7.2.4 Social Environment
Seniors in Hawaii County face challenges in housing and food security. Many seniors live alone
without significant others to support them, according to a key informant. Quantitative data
corroborate the observation: 9.2% of seniors lived alone in 2010, the highest value in the state
(8.6% average).17 In addition, 5.5% of people 65+ had low access to a grocery store in 2010,
higher than the median value of U.S. counties (2.8%). At 9.6%, Hawaii County had the highest
percentage in the state of people 65+ living below poverty level in 2009-2013.
7.3 Low-Income Population
Key issues
• Issues of access to health services are exacerbated and result in poor outcomes
• Poor oral health and behavioral health issues
17North Hawaii Outcomes Project. (Accessed October 5, 2015). Hawaii County Community Health Profile, 2012. Retrieved from http://nhop.org/wp-
content/uploads/2012/06/R.Master06.06.12.pdf
Hawaii County Hawaii HP2020
ED Visits for Asthma, 2011* 52.0 30.0 13.7
Asthma Death Rate, 2004-2013** 38.9 36.7 21.5
Table 7.1: ED Visits and Deaths due to Asthma Among Seniors
The tsunami of need among the elderly is
growing, and no one
is planning for it
53
Opportunities and strengths
Increase dentists who take Medicaid patients through policy change
Expand dental chairs in collaboration with
Federally Qualified Health Centers, which accept Medicaid patients
Across the qualitative data, issues of access to health services, which are exacerbated for the
low-income population, emerged as a common theme. Key informants observed that barriers for
this population include: inadequate Medicaid and health insurance coverage for behavioral
health and oral health services; too few medical providers, behavioral health providers, and
dentists accepting Medicare or Medicaid; and lower health literacy and health navigations. Poor
access to services results in delayed diagnosis and treatment, worsened conditions,
unnecessary hospital visits, and hastened death, according to key informants.
Multiple key informants additionally observed that the low-income population and the rural
population are commonly one and the same. People with lower incomes in rural areas may not
have a car or any reliable alternatives, and face transportation barriers to healthcare services,
as well as to food and other basic services, as discussed in Section 6.1. According to qualitative
data, a higher percent of children in Puna qualify and receive free or reduced lunch compared to
the rest of the Big Island, which aligns with data from the SocioNeeds Index.
Several key informants noted that conditions of low-income contribute to feelings of
disenfranchisement, despair, and low resilience, negatively impacting quality of life overall and
leading to poor mental health and higher substance abuse. The low-income population also
experiences poor oral health; the low-income child population is especially vulnerable to this,
resulting in poor concentration and low educational attainment.
The low-income population is also at higher risk of obesity due to low access to healthy foods
and the convenience of fast foods, as discussed in Section 6.2.1.
7.4 Rural Communities
As highlighted by key informants throughout the report, transportation and infrastructure remain
significant challenges for many Hawaii County residents. Residents of rural communities were
observed to typically have lower incomes and poorer social determinants of health. One key
informant noted that because low-income residents often live in rural areas, fast food is very
appealing because it is inexpensive, easy, and requires little time commitment after a long
commute to work. Lack of sidewalks in rural areas prevents older residents from being able to
age in place. As discussed in Section 6.1.1, the difficulty of accessing services leads residents
to delay seeking care until their health issues are exacerbated.
7.5 People with Disabilities
Key Issues
• High percentage of adults with activity limitations due to health
54
• Lack of services and access to care
Opportunities and Strengths
Need to increase social worker resources Need developmentally staged, integrated, psychologically stimulating childcare and
after school care
There is documented need for transportation
for people with disabilities Telehealth is a big opportunity
In 2013, 18.8% of adults in Hawaii County reported having any limitations in any activities
because of a physical, mental, or emotional problem – the highest in the state (limitations due to
arthritis are discussed in Section 6.2.4). A key informant noted that Hawaii County has the
highest ratio of people with disabilities in the state – the caseload is 50 clients per social worker.
Many key informants expressed concern over the lack of services in Hawaii County. People with
developmental disabilities describe access to dental care as one of the most needed services
because many dentists do not accept Medicare or Medicaid. Many services for people with
disabilities are insufficient – physical therapy, occupational therapy, and speech therapy.
Moreover, schools are unequipped and not providing certified professionals. There are people
newly disabled through trauma, and these patients must travel to Oahu for care because of the
lack of rehabilitation services. Hawaii County has a number of wheelchair-bound clients who
have limited access to care because they live in remote areas and do not have transportation
that can accommodate the wheelchair and cannot afford a taxi either.
7.6 Homeless Population
Key Issues
• Access to homeless services
• Mental health and addiction
Opportunities and strengths
Outreach to and develop relationships with people who are homeless
In the 2014 fiscal year, Hawaii County had 1,770 of the state’s 14,282
homeless service clients. Hawaii County experienced the highest
percentage of chronic homelessness among its clients (34%) compared
to other Hawaii counties. At 60%, Hawaii County’s proportion of new
homeless service clients was higher than the state average of 38% and
increased from the previous year by 53%.
Of the new homeless service clients, 80.8% were recently
homeless, or experienced homelessness less than one year
prior to receiving homeless services. Table 7.2
illustrates a breakdown of the homeless programs Hawaii County, FY 2014 Count
Table 7.2: Number of Homeless Served by Program Type
Housing is key
to health and
wellness
55
utilized.18 Hawaii County had the highest percentage of
clients using its outreach services at 79% compared to
other counties; outreach services are typically the first
point of contact for homeless individuals and connects
them with programs and services. During inclement
weather, homeless people utilize the emergency room
for food and shelter, observed a key informant.
7.7 People from Micronesian Regions
Key issues
• Transportation, language, and cultural barriers to accessing care
• Frequent use of emergency room for nonemergency healthcare needs
Opportunities and strengths
Outreach to people from Micronesian regions Increase the number of interpreters
Key informant testimony on issues affecting people from Micronesian regions focused largely on
this population’s increased difficulty in accessing care. Financial assistance policies for this
population are changing and will affect this population’s access to healthcare in the future. As a
key informant observed, language barriers and lower health literacy contribute to delayed
diagnosis and treatment. Individuals from Micronesian regions mostly live in Kau and Ocean
View and lack transportation, contributing to additional difficulties in accessing care. Multiple key
informants commented that many use the emergency room for nonemergency healthcare needs
– even if they have a primary care physician, due to familiarity and prior experience with the
hospital. A key informant expressed concern that this population does not use car seats for
children.
Key informants also spoke to the Marshallese community specifically: Kau Hospital, a critical
access hospital, has difficulty getting services to the population, and on the other hand, the
Marshallese do not go to hospitals due to lack of transportation, long traveling distances, and
cultural barriers.
7.8 Disparities by Race/Ethnic Groups
Both quantitative and qualitative data illustrate the health disparities that exist across Hawaii
County’s many racial and ethnic groups. Figure 7.1 identifies all health topics for which a group
is associated with the poorest value for at least one quantitative indicator. Within each list,
Quality of Life measures are presented before the Health Topic Areas. The list is particularly
18 Center on the Family, University of Hawaii at Manoa. (Accessed August 17, 2015). Homeless Service
Utilization Report 20142. Retrieved from http://uhfamily.hawaii.edu/publications/brochures/60c33_HomelessServiceUtilization2014.pdf
Homeless Programs 1,770 Rapid Rehousing 74
Outreach 1,401
Shelter 746 Emergency 516
Transitional 287
* The sums of the program types exceed the total counts because some clients accessed multiple types of homeless programs.
56
long for the Native Hawaiian and Pacific Islander, White, and Filipino populations. Key
informants also took note of issues pertaining to the Hispanic/Latino population, which makes
up a larger share of the total population in Hawaii County than in the state overall.
57
Figure 7.1: Disparities by Race/Ethnicity
Asian
Public Safety
Social Environment ---
Teen & Adolescent Health Wellness & Lifestyle
White
Access to Health Services Cancer
Diabetes Disabilities Heart Disease & Stroke Immunizations & Infectious Diseases Maternal, Fetal & Infant Health Men's Health
Mental Health & Mental Disorders Older Adults & Aging
Oral Health Other Chronic Diseases Respiratory Diseases
Substance Abuse Wellness & Lifestyle Women's Health
American Indian/Alaska Native
Economy Education
Transportation --- Exercise, Nutrition, & Weight
Maternal, Fetal & Infant Health Older Adults & Aging Prevention & Safety
Native Hawaiian
Education
Public Safety Social Environment ---
Access to Health Services Cancer Disabilities Environmental & Occupational Health
Exercise, Nutrition, & Weight Heart Disease & Stroke Immunizations &
Infectious Diseases Maternal, Fetal & Infant Health
Pacific Islander
Education
--- Disabilities Family Planning Maternal, Fetal & Infant Health
Asian/Pacific Islander
Cancer
Women’s Health
Native Hawaiian/Pacific Islander
Public Safety --- Cancer
Diabetes Family Planning Heart Disease & Stroke
Maternal, Fetal & Infant Health Men's Health Mental Health & Mental Disorders
Prevention & Safety Respiratory Diseases Substance Abuse
Teen & Adolescent Health Women's Health
Japanese
Cancer Diabetes Disabilities
Exercise, Nutrition, & Weight Heart Disease & Stroke Maternal, Fetal & Infant Health Older Adults & Aging
Filipino
Social Environment ---
Access to Health Services Cancer Exercise, Nutrition, & Weight
Heart Disease & Stroke Immunizations & Infectious Diseases Mental Health & Mental Disorders Oral Health
Substance Abuse Teen & Adolescent Health Wellness & Lifestyle
Hispanic/Latino
Economy --- Cancer Respiratory Diseases
Chinese
Maternal, Fetal & Infant Health
Black/African American
Economy Public Safety
Social Environment Transportation --- Maternal, Fetal & Infant Health Teen & Adolescent Health
Mental Health & Mental Disorders
Oral Health Prevention & Safety Respiratory Diseases
Substance Abuse Teen & Adolescent Health
Wellness & Lifestyle Women's Health
58
Qualitative data collected from health experts in Hawaii County highlighted the substantial
transportation and cultural barriers faced by people from the Micronesian regions and other
groups. Below are a few excerpts taken from conversations with key informants that highlight
the issues impacting racial and ethnic groups in Hawaii County.
Figure 7.2: Key Informant-Identified Health Issues Impacting Racial/Ethnic Groups
Blue: Socioeconomic factors
Orange: Language/cultural barriers Green: Poor outcomes
The Micronesian, Chuukese,
and Yapese are mostly located
in Kau and Ocean View and
have their own cultural needs
and challenges, and also face
transportation difficulties
There are cultural factors, such as
relying on traditional medicine
before trying to access Western
health services
Cultural trauma still exists in
Native Hawaiian communities, as
indicated by high rates of suicide,
joblessness, and smoking, and
lower educational levels
Individuals from Micronesian
regions have lower health literacy
and experience language barriers
that affect timely diagnosis and
treatment
Micronesians prefer using the
emergency room even if they
have a primary care physician
because it's what they know
Government medical coverage
policies don't address access for
people from Micronesian regions,
who are unable to access
healthcare resources
Usage of car seats for
children is an issue
among Micronesians
Some Native Hawaiian residents
have concerns about Western-
style medical care and how illness
is explained; this affects how and
when they access health services
There is a growing Hispanic
migrant population in West
Hawaii; they have the fewest
transportation options
59
8 Conclusion
While there are many areas of need, there are also innumerable community assets and a true
aloha spirit that motivates community health improvement activities. This report provides an
understanding of the major health and health-related needs in Hawaii County and guidance for
community benefit planning efforts and positively impacting the community. Further investigation
may be necessary for determining and implementing the most effective interventions.
Community feedback to the report is an important step in the process of improving community
health and is encouraged and welcome. To submit your thoughts to North Hawaii Community
Hospital, please call 808-881-4695.