Hawaii County Community Health Needs Assessment. July 3, 2013

Transcription

1 Hawaii County Community Health Needs Assessment July 3, 2013

2 Table of Contents Executive Summary... 4 Introduction... 4 Approach... 4 Data Sources and Methods... 4 Selected Priority Areas... 7 Note to the Reader Introduction Summary of CHNA Report Objectives and context Healthcare Association of Hawaii Member Hospitals Advisory Committee Consultants Hospital Community Benefit Team and Goals Definition of Community + Map Methods Core Indicator Summary Data Sources Comparisons: Analytic Approach Indicator and Topic Area Scoring Shortage Area Maps Hospitalization Rates Key Informant Interviews Community Survey Community Health Needs Assessment Findings Demographics Population Economy Education Overview of Needs Assessment Access to Health Services Cancer Diabetes Disabilities Economy Education Environment Exercise, Nutrition & Weight Family Planning Heart Disease & Stroke Immunizations & Infectious Diseases Injury Prevention & Safety Maternal, Fetal & Infant Health Mental Health & Mental Disorders Older Adults & Aging

3 Oral Health Respiratory Diseases Social Environment Substance Abuse & Lifestyle Transportation Community Health Needs Summary Findings/Conclusions Disparities Highlights Identified Data Gaps Limitations and Other Considerations Selected Priority Areas Appendix A: HCI Provided Data About HCI Provided Data Framework for Indicator/Data and Topic Selection Core Indicator Data Summary: Analytic Approach and Scoring Methodology Core Indicator Data Appendix B: Hospitalization Data Hospital Service Areas Hospitalization Rates Appendix C: Key Informant Interview Participants Completed Interviews Attempted Interviews Appendix D: Identified Community Resources Appendix E: Referenced Reports Appendix F: Road map to IRS Requirements in Schedule H Form Appendix G: Authors

4 Tables Table 3.1: Population Density and Change Table 3.2: Core Indicator Summary Scores Table 3.3: Hospitalization Rates due to Preventable Causes in Hawaii County, Table 3.4: Core Indicators Cancer Table 3.5: Percent of Persons with a Disability, Table 3.6: Core Indicators Economy Table 3.7: Core Indicators Environment Table 3.8: Core Indicators Family Planning Table 3.9: Core Indicators Heart Disease & Stroke Table 3.10: Core Indicators Injury Prevention & Safety Table 3.11: Core Indicators Mental Health & Mental Disorders Table 3.12: Core Indicators Respiratory Diseases Table 3.13: Core Indicators Substance Abuse & Lifestyle Table 3.14: Core Indicators Transportation Figures Figure 1.1: Service Area Map [Each hospital will add its own map in its submitted report.] Figure 2.1: Comparison Methods Figure 3.1: Population by Age, Figure 3.2: Population by Race/Ethnicity, Figure 3.3: Breakdown of Population Reporting Race of Asian Only, Figure 3.4: Breakdown of Population Reporting Race of Native Hawaiian/ Other P.I. Only, Figure 3.5: Poverty by Race/Ethnicity, Figure 3.6: PQI Composite Hospitalization Rates Figure 3.7: Key Informant Interview Word Cloud Figure 3.8: High-Risk Race/Ethnicity Groups Identified through Community Survey Figure 3.9: Federally-Designated Medically Underserved Populations Figure 3.10: Federally-Designated Primary Health Care Professional Shortage Areas by Census Tracts Figure 3.11: Hospitalization Rates due to Diabetes, Figure 3.12: Percent of Persons with a Disability by Age and Race/Ethnicity: Hawaii County, Figure 3.13: Percent of Population Living Below Poverty Level, Figure 3.14: Hospitalization Rates due to Heart Disease, Figure 3.15: Hospitalization Rates due to Bacterial Pneumonia, Figure 3.16: Low Birth Weight Rate per 100 Live Births, Figure 3.17: Federally-Designated Mental Health Professional Areas and Population Groups by Census Tracts Figure 3.18 Mental Health Hospitalizations by Race: Hawaii County, Figure 3.19: Unadjusted Composite Hospitalization Rates, Figure 4.1: Areas of Disparity for Race/Ethnicity Groups Figure 5.1: Hawaii County Hospital Service Areas

5 Executive Summary Introduction The Healthcare Association of Hawaii and its member hospitals are pleased to present the 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. This document serves as a foundation report for member hospitals to use in producing a completed CHNA report for their institutions. The goal of this report is to offer a meaningful understanding of the health needs in the community, as well as help guide the hospitals in their community benefit planning efforts and development of an implementation strategy to address prioritized needs. Special attention has been given to identify health disparities, the needs of vulnerable populations, and unmet health needs or gaps in services. Although this report focuses on needs within the community, it is important to note there are also innumerable community assets and a true aloha spirit that provide ample foundation for community health improvement. Approach In Fall 2012, the Healthcare Association of Hawaii partnered with Healthy Communities Institute to conduct a CHNA for Hawaii County. Our approach followed the public health model of assessing and understanding community health holistically. A framework for analysis was constructed based on determinants of health; the framework included a broad definition of community health that considers extensive secondary data on the social, economic, and physical environments, as well as health risks and outcomes. The influence of mauka ( toward the mountains ), or upstream factors, and the resulting makai ( toward the ocean ), or downstream impacts, on health is a transcending theme. Key informant interviews with those having special knowledge of health needs, health disparities, and vulnerable populations provided vital information that increased the understanding of the health needs in Hawaii County. A small set of community residents provided additional insights on the health needs in Hawaii County. It is hoped that this report will provide a foundation for community health improvement efforts and that community health partners will build on this report. Data Sources and Methods An extensive array of secondary and primary data was collected and synthesized for this report. Core Indicators: Secondary data was analyzed using Hawaii Health Matters ( a publicly available data platform with a dashboard of over 100 indicators from over 20 sources; much of the data comes from Hawaii Department of Health, allowing for Hawaii-specific race, age and gender details. This extensive core data was analyzed using a highly systematic and quantitative approach that incorporated multiple benchmarks and comparisons to understand the question: How is Hawaii County performing? Hospitalization Indicators: Eighteen indicators on key preventable causes of hospitalization, analyzed at the sub-county/hospital service area level, supplemented the core indicators. This data was provided by Hawaii Health Information Corporation (HHIC) and enabled valuable insights into utilization patterns, geographic disparities in hospitalization rates, and enhanced the core indicator data for important topic areas. Supplemental Information: Recently published reports on Hawaii County s health and access to care were reviewed for additional key information on important topics such as health disparities, primary care needs, and mental health. The 2012 Hawaii County Community Health Profile was reviewed, and the current effort builds upon this recent report. 1 1 From the North Hawaii Outcome Project s Community Health Profile Report 2012, May

6 Key Informant Interviews: Storyline Consulting, a local partner of the project, interviewed 15 key informants who had knowledge of the health needs in Hawaii County. The selection of the key informants was guided by preliminary core indicator data findings and followed a structured nomination and selection process by the HAH Advisory Committee. These 15 county-specific interviews were supplemented by relevant information provided by additional key informants who were interviewed for the State of Hawaii. The input by local key informants was invaluable and greatly enhanced the understanding of health needs and offered insight into health resources and health improvement approaches. Community Survey: A small sample of community residents, via an online survey, supplemented the key informant interviews. Highlights of these surveys, or Voices from the Community, are incorporated throughout the report. Areas of Need This report provides an overview of Hawaii County s community health needs. Community health was assessed for Hawaii County as a whole, for race sub-groups, and for sub-geographies. The findings revealed overall or sub-population community needs in the following areas: Access to Health Services Cancer Diabetes Disabilities Economy Education Environment Exercise, Nutrition, & Weight Family Planning Heart Disease & Stroke Immunizations & Infectious Diseases Injury Prevention & Safety Maternal, Fetal & Infant Health Mental Health & Mental Disorders Older Adults & Aging Oral Health Respiratory Diseases Social Environment Substance Abuse & Lifestyle Transportation Several overarching themes emerged across the topic areas: All groups experience adverse health outcomes due to chronic disease and health risk behaviors While there are significant disparities in chronic disease, it is important to note that areas such as heart disease and stroke, cancer, diabetes, and asthma affect many residents of Hawaii County. Moreover, key health behaviors that impact chronic disease, including optimal exercise, nutrition, and weight, need attention across all age, gender, and race/ethnic groups. However, the rise in poor health outcomes and risky behaviors among children and teens is particularly alarming. Chronic diseases and their drivers are becoming more prevalent in the county; obesity has been on the rise, and diabetes is going undiagnosed. Unmanaged heart disease has led to high rates of hospitalizations and deaths among residents of the Big Island. Hawaii County residents are at special risk for chronic respiratory problems, evidenced by unusually high asthma rates and high rates of COPD and asthma hospitalizations. Factors contributing to poor respiratory health include high smoking rates, high particulate pollution, and exposure to volcanic gases. Mental health and associated substance abuse are key concerns as chronic conditions that significantly influence overall health in Hawaii County. The low-income population is particularly afflicted by substance abuse, but the issue impacts all groups. Attention to health risk factors, at all levels of intervention, could have an enormous positive impact on the long-term health of the community. 5

7 Greater socioeconomic need and health impacts are found among certain groups and places in Hawaii County Primary data across many topic areas stressed that the low-income residents of Hawaii County are the most impacted by health problems and often also the most difficult to help. The entire county has higher rates of poverty than the other counties in the state, and poverty is most concentrated in Puna and Kau. The Native Hawaiian, Pacific Islander, and Filipino populations have lower levels of educational attainment than the county overall and are also most impacted by limited access to care and poor health outcomes; areas identified as having particularly large disparities are heart disease, diabetes, and teen birth rates. When planning for heath improvement, careful consideration should be given to highest-need groups identified by socioeconomic measures. Cultural and language barriers inhibit effective intervention for the most impacted populations Because of the strong correlation between poverty and race/ethnicity, some of the groups most impacted by health issues often face cultural barriers to health improvement. Language differences, including limited English proficiency, and poor health behaviors that are common within a culture are challenges that must be overcome in order to effectively prevent disease. Key informants called for improved translation services for the Spanish-speaking, Micronesian, and Filipino populations in particular. Misinformation, mistrust, and a reluctance to seek care from providers of a different culture prevent many Micronesians in Hawaii County from accessing preventative care and treatment. Differing views of pregnancy, birth control, and women s health across the cultures represented on the Big Island also impact the rates of cancer screening, prenatal care, and teen births. These cultural barriers must be overcome in order to improve health outcomes. Limited access to care results in greater health impacts Because many health services are based on the Island of Oahu, Hawaii County suffers from limited access to various types of care. Key informants interviews and secondary data show a lack of both primary and specialty care physicians in the small communities; the shortage is especially severe in Puna, Kau, and Waikoloa. Large areas are designated as mental health provider shortage areas as well, with a notable lack of substance abuse and mental health treatment options. Residents of Hawaii County experience both transportation and availability of care challenges that are compounded by the expansive and rugged geography. Community health centers and schools are key community assets for effective interventions Given the barriers described above, several key informants recommended focusing on intervention through community health centers. Locally-based care has many advantages, including the ability to bring primary care services that are culturally appropriate. In addition, key informants noted the centers could fill some provider gaps as shortages worsen. Staffing community health centers with residents from the served community offers opportunities for economic advancement and an improved social environment. Health interventions for children and teens can have a two-fold benefit of establishing healthy life-long behaviors among Hawaii s youth, as well as influencing the health of their families. Preventative services and education on health risks can be effectively delivered in school environments. Key informants often recommended interventions that are school-based or involve collaboration with Hawaii schools. Schoolbased health interventions cited by key informants include vision and dental care, vaccination programs, obesity prevention through physical activity and nutrition, substance abuse prevention among teens, 6

8 and family planning education to reduce teen births. The need to increase health literacy and overall health can successfully be addressed in the school environment. Selected Priority Areas Each hospital will customize this section for its own needs in its submitted report. Note to the Reader Beyond the Executive Summary, readers may choose to study the entire report or alternatively focus on a particular topic area. An overview is provided for each key type of data included in the report: core indicators, hospitalization rates, key informant interviews, and on-line community survey. To more deeply understand a topic area, the reader can turn to any of the 20 topic area presentations and find all data for the topic and summary conclusions. Each topic-specific section is organized in the following way: Core Indicators and Supplemental Information Hospitalization Rates (when available) Key Informant Interview Information Summary of Topic Area 7

9 1 Introduction 1.1 Summary of CHNA Report Objectives and context The state of Hawaii is unique in that all of its community hospitals and hospital systems joined efforts to fulfill new requirements under the Affordable Care Act, which the IRS developed guidelines to implement. The Healthcare Association of Hawaii (HAH) led this collaboration to conduct state- and county-wide assessments for its members Healthcare Association of Hawaii HAH is the unifying voice of Hawaii s health care providers and an authoritative and respected leader in shaping Hawaii s health care policy. Founded in 1939, HAH represents the state s hospitals, nursing facilities, home health agencies, hospices, durable medical equipment suppliers, and other health care providers who employ about 20,000 people in Hawaii. HAH works with committed partners and stakeholders to establish a more equitable, sustainable health care system driven to improve quality, efficiency, and effectiveness for patients and communities Member Hospitals Twenty-six of 28 Hawaii hospitals, 2 including all Hawaii County hospitals, participated in the CHNA project. Located in Hawaii County: Hale Ho`ola Hamakua Hilo Medical Center Ka`u Hospital Kohala Hospital Kona Community Hospital North Hawaii Community Hospital Serve Hawaii County residents: Kahi Mohala Behavioral Health Kaiser Permanente Medical Center Kapi`olani Medical Center for Women & Children Rehabilitation Hospital of the Pacific Shriners Hospitals for Children - Honolulu The Queen s Medical Center Advisory Committee The CHNA process has been 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 health care, public health, and their respective communities as part of this group. Howard Ainsley - Hawaii Health Systems Corporation Bruce Anderson, PhD Hawaii Health Systems Corporation Joy Barua Kaiser Permanente Hawaii 2 Tripler Army Medical Center and the Hawaii State Hospital are not subject to the IRS CHNA requirement and were not a part of this initiative. 8

10 Maile Ballesteros St. Francis Home Care Kauai Wendi Barber, CPA, MBA Castle Medical Center Rose Choy - Kahi Mohala Behavioral Health Kathleen Deknis, RN, MPH Home Health by Hale Makua Karen Fernandez Wahiawa General Hospital Mark Forman, JD Hawaii Medical Service Association Foundation Loretta J. Fuddy, ACSW, MPH State of Hawaii Department of Health Robert Hirokawa, DrPH Hawaii Primary Care Association Mari-Jo Hokama Kahi Mohala Behavioral Health Fred Horwitz Life Care Center of Hilo Susan Hunt, MHA Hawaii Island Beacon Community Richard Keene The Queen s Health Systems Jeannette Koijane, MPH Kokua Mau Jay Kreuzer - Hawaii Health Systems Corporation Greg LaGoy, ND, MBA Hospice Maui Bernadette Ledesma, MPH Pearl City Nursing Home Vince Lee, ACSW, MPH - Hawaii Health Systems Corporation Wesley Lo - Hawaii Health Systems Corporation Pat Miyasawa Shriners Hospitals for Children-Honolulu R. Don Olden Wahiawa General Hospital Quin Ogawa Kuakini Health System Jason Paret, MBA North Hawaii Community Hospital Ginny Pressler, MD, MBA, FACS Hawaii Pacific Health Hilton Raethel, MBA, MHA Hawaii Medical Service Association Hardy Spoehr - Papa Ola Lokahi Jerry Walker - Hawaii Health Systems Corporation Katherine Werner Ciano, MS, RN North Hawaii Hospice Ken Zeri, RN, MSN Hospice Hawai`i Lori Miller Kauai Hospice Marie Ruhland, RN Home Healthcare Services of Hilo Medical Center Neill Schultz Castle Medical Center Corinne Suzuka, RN, BNS, MA St. Francis Home Care Peter Sybinsky, PhD Hawaii Health Information Corporation Ty Tomimoto Rehabilitation Hospital of the Pacific Sharlene Tsuda The Queen s Health Systems Stephany Vaioleti, LSW, JD - Kahuku Medical Center Sharon Vitousek, MD North Hawaii Outcomes Project Consultants Healthy Communities Institute The Healthy Communities Institute (HCI) mission is to improve the health, environmental sustainability and economic vitality of cities, counties and communities worldwide. The company is rooted in work started in 2002 in concert with the Healthy Cities Movement at the University of California at Berkeley. HCI offers a spectrum of technology and services to support community health improvement. HCI s webbased dashboard system makes data easy to understand and visualize. The web system and services enable planners and community stakeholders to understand all types and sources of data, and then take 9

11 concrete action to improve target areas of interest. HCI has over 100 implementations of its dashboard for clients in 40+ states. The HCI team is composed of experts in public health, health informatics, and health policy. The services team provides customized research, analysis, convening, planning and report writing to meet the organizational goals of health departments, hospitals, and community organizations. To learn more about Healthy Communities Institute please visit Storyline Consulting Storyline Consulting is dedicated to serving and enhancing Hawaii s nonprofit and public sectors. Storyline 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 Hospital Community Benefit Team and Goals Each hospital will customize this section for its own needs in its submitted report Definition of Community + Map [Each hospital will also customize this section in its submitted report.] The hospital service area is defined by a geographical boundary of Hawaii County, which encompasses the Island of Hawaii (or Big Island ). Hawaii County will serve as the unit of analysis for this Community Health Needs Assessment. Hence, the health needs discussed in this assessment will pertain to individuals living within this geographic boundary. When possible, highlights for sub-geographies within Hawaii County are provided. The specific area served by the hospital is indicated in Figure 1.1. Figure 1.1: Service Area Map [Each hospital will add its own map in its submitted report.] Note: this map is a placeholder and should be replaced with a service area map specific to the hospital. 10

12 2 Methods The starting point for this needs assessment is a summary of secondary or core indicator data, which applies a systematic and quantitative method of comparing the relative severity of health indicators across 20 topic areas. When possible, other data are considered, including rates of hospitalization due to preventable causes, to more closely examine the most severe health needs and their impact on health care utilization. The secondary data findings are further informed by collected primary data. Individuals with special knowledge regarding the health needs of the community, including those with expertise in public health and community health, were interviewed through a key informant interview process. An online survey collected additional opinions from community residents. The quantitative, secondary data is then combined with the knowledge of key informants who have awareness of health needs specific to their community and highlighted with resident opinions on community health concerns. 2.1 Core Indicator Summary Data Sources The core indicators included in this summary originated from Hawaii Health Matters ( a publicly available data platform with a dashboard of over 100 indicators from over 20 sources. Hawaii Health Matters (HHM) was developed as a partnership between Hawaii Health Data Warehouse and Hawaii Department of Health, with technology provided by Healthy Communities Institute. The core indicators cover health outcomes, behaviors that contribute to health, and other factors that are correlated with health. The secondary data available on HHM is continuously updated as sources release new data. The data included in this summary is as of October 17, 2012, and may not reflect data currently on the site. Additional data specific to race, gender, and age subgroups was obtained directly from Hawaii Department of Health. Each of the indicators was categorized into one of 20 topic areas, spanning both health and quality of life issues. All indicators, including measurement date, sources and topic area assignment, are included in the Appendix of this report Comparisons: Analytic Approach The status of Hawaii County was assessed one indicator at a time using up to four comparison methods. 1. First, Hawaii County was compared geographically, to the rest of the state as well as the nation. Comparisons of Hawaii County to the United States, the state average, and the county in Hawaii with the best value for the indicator were averaged (see Appendix A for more details and an example). This average was used to determine whether Hawaii County compares poorly to other geographies. 2. The second comparison examined the trend of the data. If Hawaii County s indicator value had worsened by at least 2.5% of the baseline value per year, the trend for the indicator was considered poor. 3. A third comparison measured disparities among sub-populations in Hawaii County. If one subpopulation had a value at least four times worse than another for the indicator, then the disparity measurement was considered poor. 4. Finally, the indicator value was compared to nationally recognized Healthy People 2020 (HP2020) benchmarks. The indicator was considered poor if Hawaii County had not yet met the target set by the U.S. Department of Health and Human Services (see Appendix A for more information on HP2020 benchmarks). 11

13 Figure 2.1: Comparison Methods Indicator and Topic Area Scoring After the status of all possible comparisons was assessed, indicators were aggregated into their respective topic areas. The total number of poor comparisons was divided by the total possible comparisons within the topic area to calculate the topic area score. This score, measuring the proportion of poor comparisons within the topic, ranges from zero to one. Scores were not calculated for topic areas that had one or zero indicators, as these areas were deemed to lack an adequate number of indicators. The top ten topic areas with the highest scores were used to guide primary data collection. Please see Appendix A for more details and an example of this process Shortage Area Maps Core indicator data for relevant topic areas was supplemented with maps illustrating the following types of federally-designated shortage areas and populations: Medically underserved populations Primary care health professional shortage areas Mental health professional shortage populations and/or areas Criteria for medically underserved areas and populations can be found at: Criteria for health professional shortage areas can be found at: Maps of shortage areas and populations were based upon shapes generated using the Community Issues Management site s mapping tool: Maps were further customized by Healthy Communities Institute. As many comparisons as possible were applied to each indicator. The possible comparisons varied for each indicator depending on the availability of data. Geographic comparisons were only possible when national data was available for the same indicator and time period. Trend comparisons were only possible when at least three periods of measure were available to avoid misinterpreting slight changes between two periods. The availability of sub-population data varied by indicator, and so disparity comparisons were incorporated whenever possible. Finally, HP2020 benchmarks only exist for a subset of the indicators included in the summary. Please see Appendix A for more details and examples of this process. 12

14 2.2 Hospitalization Rates While the Core Indicator Summary included several unadjusted hospitalization rate indicators, further risk-adjusted rates were obtained for comparison between geographies of varying population makeup. Rates were provided by Hawaii Health Information Corporation (HHIC), and are defined by the Agency for Healthcare Research and Quality (AHRQ) as a set of measures that can be used to identify quality of outpatient care that can potentially prevent the need for hospitalization. Risk adjustment attempts to account for differences in indicators across providers and geographic areas that are attributable to variations in patient mix. AHRQ s risk adjustment methodology employs multivariate ordinary least squares regression to estimate an expected value of each indicator an area would exhibit with an average case-mix. The model adjusts for patient demographics, including age, sex, all age-sex combinations, All-Payer Refined DRGs (a refinement of CMS s DRGs that additionally classifies non- Medicare cases) and severity-of-illness. HHIC applies AHRQ s risk adjustment methodology to further control for the top four dominant races in Hawaii, as determined by the Hawaii State Department of Health s Hawaii Health Survey. Risk adjustment coefficients are estimated using the Healthcare Cost and Utilization Project s (HCUP) State Inpatient Databases (SID). Please see for a complete definition of indicators. Because the area of mental health was not well represented in the Core Indicator Summary, HHIC also provided unadjusted rates of hospitalization for any mental health-related primary diagnosis. Sub-county hospitalization rates are included for Hospital Service Areas (HSA), which were defined in 1995 by hospital CEOs and are composed of contiguous zip codes surrounding a hospital s self-defined service area. Please see Appendix B for a list of the zip codes contained within each HSA. Also included in Appendix B are unadjusted rates for age, gender, and race/ethnicity sub-populations. The inclusion of these rates in the Findings discussion is limited due to uncertainties in the comparability of these unadjusted rates with the risk-adjusted rates. All rates are based upon patient residence, and values were suppressed if there were fewer than 10 cases. Population estimates are based on the U.S. Census Bureau, Population Division, Intercensal Estimates of the Resident Population for Counties of Hawaii and Hawaii State Department of Health, Office of Health Status Monitoring, Hawaii Health Survey. Sub-county demographic counts are based on estimates/projections provided by Pitney Bowes Business Insight, Population estimates by race were provided by the Hawaii State Department of Health, Office of Health Status Monitoring, Hawaii Health Survey Hospitalization rate area maps were created by HCI using HHIC-provided Hospital Service Area maps, where darker shading of Hospital Service Areas reflects higher rates. 2.3 Key Informant Interviews In order to supplement the quantitative findings, key informants were interviewed to further assess the underlying drivers for health outcomes, current community efforts, and obstacles to health. These key informants were chosen by the HAH Advisory Committee on November 7-8, 2012 through a structured nomination and selection process, which followed a thorough review of the preliminary core indicator data. Advisory members nominated community members with expertise in public health, in the top ten topic areas from the core indicator analysis, as well as in those topic areas where there were data gaps. Key informants were also nominated for their knowledge of vulnerable populations, such as low-income or more adversely impacted racial/ethnic groups. After the nomination process, the advisory members prioritized the list through a voting process. 13

15 The key informant interview process was part of a larger statewide CHNA effort in which a total of 105 community experts were nominated, then prioritized down to a list of 75. The remaining 30 nominated key informants were maintained on an alternate list, in the event that a key informant was not available. Roughly 15 key informants were allotted for each of the four counties and for the overall state perspective. For this Hawaii County report, 15 key informants were interviewed for their specific knowledge of the health needs of this community. When certain topic areas were lacking an interview specific to Hawaii County, findings from the statewide perspective were included. The interviews were conducted by local consultants, Storyline Consulting. The interviews took place between November 19, 2012 and January 2, 2013 and lasted minutes in length. Most interviews took place by phone; a few took place in person. Storyline Consulting typed notes from the interviews during the conversation, capturing the bulk of the conversation verbatim. Interview notes were then condensed and entered into a data collection spreadsheet. The information obtained from these interviews was incorporated into this report in three ways. A summary qualitative analysis tool called a word cloud was produced using TagCrowd.com to identify the most common themes and topics. Words or phrases that were mentioned most often display in the word cloud in the largest and darkest font (see Figure 3.7). Next, input from the key informants was included in each relevant topic area in Section 3.2. Lastly, any recommended community programs or resources are referenced in Appendix D: Identified Community Resources. A Key Informant Interview Guide was developed to guide the interviews. Storyline Consulting adapted the interview guide to best suit Hawaii s context, unique ethnic/racial profile, and culture. The questions used in the guide are listed below: Q1: Could you tell me a little bit about yourself, your background, and your organization? Q2: You were selected for this interview because of your specialized knowledge in the area of [topic area]. What are the biggest needs or concerns in this area? Q3: What is the impact of this health issue on low income, underserved/uninsured persons? Q4: Could you speak to the impact on different ethnic groups of this health concern? Q5: Could you tell me about some of the strengths and resources in your community that address [topic area]? Q6: Are their opportunities for larger collaboration with hospitals and/or the health department that you want us to take note of? Q7: What advice do you have for a group developing a community health improvement plan to address these needs? Q8: What are the other major health needs/issues you see in the community? Q9: Is there anything else you d like us to note? 14

16 2.4 Community Survey An online survey was used to collect community opinions on the greatest health needs for Hawaii County. The survey link was virally distributed by members of the HAH Advisory Committee and was posted on several local websites, including The survey was open from November 28 to December 24, Because the survey sample is a convenience sample, it is not expected to be representative of the population as a whole. Survey respondents provided select personal characteristics, including gender, age, sex, and zip code of residence and whether or not the resident works in the health field. Residents were asked to rank the top ten topic areas from the core indicator analysis in order of importance for their community, as well as informing us about other topic areas of concern. Respondents were also asked which racial/ethnic groups they felt experienced more health problems than average. Lastly, there was an open-ended question asking the resident if there was anything else they would like to share with us, in terms of health concerns in their community. Opinions gathered with this survey are included in this report as highlights, called Voices from the Community, in describing notable areas of need. 15

17 3 Community Health Needs Assessment Findings 3.1 Demographics The demographics of a community significantly impact its health profile. Different ethnic, age, and socioeconomic groups may have unique needs and take varied approaches to health. This section provides an overview of the demographics of Hawaii County, with comparisons to the State of Hawaii and the United States for reference. All estimates are sourced from the U.S. Census Bureau s American Community Survey unless otherwise indicated Population In 2010, Hawaii County had a population of 185,079, with a population density lower than the State of Hawaii and the U.S. overall. While the county is home to only 13.5% of the state s population, Hawaii County grew at a much faster rate than the state overall between 2000 and 2010, as Table 3.1 shows. Population density, 2010* Population change, * Age Table 3.1: Population Density and Change Hawaii County Hawaii U.S. 46 persons/sq. mi 212 persons/sq. mi 87 persons/sq. mi 24.5% 12.3% 9.7% *2010 U.S. Census As seen in Figure 3.1, the Hawaii County population is older than that of Hawaii and the rest of the country, with a median age of 40.4 (compared to 35.4 for Hawaii and 36.9 for the U.S.). Children under 18 make up 22.5% of Hawaii County, and adults ages 18 to 44 make up only 32.4% of the population, compared to 36.4% of the U.S. and 36.3% of the state. Hawaii County also has a much larger population of year olds, at 29.9% of the population. Figure 3.1: Population by Age,

18 Racial/Ethnic Diversity Hawaii County s population also differs from the state s and nation s in terms of race/ethnicity makeup. In Figure 3.2 below, the race groups displayed to the left of the blue line include residents reporting one race only, while residents reporting two or more races and Hispanic/Latino ethnicity (of any race) are shown to the right of this line. The population in Hawaii County reporting a race of White Only is considerably higher than the state s, at 32.7% versus 25.0%, but is still much lower than that of the U.S. (74.1%). Black/African American, Hispanic/Latino, and Other race/ethnicity groups are also much smaller than the U.S. overall. Figure 3.2: Population by Race/Ethnicity, 2011 The second-largest single race group in Hawaii County (after White Only) is Asian Only, at 21.4%. While this is a much larger share of the population than the nation s 4.8%, it is much smaller than the state s 38.1%. The majority of the Asian population is Japanese or Filipino, as seen in Figure 3.3 (which includes all residents reporting a race of Asian only regardless of Hispanic/Latino ethnicity). Hawaii County has much larger Native Hawaiian/Other Pacific Islander (10.7%) and multiracial populations (30.7%) than the rest of the state and country. Native Hawaiians, at 7.5% of the total population, make up the largest share of the Native Hawaiian/Other Pacific Islander single race group (Figure 3.4). Figure 3.3: Breakdown of Population Reporting Race of Asian Only, 2011 Figure 3.4: Breakdown of Population Reporting Race of Native Hawaiian/ Other P.I. Only,

19 A lower percent of Hawaii County is foreign-born compared to the U.S. and to the State of Hawaii. In , 11.2% of Hawaii County was foreign-born, compared to 17.7% of Hawaii and 12.7% of the U.S. overall. A lower percent of Hawaii County households were linguistically isolated as well: 2.9% of households reported that all of its members ages 14 and over had some difficulty speaking English, contrasted with 6.2% of households in Hawaii and 4.8% of households in the U.S Economy Income in Hawaii County is low compared to the state, whether considering median household income or per capita income. Median household income in was $54,996, substantially lower than the state value of $66,420. However, this was still higher than the national value of $51,914. The measure of per capita income places Hawaii County s $26,194 below both the state ($28,882) and U.S. values ($27,334). Hawaii County has the highest levels of poverty in the state (14.4% vs. 9.6%). While the state overall has less poverty than the nation, Hawaii County s poverty level is above the national average of 13.8%. Within the county, the eastern regions of the island are the most impoverished, with the highest poverty rates in the sub-county regions of Kau, Pahoa-Kalapana, and Keeau-Mountain View. Certain race/ethnicity groups are also more affected by poverty, as seen in Figure 3.5. The Black/African American and Native Hawaiian/Other P.I. populations have the highest poverty rates at 25.0% and 23.7% respectively. The two least impoverished groups are Asian (7.4%) and Two or More Races (14.3%). 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 residents who struggle to provide for themselves due to the high cost of living in the state Figure 3.5: Poverty by Race/Ethnicity, Education In , a higher percent of Hawaii County residents aged 25 and older had at least a high school degree (90.5%) than the state (89.8%) and the nation (85.0%). However, in terms of residents with at least a bachelor s degree, the county s 26.6% falls below both the State of Hawaii (29.4%) and the U.S. (27.9%). 18

20 3.2 Overview of Needs Assessment Core Indicator Summary Ninety-six indicators of health drivers and outcomes were included in the systematic review of secondary data. Table 3.2 shows the weighted ranking scores for each topic area, from most severe to least. Table 3.2: Core Indicator Summary Scores Topic Area Indicators Score Rank Respiratory Diseases Mental Health & Mental Disorders Family Planning Heart Disease & Stroke Transportation Environment Injury Prevention & Safety Economy Substance Abuse & Lifestyle Cancer Access to Health Services Maternal, Fetal & Infant Health Immunizations & Infectious Diseases Exercise, Nutrition, & Weight Oral Health Education Diabetes 1 n/a n/a Disabilities 0 n/a n/a Older Adults & Aging 1 n/a n/a Social Environment 1 n/a n/a The ranking of scores for the topic areas provides a systematic way to assess a large number of indicators across many topic areas. Because the absolute and relative scores are influenced by the number of available inputs for the scoring equation, scoring differences can arise due to availability of data, so it is important to consider the scores in the context of the primary data and the interrelatedness of many of the topic areas. Findings of both quantitative and qualitative nature are presented below by topic area, along with a discussion of what can be learned from these results. For a complete list of indicators included in the core indicator summary, see Appendix A. Hospitalization Rates Risk-Adjusted Hospitalization Rates due to Preventable Causes in Hawaii County for the most recent year available, 2011, are presented in Table 3.3. The specific causes of hospitalization with the three highest overall rates are Mental Health, Heart Failure, and COPD or Asthma in Older Adults. Specific causes of hospitalization are further discussed in applicable topic areas below. All hospitalization rates are listed in Appendix B. 19

21 Table 3.3: Hospitalization Rates due to Preventable Causes in Hawaii County, 2011 Preventable Cause Hospitalizations Risk-Adjusted Rate per 100,000 (95% CI) Mental Health* ( ) Heart Failure ( ) COPD or Asthma in Older Adults (Ages 40+) ( ) Bacterial Pneumonia ( ) Urinary Tract Infection ( ) Low Birth Weight** ( ) Diabetes Long-Term Complication ( ) Dehydration ( ) Hypertension ( ) Diabetes Short-Term Complication ( ) Perforated Appendix*** ( ) Rate of Lower-Extremity Amputation ( ) Angina Without Procedure ( ) Asthma in Younger Adults (Ages 18-39) ( ) Uncontrolled Diabetes ( ) Composite Hospitalization Rates PQI Composite Acute Conditions ( ) PQI Composite Chronic Conditions ( ) PQI Composite ( ) * Rate for this cause is unadjusted **Rate is per 100 live births ***Rate is per 100 appendicitis admissions Included in Acute Conditions Composite Rate Included in Chronic Conditions Composite Rate Examining sub-geographies in the county, the highest composite rate for preventable hospitalizations in 2011 was in West Hawaii. Figure 3.6: PQI Composite Hospitalization Rates 20

22 Key Informant Interviews The word cloud below illustrates the Hawaii County needs mentioned most often by key informants, where the size and shading of the word reflects the frequency of its use. The concerns include both those pertaining to the informants specific areas of expertise, as well as other issues they see in the community as a whole. Interviews are summarized by the topic area covered by the interviewees expertise in sections through Figure 3.7: Key Informant Interview Word Cloud Community Survey During the period of November 28 to December 24, 2012, 322 surveys were completed online by Hawaii County residents. As the survey was a convenience sample, it was not expected to be representative of the county population as a whole. Of the respondents who specified, 76.9% were female, 23.1% male. Just over half of respondents were between the ages of 45 and 64; 25.8% were under 45 and 23.3% were 65 or older. Slightly more than half of respondents were Community Health or Public Health Professionals (52.2%). Highest Ranked Topic Areas Cancer Diabetes Heart Disease & Stroke Maternal, Fetal & Infant Health Substance Abuse & Lifestyle From the topics that scored highest in the core indicator summary, residents ranked the topic areas to the left highest. From the topic areas that did not score high based on core indicator data, five were selected as also being a concern. Other Areas of Concern Access to Health Services Education Exercise, Nutrition & Weight Mental Health & Mental Disorders Older Adults & Aging 21

23 Figure 3.8: High-Risk Race/Ethnicity Groups Identified through Community Survey The race/ethnic group most commonly reported as experiencing more health problems than average was Native Hawaiians, followed by Other Pacific Islanders. Health professionals were more likely than non-health professionals to include Filipino and Caucasian groups as experiencing more health problems than average. Please see highlights throughout this report of respondent opinions titled Voices from the Community. The sections below, , will describe the findings by topic area in the following format: Core Indicators and Supplemental Information This section is more extensive for those topics where need demonstrated in the Core Indicator Summary was greatest. The top ten scoring topic areas include a list of highlights followed by a table including the indicators, most recent value, and how Hawaii County fared across the four comparison methods. Green checkmarks indicate that the comparison was good, red X s indicate a poor comparison, and a blank cell indicates no comparison was possible. Further information about core indicators is included in Appendix A. When possible, data is supplemented by additional information obtained from previous needs assessments and reports. Hospitalization Rates As applicable, preventable hospitalization rates are compared to values across the State of Hawaii. Rates by Hospital Service Area are presented to identify the sub-county geographies with the highest level of burden. All hospitalization data for Hawaii County and a description of the Hospital Service Areas are included in Appendix B. Key Informant Interviews The information gleaned from key informants who were interviewed for their expertise in the relevant topic area is summarized in a table. Main points made by interviewees are organized by the needs and concerns for Hawaii County; the impact on low-income, underserved or uninsured, and/or race or ethnic groups; and the opportunities and strengths that they have identified in their community. Summary All findings are summarized for the topic with a focus on common themes. 22

24 3.2.1 Access to Health Services Core Indicators and Supplemental Information Access to Health Services in Hawaii County, measured by the percent of adults/children without health insurance and the percent of adults who have a usual source of health care, is poor compared to the rest of the state. The Health Resources and Services Administration has designated the entire county medically underserved. Primary health care professionals are especially scarce in Waikoloa, Kau, and Puna, as illustrated in Figure However, compared to the U.S. overall, Hawaii County has a much lower percentage of adults without health insurance (10.9% vs. 17.8% in 2010). In addition, the racial, gender, and age disparities surrounding access to care are relatively small, and all indicators in this area have been trending in a good direction. Figure 3.9: Federally-Designated Medically Underserved Populations Figure 3.10: Federally-Designated Primary Health Care Professional Shortage Areas by Census Tracts Voices from the Community It is unfortunate that Big Island residents have to fly to Oahu for any major health concerns or treatment, or feel like they have to go to the mainland because treatment options in the islands are not up to par with those that can be found on the mainland. I really think there should be some focus put on improving the quality and availability of care here in Hawaii, for all islands. Key Informant Interviews Needs/Concerns *Access to any kind of services difficult because of geography *Very limited public transportation, available only for morning/evening Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Underserved communities are based on geography/lack of transportation more than ethnicity *Native Hawaiians, Pacific Islanders Opportunities/Strengths *Community health centers are making a huge impact on indigent population and have immense potential to expand reach as 23

25 commute *Shortage of all types of medical personnel because of provider attrition/retirement; will worsen unless something is done *Malpractice insurance too high *Doctors are deterred from working on the Big Island because they must take on many more patients due to shortage *Primary care providers in Hawaii County are not taking new patients, forcing people into urgent care and ER *Hawaii in general is not a Physician Assistant-friendly state and is missing the opportunity to increase access to health care in rural communities through increased use of PAs *Doctors providing unreimbursed services due to lack of funding for serving uninsured patients *Not focusing on primary & preventive care or outreach, just "putting out fires" *Children do not have screenings for dental, vision, and these are barriers to doing well in school *Need more school-based FQHCs disproportionately impacted *Goes beyond language barriers; hospitals, schools, other public entities do not understand Marshallese culture *"Local" population of mixed ethnicity has poor health outcomes similar to Native Hawaiian in terms of health behaviors, access to care, and health outcomes like teen pregnancy, prenatal care, etc. *Need Spanish and Micronesian language interpreters *Many Micronesians settling in the south/ocean View, which is geographically isolated with no access to services *In rural areas, Native Hawaiians have a great need for specialty care related to heart disease and diabetes but have a hard time accessing it *20% of people who walk into clinics are uninsured *In outlying areas like Ocean View, even access to running water and electricity is an issue physician shortage worsens *Medical technology and IT has been beneficial; Beacon group's work has been encouraging *Low health literacy; opportunity for workshops or other educational efforts *Could experiment with more of a wellness approach, follow people with chronic diseases, have a case manager, do preventative care *Coalitions and coordination of care have improved hospital partnerships immensely *In the summer and short term, could see if UH school of nursing would provide manpower to Bay Clinic and make concerted effort in our 9 schools so kids can get their screenings Summary In the online community survey, Hawaii County residents highlighted access to care as a key need in their community. Aggregate findings from the key informant interviews also indicate that access is a top concern. The word cloud tool to analyze qualitative, text based information from the key informant interviews prominently showed that access was the single most frequently noted health concern among key informants. Shortages, primary care, and transportation also came up frequently. The county is performing poorly relative to the rest of the state, which key informants attributed to the large size of the county, limited public transportation options, severe provider shortages, and limited insurance coverage. The depressed local economy is a common theme tying together these issues. Key informants suggest that community health centers are best positioned to assist hard-to-reach populations, especially as provider shortages worsen. Voices from the Community We need more Primary Care Physicians in all communities of the Big Island. It is very difficult to establish continuous care when the only option is to go to Urgent Care or an Emergency Room. 24

26 3.2.2 Cancer Core Indicators and Supplemental Information While there are many drivers of cancer, early detection and steps toward prevention can lessen the burden on a community s health. In Hawaii County, the incidence and death rates due to several different types of cancers ranked this area as a topic of concern: Regarding screenings: The share of women ages 40+ in Hawaii County who have had a mammogram in the past two years is lower than both the state (76.5%) and national average (75.2%) A lower percent of women ages 18+ in the county have had a Pap smear within three years as compared to the state (77.4%) Colon cancer screening has been trending poorly, decreasing from 39.5% in 2003 to 17.7% in 2010 among people ages 50 and over Regarding new cases and mortality rates: While the death rate due to breast cancer in Hawaii County was a little lower than the state s (14.2 deaths per 100,000 females), Native Hawaiian/Pacific Islander women experienced a much higher death rate of 52.6 deaths per 100,000 females Between and , cervical cancer incidence increased from 7.6 to 8.5 cases/100,000 females Hawaii County is in the bottom quartile of all U.S. counties in terms of liver and bile duct cancer incidence, which increased from 8.2 cases/100,000 pop in to 9.2 in The county is also in the bottom quartile of U.S. counties for melanoma incidence rate. Caucasians have the highest rate at 65.7 cases per 100,000 population Table 3.4: Core Indicators Cancer 25

27 Key Informant Interviews Needs/Concerns *Difficult to promote mammograms, even if free and transportation is provided *By the time mammograms catch breast cancer, it is often in its advanced stages *Smoking cessation is really difficult since tobacco is the most addictive substance out there *Difficult to engage males in colorectal screening *Starting to see younger people come through our doors with stage 3-4 cancer *Fewer people are getting ongoing care and education, and by the time they seek care, they are so far along in their illness and treatment is more difficult Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Due to of lack of insurance, people delay treatment as long as possible *Unemployed people are not able to be more proactive and preventative in their illness *Cultural issues around self-breast exams and mammograms *Issues in West Hawaii around language translation and culture, with more Hispanic individuals that need translation services *Non-English speakers sometimes don t fully understand treatment regimens *Native Hawaiians are often hesitant to seek medical care from someone "Western" who doesn't look like them *Native Hawaiian culture has traditionally believed that physical illness stemmed from a moral wrongdoing, so there may still be some hesitation in seeking care Opportunities/Strengths *People care about each other and everyone knows each other *Opportunity for greater cultural sensitivity Summary Both primary and secondary data indicate there are significant concerns surrounding cancer screening and incidence in Hawaii County. Cultural barriers, lack of insurance, and financial concerns prevent people from seeking preventive care and early treatment. Even if the uninsured seek earlier care, a shortage of free or low-cost providers means they often have to wait a long time before they can receive treatment. Community health centers are a vital source of care for those who otherwise would not have any. Voices from the Community Hawaii needs cancer treatment centers [with] equivalent quality of care and expertise [as] those on the mainland. 26

28 3.2.3 Diabetes Core Indicators and Supplemental Information While Diabetes as a topic area was not ranked due to limited core indicator data, the proportion of adults with diabetes in Hawaii County (8.2%) is the second-highest in the state. The groups most impacted by high diabetes rates are Japanese (12.3%) and Native Hawaiian (10.4%) adults. Hospitalization Rates Although the county has the lowest hospitalization rates in the state in terms of both short- and longterm complications, Hawaii County has the highest rate of hospitalization due to uncontrolled diabetes, and the rate has increased from 6.9/100,000 population in 2009 to 9.8/100,000 population in The rate of lower-extremity amputations was lower in Hawaii County than the state average in East Hawaii s hospitalization rates due to complications of diabetes were all higher than the county rate in Sub-county rates due to uncontrolled diabetes were suppressed due to low counts. While these rates provide insight into the hospital utilization for diabetes related outcomes in Hawaii County, the data does not fully portray the impact of diabetes or the spectrum of health care services needed to successfully manage diabetes. Further analysis may be needed to better understand the diabetes hospitalization patterns and other related health care needs. Figure 3.11: Hospitalization Rates due to Diabetes,

29 Key Informant Interviews Needs/Concerns *National trend is that 1:3 children will have Type II diabetes; in Hawaii, much higher rate of 1:2 children *Childhood obesity will lead to diabetes becoming an even bigger problem in the future; the amount of resources spent on diabetes will double *Providers starting to see younger people with full-blown diabetes *Diabetes is going undiagnosed in many Hawaii residents Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Native Hawaiians have a higher rate of diabetes, and those living in rural areas have little access to specialists *Higher prevalence for diabetes among Native Hawaiians, other Pacific Islanders, Japanese, and Filipinos and we have such a blend of those bloodlines in Hawaii. *Difficulties in translating messages to Samoan and other Pacific Island languages *Outlying areas, low-income population high rates could be lack of overall knowledge of assessment of body and lack of access to critical care Opportunities/Strengths *Work with American Heart and American Cancer Associations to combat obesity *Work with schools to increase physical activity *Ask legislature to put physical education back in schools Summary The prevalence of diabetes in Hawaii County currently affects a large number of adults and is projected to increase in severity due to childhood obesity. Diabetes greatest impact is on low-income residents with limited access to medical care, and also disproportionately affects those of Japanese and Native Hawaiian ancestry. The relatively high rate of hospitalization due to uncontrolled diabetes, while hospitalizations due to short- and long-term complications are the lowest in the state, suggests that patients with diabetes in Hawaii County are less likely to have their disease well managed. Reducing the impact of diabetes in Hawaii County requires two approaches: 1) providing primary care management to those who already have disease, and 2) preventing new cases from developing, by bringing together schools, employers, city planners, and community-based organizations to promote physical activity and reduce obesity across generations Disabilities Supplemental Information There was no data included in the Core Indicator Summary specific to Disabilities. (Please see Section for a discussion on data gaps.) Based on data from the 2011 American Community Survey, 13.8% of Hawaii County residents have a disability, higher than the national average of 12.1%. Of people with a disability in Hawaii County, 38.0% are living in poverty, well above the 75 th percentile cutoff of U.S. counties (31.4%). 3 The most common type of difficulty is ambulatory (serious difficulty walking or climbing stairs), as seen in Figure U.S. Census, American Community Survey, 2011 Estimates 28

30 Table 3.5: Percent of Persons with a Disability, Figure 3.12: Percent of Persons with a Disability by Age and Race/Ethnicity: Hawaii County, Hawaii State County Persons with a Disability Hearing Difficulty Vision Difficulty Cognitive Difficulty (ages 5+) Ambulatory Difficulty (ages 5+) Self-Care Difficulty (ages 5+) Independent Living Difficulty (ages 18+) Children with a Disability One consideration of this needs assessment should be the identification of two priorities for children with special health care needs in a recent statewide needs assessment of Maternal and Child Health Needs: 4 Includes all ages unless noted Promote the identification of children with developmental delay Promote the transition of adolescents with special health care needs to adult health care Furthermore, given the large proportion of aging adults 65+ with a disability (39.1%), 5 the living needs (including housing, transportation, health care, and social support) of the aged and disabled population must be strongly considered in community planning. Summary The population of Hawaii County with a disability must not be ignored in a needs assessment as their needs may require special attention. Adults with a disability may require special housing, transportation, and health care services. Early identification of needs among children is needed to lessen the burden of disability on their health and wellness, and special focus may be needed to ensure a smooth transition from pediatric to adult health care. Hawaii County has a higher percent of residents living with a disability compared to the nation, and a much larger proportion of disabled persons who live in poverty. Socioeconomic constraints put this population at further disadvantage Economy Core Indicators and Supplemental Information Economic conditions are highly correlated with health. Core indicator data indicate that poor economic conditions are a problem in Hawaii County: All poverty indicators compare poorly to the rest of state (see Appendix A for all geographic comparison values) The median household income in Hawaii County is much lower than the state value of $66,420 4 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November U.S. Census, American Community Survey, 2011 Estimates 29

31 Between 2006 and 2009, the proportion of students eligible for the free lunch program increased from 38.1% to 44.9% The percent of households receiving cash public assistance is 33% higher than the state average of 3.3% Unemployment (as of June 2012) was higher than all the other counties in Hawaii Table 3.6: Core Indicators Economy Geographically, the highest poverty rates are found in Puna and Kau, 6 as seen in Figure Figure 3.13: Percent of Population Living Below Poverty Level, Map created with Community Issues Management tool: 6 U.S. Census, American Community Survey, Estimates 30

32 Key Informant Interviews Needs/Concerns *Big Island is the last to experience the country s economic recovery, since the local economy is based on tourism, real estate, and construction; people are now finally starting to shop and eat out, carpenters finally getting back to work *Need to diversify economic development opportunities *Focus for now is on keeping businesses alive vs. creating new opportunities. *Limited access to higher education/training opportunities; need to leave the island for some degrees and certifications (like EMT) or drive 4-5 hours round-trip to Hilo *Trying to make UH Hilo a first-class 4-year school, but not enough housing for all the students *Access to care issues push some residents to move from the island Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Some language barriers, but cultural differences may actually have a larger impact *Marshallese population may not be comfortable seeking out health care and services Opportunities/Strengths *Local government is bringing in affordable housing and road projects, transitional housing projects, and streamlining permits to boost employment *Exploring renewable energy sources, such as deep-water energy, geothermal, solar, etc. *Renewed interest in Science, Technology, Engineering and Math (STEM) fields and STEM education due to new 30mm telescope at Mauna Kea observatory *West side of island is opening Hawaii Community College Palama Nui site in 2014, which will help local residents gain qualifications for better jobs *NELOHA adjacent to Hawaii Airport does aquaculture, energy demonstration projects, interesting and diversified job development opportunities *New Kona hospital is in the planning stages Summary Hawaii County is performing poorly on most economic indicators relative to the rest of the state. Poverty is unevenly distributed, both geographically and among race groups. Furthermore, because federal definitions of poverty do not adjust for geographic variations in the cost of living, the data likely does not adequately reflect the proportion of residents who struggle to provide for themselves due to the high cost of living in Hawaii. The economy is widely understood to be a determinant of health, along with education and the social environment, so a poor local economy has many impacts on the health and wellbeing of its residents. However, Hawaii County is starting to see a slow recovery with businesses and new construction projects returning to the area. The new projects are designed to have a lasting impact on the local economy by introducing greater economic diversity and more educational opportunities for the county s residents. 31

33 3.2.6 Education Core Indicators and Supplemental Information Secondary data for Hawaii County shows that its residents generally have higher levels of educational attainment compared to the nation, both at the high school and college levels. In 2010, 4.3% of county residents over age 18 did not have a high school degree, compared to 7.5% of U.S. residents. In , 26.6% of county residents over age 25 had at least a bachelor s degree compared to just 16.9% of the nation. However, a larger proportion of the Filipino and Native Hawaiian populations ages 18 and over do not have a high school degree (8.3% and 7.8%, respectively) compared to the U.S. In addition, data for the North Hawaii region show 3 rd grade students there are falling behind the rest of the state in math and reading proficiency. 7 Key Informant Interviews Needs/Concerns *Need to first address children s health needs so that meeting their educational needs is possible *Many barriers prevent kids from attending school regularly and/or being ready to learn: physical health issues (e.g. conjunctivitis, impetigo, staph infections, lice, etc.), mental health issues, domestic abuse, impacts of drug use, poverty and hunger *Because of the rural setting, transportation options are dangerous and very limited; kids may have to walk up to 5 miles to get home from the bus stop. They skip school if they miss the bus *Meth and medication abuse are rising among students Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Many migrant children; in the first semester of the last school year, 20% of students moved schools at least once to areas with more affordable housing *Relatively large Marshallese student population, who are impacted by poor health and language/cultural barriers *A lot of Micronesians/ Marshallese live in Ocean View, and school is miles away each way *Many Filipino English Language Learner students Opportunities/Strengths *Community health organizations go to schools and provide vision and dental care to students *Single most important thing to be done today is establishing an early learning base *Many after-school support systems are in place today, which are incredibly important *Groups are making home visits to dropouts to re-engage them in learning *Should develop village-oriented efforts to share success and accountability with community *Prioritize funding for children Summary Access to high-quality education influences and is simultaneously influenced by many other factors, including health, the economy, and the social and built environments. While secondary data shows that educational attainment is generally high at the high school and college levels, certain racial/ethnic groups are trailing Voices from the Community [There are] two tiers [of] education for many of the children: excellent if in private school but much less [so] if in public education. 7 From the North Hawaii Outcome Project s Community Health Profile Report 2012, May

34 behind. Key informants stress the huge negative impacts of poverty in Hawaii County on children s preparedness to learn. Children living in poverty are also more likely to encounter difficulties getting to school, and often suffer from poor health due to low health literacy in their communities. Some groups are using schools as a setting to improve student health, which may be the first step in addressing some of the critical issues in Hawaii County s K-12 education, such as chronic absenteeism Environment Core Indicators and Supplemental Information Hawaii County s environmental indicators compare unfavorably to other counties in the state: The county received an F in the American Lung Association s Annual Particle Pollution Air Quality Index grading scale Higher levels of both PBT (Persistent, Bioaccumulative, and Toxic Chemicals) and carcinogens were released in Hawaii County than in either Maui and Kauai counties Of water samples collected from county beaches in 2011, 4% exceeded state health standards for pathogenic organisms Table 3.7: Core Indicators Environment Summary While there may be little that can be done about poor air quality resulting from the island s volcanic activity, care should be taken to limit the amount of pollution released by humans. Air and water quality has the strongest health effect on the most vulnerable in the community, including children and older adults. The presence of pollutants in the atmosphere may most immediately affect those suffering from respiratory conditions, but sustained exposure can lead to an array of other long-term health problems. Poor environmental conditions may also negatively impact tourism, an important component of Hawaii County s economy Exercise, Nutrition & Weight Core Indicators and Supplemental Information Physical activity, diet, and weight have profound effects on chronic disease. Hawaii County is relatively healthy in this topic area by national standards, although it falls behind some of the other counties in the state. Relative to the state average, a higher percentage of adults in the county do not engage in any physical activity (20.2% vs. 19.2% for the state) and are obese (26.4% vs. 23.1% for the state). Obesity is much more prevalent among certain sub-populations, including Native Hawaiians (51.9%), males (29.3%) and adults ages (30.8%). Filipino and Japanese residents are also less likely to engage in 33

35 regular physical activity and eat at least 5 servings of fruits and vegetables per day (see Appendix A for all values). Furthermore, a recent statewide needs assessment of Maternal and Child Health Needs identified reducing the rate of overweight and obesity in young children ages 0-5 as a priority for children in the state. 8 Key Informant Interviews Needs/Concerns *Need for more required physical activity and education in schools *Though sugar-sweetened beverages are less available in schools, parents bring in snacks not compliant with USDA policy *Need more walkable/bikeable communities less reliant on cars *Need for improved food hubs and access to farm foods on the Big Island Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Low-income residents have limited access to safe walking routes *Traditionally, Micronesians stayed physically active just through their daily work; now must find a way of promoting the concept of exercise for good health Opportunities/Strengths *Farmers markets now accept EBT, and have double dollar days Summary Given its large impact on health outcomes, Hawaii County residents would benefit from improved exercise patterns, eating habits, and weight control. Children should be introduced to beneficial nutritional and fitness concepts at a young age to encourage a lifetime of health. Certain sub-populations are more likely to exhibit unhealthy behaviors, perhaps reflecting a need to frame the importance of physical activity and good nutrition in culturally-relevant terms. Potential avenues for improving health in this area include enhanced education on nutrition and physical activity, increasing access to healthy foods, and providing support and incentives for weight control. Voices from the Community Obesity and lack of exercise are pervasive and the root causes of most of the chronic health problems people have around here. More social outlets such as sports, exercise classes, education about nutrition and cooking would ameliorate this significantly and contribute to the community's cohesiveness and spiritual wellbeing. 8 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November

36 3.2.9 Family Planning Core Indicators and Supplemental Information Data indicate significant family planning issues in Hawaii County, with particularly large disparities: The county s teen birth rate is 32% higher than the state average of 52.6 births/1,000 women ages 15-19, and is extremely high among Native Hawaiians (196.6 births/1,000 women ages 15-19) The proportion of infants born to mothers with less than 12 years of education is twice that of the best Hawaii county (Honolulu, at 5.8%) The percentage of pregnancies that are intended (52.4%) does not meet the HP2020 target of 56% Table 3.8: Core Indicators Family Planning Furthermore, a recent statewide needs assessment of Maternal and Child Health Needs identified reducing the rate of unintended pregnancy (including a focus on teen pregnancy) as a priority for Women and Infants. 9 Key Informant Interviews Needs/Concerns *Hawaii County has highest teen birth rates in the state *Cultural acceptance of teen births *Schools' education and training programs for teen birth prevention are inadequate *Lack of options for teens that steer them away from alcohol, drugs, and other things that lead to promiscuous behaviors *Teen mothers who do not seek prenatal care end up with high-risk deliveries; Hawaii County has one of the highest infant mortality rates Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Poverty levels, low education levels lead to poor choices and/or a lack of understanding of available options *Cultural differences in how Pacific Islanders view pregnancy, birth control, family planning, child rearing, women's health, and STDs *The best way to reach Pacific Islanders is through church, but this limits discussion of topics like family planning/stds Opportunities/Strengths *Should partner with DOH, hospitals, DHS to improve access to services for disadvantaged expectant mothers 9 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November

37 and highest incidence of low birth weight partly as a result of limited prenatal care Summary Family Planning is an area of need in Hawaii County, especially for disadvantaged teens. Access to longacting, reversible contraception would help reduce the proportion of pregnancies that are unintended, but the cost of these family planning methods is prohibitive in some communities. The high teen birth rate is problematic for the social and educational development of mothers and healthy birth outcomes for newborns. Certain cultural differences compound the difficulties in promoting family planning among the populations most affected Heart Disease & Stroke Core Indicators and Supplemental Information Strongly driven by poor lifestyle patterns, heart disease and stroke are a major concern for Hawaii County. The score for this topic ranks it fourth among the core indicator areas. Notable findings include: High blood pressure incidence increased from 23.7% in 2003 to 30.1% in 2009 High cholesterol incidence increased from 25.9% in 2003 to 39.3% in 2009 Death rate due to heart disease is extremely high among American Indians/Alaska Natives (386.2 deaths/100,000 population), Blacks/African Americans (305.9 deaths/100,000 population) and Native Hawaiians/Pacific Islanders (274.3 deaths/100,000 pop) The stroke death rate in the county is 41% higher than best Hawaii county (Maui, at 28.1 deaths/100,000 population) Table 3.9: Core Indicators Heart Disease & Stroke Hospitalization Rates Among Hawaii counties in 2011, Hawaii County had the highest rate of hospitalization due to hypertension, and the second highest due to heart failure. While East Hawaii experienced higher rates of hospitalizations due to hypertension in 2011, West Hawaii had the highest rates of heart failure hospitalizations in the county. The rate of angina without procedure is only available for East Hawaii due to low counts. 36

38 Figure 3.14: Hospitalization Rates due to Heart Disease, 2011 Key Informant Interviews Needs/Concerns *Big Island has a higher stroke death rate than other islands *Higher incidence of high blood pressure, which is frequently uncontrolled due to limited primary care access *Higher rates of hospitalization and death due to congestive heart failure *Need for improved primary care access and economic development to prevent, manage, and reduce Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Poverty and obesity are linked, and both contribute to heart disease *Access to care on the island is an issue for both the insured and uninsured, but people with means can fly elsewhere to receive care *Hawaiians and Filipinos are disproportionately affected by cardiovascular disease *Filipinos have disparities that may be partly due to more recent immigration, language barriers, and Opportunities/Strengths *Hui Malama, a Native Hawaiian health organization, now collaborating with several FQHC and working to do culturally appropriate care and prevention *Beacon Project brought a lot of providers together; a big opportunity to sustain the collaboration that is emerging *Opportunities for using telemedicine to provide stroke care for residents living in remote areas *Economic development of the 37

39 hypertension lack of translators *No distinction in data between recent immigrants and people who have been in in Hawaii for several generations health care sector could provide jobs and increase access. Great need for outpatient ambulatory primary care on the island Summary The greatest barrier to cardiovascular health on the Big Island is the limited access to care. Many residents, especially the poor, cannot receive the preventive or management care they need. Language is an additional obstacle for the recent immigrant population in Hawaii County. Cardiovascular health is a big issue on the island, but there are also many emerging opportunities for collaboration in this area. Economic development, especially in the health care sector, would address some of the problems that make cardiovascular health such a large concern in Hawaii County Immunizations & Infectious Diseases Core Indicators and Supplemental Information Infectious disease incidence rates in Hawaii County are low compared to the state. Rates of syphilis and acute hepatitis B (both 0.6 cases per 100,000 population) and tuberculosis (3.2 cases per 100,000 population) are the lowest of any county within the state. Incidence rates of infectious diseases have also been trending in a good direction over the past few years, with the exception of chlamydia. However, rates of vaccination among county residents ages 65 and over against influenza (67.0%) and pneumonia (64.3%) compare unfavorably to the nation, the state, other Hawaii counties, and the HP2020 target (see Appendix A for geographic comparison values). Caucasian and male seniors are least likely to receive these vaccinations. Hospitalization Rates Hawaii County had the lowest rate of hospitalization due to bacterial pneumonia of all Hawaii counties in However, bacterial pneumonia was the fourth most frequent cause of hospitalization (n=252) in the county among the 15 preventable causes studied. By Hospital Service Area, the highest rate was in West Hawaii. Figure 3.15: Hospitalization Rates due to Bacterial Pneumonia,

40 Key Informant Interviews Needs/Concerns *Growing trend of vaccine refusals *Rural communities and Neighbor Islands have difficulty with access to care, which is necessary for routine vaccinations *Culture of solo practitioners rather than group practices in the state, so people may have trouble seeing their doctors when they need to *Foodborne diseases and noroviruses are highly communicable and have caused many outbreaks in the state *Limited tracking and surveillance resources for respiratory pathogens *Growing issue of hospital-borne infections and resistant bacteria, which are spurred by inappropriate frequent use of antibiotics *Zoonotic diseases are a concern in the state; mice and rats harbor diseases in the tropical jungle and they spread through vectors like fleas Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Growing Micronesian migrant/immigrant population that has not received immunizations and do not have health records *Misinformation and mistrust prevent Micronesians from receiving the care they need *Higher rates of Hep C and vaccination-preventable Hep B with immigrants and IV drug users *In rural areas with no access to primary care, burgeoning use of homeopathic medicine, which frequently is not science-based and can be harmful to patients *Patients who are quickly discharged from hospitals in Oahu may return to rural homes without the resources (running water, electricity) to maintain their treatment regimen Opportunities/Strengths *School-located vaccination programs have created some strong and nontraditional partnerships *Partnerships with schools, schools of nursing, health insurers, general community, and healthcare providers helps with communication Summary Overall, Hawaii County is trending well in terms of infectious disease incidence. However, core indicator data shows that low vaccination rates are an issue among older adults. The frequent hospitalizations due to bacterial pneumonia could, in many cases, be prevented by increasing vaccination rates among adults ages 65 and older from the 64.3% coverage rate to the HP2020 target of 90% coverage. Key informant interviews also indicated that refusals of children s vaccines are a growing problem in the state. The terms of the Compact of Free Association (COFA) present a unique challenge to infectious disease management in the state, as residents of COFA nations can enter and leave Hawaii without medical records or immunizations. Rural residents are especially vulnerable to infectious diseases as they live closer to some vectors of disease and do not have easy access to primary care. Voices from the Community Hepatitis and STDs (including HIV) really do need some focused attention as Big Island rates are higher than the rest of the Neighbor Islands. 39

41 Injury Prevention & Safety Core Indicators and Supplemental Information Injuries are a concern for Hawaii County; some types of injury cause significant deaths and hospitalizations among residents: All injury death rates are higher than the state averages (see Appendix A for geographic comparison values) The death rate due to poisoning increased from 13.5% in to 15.8% in While the hospitalization rate due to assault is lower than state average, it is 2.6 times that of best Hawaii county (Kauai, at 6.3 hospitalizations/100,000 population) Table 3.10: Core Indicators Injury Prevention & Safety Key Informant Interviews Needs/Concerns * More than half of the county s trauma fatalities are from alcohol and drugs, drinking and driving *Cultural acceptance of drinking and driving *A lot of DUI drivers are repeat offenders *High diabetes prevalence, which complicates trauma injuries *Lack of mental health resources Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *High injury rates among Hawaiians, Caucasians and Micronesians *Health disparities might not seem as obvious as with chronic disease, but they do exist *Car seats and helmets may be costly for low-income families *People with less education may be less likely to engage in protective risk reduction factors (e.g. wearing a Opportunities/Strengths *Opportunity for EMS and hospitals to partner to help outpatients reduce readmissions and improve health. EMS could have access to medical records and communications with providers, and could use down time to help recently-discharged patients. Especially in rural areas, hard-toreach areas, or places where transportation is difficult (e.g., Ka'u) *North Hawaii Outcomes Project 40

42 *Fall prevention for elderly, since falls are the #1 cause of hospitalization and a communityidentified priority in the state seatbelt) *Not every culture believes in or values prevention *Some communities/groups are less likely to call 911 or for ambulance services has a group focusing on crash reductions Summary In Hawaii County, injuries of many kinds lead to high death rates. Injury and safety concerns are compounded by a cultural avoidance of prevention and a shortage of primary care providers. Rural communities on the Big Island also have limited access to emergency medical care, an issue that could potentially be alleviated by enhancing the role of EMS professionals Maternal, Fetal & Infant Health Core Indicators and Supplemental Information Hawaii County has met all the maternal, fetal, and infant health HP2020 targets, and race and age disparities are relatively small in this area. However, the county performs worse relative to other counties in the state. Smoking during pregnancy is much more common on the Big Island than in the state overall (15.4% vs. 9.6%) and is increasing over time. A higher percent of mothers also binge drink during pregnancy (29.1% vs. 23.1%), indicating potential need for improved education on maternal risk factors. Furthermore, a recent statewide needs assessment of Maternal and Child Health Needs identified reducing the use of alcohol during pregnancy as one of its priorities for Women and Infants. 10 Hospitalization Rates Compared to other Hawaii counties, Hawaii County had the second-lowest rate of Low Birth Weight among its newborns in 2011, with the highest rate on the island found in East Hawaii. Figure 3.16: Low Birth Weight Rate per 100 Live Births, From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November

43 Key Informant Interviews Although no key informant spoke specifically to maternal, fetal, and infant health in Hawaii County, this topic area came up in discussions of related issues: Many teen mothers do not seek adequate prenatal care and have high-risk deliveries Hawaii County has high rates of infant mortality and low birth weight partly because of limited prenatal care Smoking during pregnancy is a big concern on the island There are cultural differences in how Pacific Islander women view pregnancy, which need to be addressed when providing care There s a need to improve access to services for disadvantaged expectant mothers, which may be achieved through a partnership with DOH, hospitals, and DHS Summary Infants and mothers in Hawaii County would benefit from improved prenatal care and maternal education about substance use during pregnancy. In general, teen mothers on the island do not utilize prenatal care resources, which results in many negative impacts for the child. Community members identified the lack of maternal and fetal care services in the county as a major barrier to improving this area of health, which was affirmed in key informant interviews. Voices from the Community Maternal and fetal health care is badly stressed in this area. The demand for midwifery services is far beyond the current availability island-wide Mental Health & Mental Disorders Core Indicators and Supplemental Information Mental Health ranked second highest among core indicator topic areas in Hawaii County, based on these poor comparisons: The county s suicide rate is 48% higher than the state average (13.1 deaths per 100,000 population), and does not meet the HP2020 target of 10.2 deaths per 100,000 population. The rate has jumped from 10.8 to 19.4 deaths per 100,000 population between and Native Hawaiians have the highest rate, at 58.2 deaths per 100,000 population. The percent of adults with a depressive disorder is more than 35% higher than the state average of 8.9%. Mental health services in Hawaii County are not able to meet the need for care. The Health Resources and Services Administration has designated both North Hawaii and Kau (shown Figure 3.17 with included Figure 3.17: Federally-Designated Mental Health Professional Areas and Population Groups by Census Tracts 42

44 census tracts) as mental health professional shortage areas. Puna is also recognized as an area where certain populations have limited access to mental health providers. Table 3.11: Core Indicators Mental Health & Mental Disorders Hospitalization Rates In 2011, mental health was the most frequent cause for hospitalization among the 15 different supplemental hospitalization indicators that were studied: 1,036 hospitalizations were due to Mental Health in Hawaii County, almost three times the condition with the second-highest number of hospitalizations, heart failure (364 hospitalizations). Almost all mental health admissions were among ages (93.5%), even though this age group represents only 62.3% of the total population. Also, more than half of mental health admissions were for males (59.7%). Figure 3.18 presents the proportion of Mental Health hospitalizations by race as well as the population proportions of these race groups according to HHIC provided data. While Whites only make up 35% of the county population, 56% of Mental Health hospitalizations were among Whites. Japanese and Filipinos had a disproportionately low number of hospitalizations relative to their populations. Because mental health hospitalization rates are not risk or age adjusted, the mental health admission rates are not compared across geographies due to uncertainties in varying population characteristics. All 2011 values are included in Appendix B. Further data on mental health hospitalizations at a sub-county level can be found in the State of Hawaii Primary Care Needs Assessment Data Book Figure 3.18 Mental Health Hospitalizations by Race: Hawaii County, Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Primary Care Needs Assessment Data Book 2012, July

45 Key Informant Interviews Needs/Concerns *Suicide epidemic, particularly among young males. Tied in with economic circumstances, chemical dependency, problem drinking *Suicide rates have doubled in last decade *Mental health and substance abuse often connected *Need to integrate physical and mental health areas, as many physical health issues are tied to mental health issues like depression or anxiety *Need far outstrips the available resources *Most children served by Child and Adolescent Mental Health Division are on Big Island *Shortages of psychiatrists are increasing over time in rural areas of Hawaii County as the few psychiatrists available are starting to reach retirement age *DOH adult mental health division services have been cut; some case management services are no longer available *Inadequate resources for the severely mentally ill and the persistently mentally ill *Few pain management specialists that can provide integrated care for addiction to pain meds Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Suicides affect Native Hawaiian community more *Stigma associated with mental health issues; in some cultures, they are a source of shame *Mental health issues common among homeless population *Few behavioral health providers who accept Medicaid/Medicare/SSI even though there is huge need in those populations *Marshallese culture is often misunderstood in schools, hospitals, and other public entities, which alienates the Marshallese and pushes them away from seeking services Opportunities/Strengths *Difficult to build capacity around physicians; need to look at other innovations and adjustments in technology that will reach rural communities in need Summary Indicators of mental health in Hawaii County show this is an area of great need. Suicide rates have increased rapidly and are a growing concern. Mental health problems lead to the largest number of hospitalizations in the county among the preventable causes studied. Mental health issues are stigmatized in some cultures, preventing some residents from seeking the care they need. Key informants note that access issues are particularly acute in mental health care, as the number of qualified mental health professionals dwindle even as needs grow. Innovative solutions are required to close the widening gap between need and capacity. 44

46 Older Adults & Aging Core Indicators and Supplemental Information Little data specific to older adults was available among the core secondary data indicators. The rate of hospitalization due to falls among people aged 65 and older in Hawaii County is lower than the state average (Figure 3.19), although the rate has increased slightly between 2003 and As seen under Immunizations & Infectious Diseases (section ), vaccination rates among Big Island residents ages 65 and older have not met Healthy People targets and compare unfavorably to the rest of the state. A greater proportion of adults 65 and older live in poverty compared to the state overall, as discussed in the Economy section (3.2.5). According to the 2012 Hawaii County Community Health Profile, 12 Hawaii County has the highest percentage in the state of seniors living alone, at 9.2%; the state average is 8.6%. Hospitalization Rates Overall, most hospitalizations occur among older adults. With the exception of Hospitalizations due to Short-Term Complications of Diabetes and Mental Health Hospitalizations, the unadjusted hospitalization rate was much higher for adults aged 65 and older. Key Informant Interviews Needs/Concerns *Hospice care is filling a primary care gap for some people, who enter a hospice and discover they have chronic diseases that they weren t aware of and haven t addressed *People are moving away for assisted living services; nothing like that available on the island *High turnover in providers affects continuity of care *Bad economy plus payers/medicaid requiring people to be more ill before they are qualified for resources is leading to higher acuity of illnesses at entry to long-term care than the norm 10 years ago Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Most people prefer to stay at home if they can afford it; those who can t enter long-term care facilities *Filipino, Japanese, Hawaiian groups have a culture of caring for the older generations themselves at home Figure 3.19: Unadjusted Composite Hospitalization Rates, 2011 Opportunities/Strengths *A lot of community support for hospice care in North Hawaii, where there is an annual fundraiser to allow the North Hawaii Hospice to provide services to everyone, regardless of their ability to pay *A group at the North Hawaii Education Research Center brings a lot of resources from all over the island to address home- and community-based services for elders 12 From the North Hawaii Outcome Project s Community Health Profile Report 2012, May

47 Summary Although health data for seniors is lacking, the longevity in Hawaii is leading to an increased need for care for seniors. In Hawaii County, the older residents are affected by provider shortages, just like the rest of the population. However, the lack of services is forcing some of the elderly population to move away in search of adequate care. Coordination of care for seniors on the island could reduce the burden of managing advice and medications from multiple providers and more effectively deliver health services for this growing population Oral Health Core Indicators and Supplemental Information Oral health among Hawaii County s adult population measures unfavorably against the rest of the state. The percent of adults who visited a dentist in the past year (62.9%) is also lower than the national average of 69.7%. Certain populations are less likely to visit a dentist for any reason: Filipinos (46.6%), Native Hawaiians (48.8%), males (61.2%) and adults ages (51.1%). However, this indicator, along with the percent of adults ages 65 and over with total tooth loss (8.8%), both meet their respective HP2020 targets of 49% and 21.6%. Although no oral health indicators in the summary addressed children, a report by the Pew Research Center gave the State of Hawaii a grade of F for meeting only one out of eight benchmarks for key policy indicators. In The State of Children s Dental Health: Making Coverage Matter, 13 Hawaii compared poorly to the nation due to several factors, including: Sealant programs were in place in 0% of high-risk schools in 2010 Optimally fluoridated water was provided to only 10.8% of citizens on community systems in 2008 As of 2010, the Medicaid program does not reimburse medical care providers for preventive dental health services Key Informant Interviews Needs/Concerns *Many dental professionals do not accept insurance since they are only reimbursed a fraction of their costs *School-based dental program that provide basic cleanings for students disappeared *Water supply is not fluoridated *People view medical and dental health as separate things, when poor oral health often exacerbates medical issues *Shortage of pediatric dentists Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Pacific Islander immigrants oral health issues may be related to lack of education, malnutrition, and changes in diet *Med-QUEST only covers emergency services; no prevention/ongoing visits means a large group of poor people with no teeth *Hamakua provides affordable general dentistry for adults, so people from Kona, Puna, and Pahoa come stand in line for a long time Opportunities/Strengths *Mobile dental care vans are now providing services to those who didn t have access before *Hamakua dental van goes to Waimea elementary school and treats Marshallese students *Partnership with Kaiser Permanente and the University of Iowa School of Dentistry brought residents to the Big Island for 2 days of clinics, during which they treated 100 children *Maui professionals are helping 13 From the Pew Research Center s The State of Children s Dental Health: Making Coverage Matter, May

48 *In the past, money has been allocated to transport children from Big Island to Oahu to get dental care, when it might have been better invested in improving local dental care *Gap group in medical care who don t qualify for Med-QUEST but who can't afford to pay for care, especially if chronic condition/disease because it isn't available anywhere else *Very few private dentists accept Medicaid *Growing Hispanic population in Kona; they are often afraid to access services because of immigration reasons *Reliance on telephone- and familybased language translation with hospital dentistry on Big Island *Doctors could be reimbursed for applying fluoride varnish on teeth at well baby visits to prevent tooth decay *Dental hygienists could go into schools and other clinics, but current legal restrictions prevent that *Some dental services have a sliding fee schedule to improve access for low-income patients Summary Given the large impact oral health has on overall health and wellbeing, it is important that Hawaii County residents have access to and utilize preventative dental care. Both insurance coverage and access to dental care are necessary to maintain good oral health. Another critical component is education about the importance of dental care, particularly among new immigrants who may not have a tradition of prioritizing oral health. The need for pediatric dental care can be easily overlooked; data on children s oral health is very limited and federal designations of dental health professional shortage areas do not account for the availability of pediatric dental care. Possible avenues for improving oral health include strengthening Medicaid coverage and supporting dental care provided through community health centers. Mobile vans have already improved access immensely on the Big Island, but key informants emphasize that pediatric dental care is still an area of great concern in the community Respiratory Diseases Core Indicators and Supplemental Information Respiratory diseases ranked highest among the core indicator topic areas of concern in Hawaii County, due to its unfavorable comparisons to the rest of the state and nation: The percent of adults with asthma in the county is 28% higher than state average of 9.4% and 32% higher than the national average of 9.1%. Asthma prevalence is highest among Native Hawaiians (23.9%), women (14.5%), and adults ages (16.6%) The percent of children with asthma is 28% higher than state average of 11.1% The Big Island does not perform well on related environmental indicators: the county scored an F from the American Lung Association on its particulate pollution grading scale. Table 3.12: Core Indicators Respiratory Diseases 47

49 Hospitalization Rates While the rate of hospitalizations due to COPD or asthma in Hawaii County adults ages 40 and over is the second lowest in the state, hospitalization data shows a relatively high rate of asthma among adults under 40. East Hawaii sees the highest rate of hospitalizations in the county on both indicators. Key Informant Interviews Needs/Concerns *Tobacco-related respiratory illness is preventable *Women who are pregnant and smoking is a concern; women who resume smoking after pregnancy also put children s respiratory health at risk *Asthma correlated with obesity for Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Lower socioeconomic levels correlated with higher smoking rates *Within the state, Native Hawaiian, Pacific Islander, and Filipino populations also have higher smoking rates *Asthma more prevalent with Opportunities/Strengths *Hawaii County passed legislation for smoke-free beaches *The state of Hawaii s progressive laws have positively impacted smoking rates in last 10 years * Catch a roach program in public housing helps reduce this asthma trigger 48

50 unknown reasons *Asthma prevalence is significant in kids ages 0-4 *Asthma most common reason for child to be hospitalized *Asthma causes school absenteeism and grades drop *In general, Hawaii County has higher smoking rates, higher unemployment, and lower incomes *Higher rates of asthma on the Hilo/East Hawaii side. Originally attributed to vog (volcanic smog), but 2 big studies did not prove the connection between vog and asthma attacks. Could be that Hilo is wetter and it's mold/mildew, not vog, exacerbating asthma poverty; higher rates where housing conditions are not good *Native Hawaiians have highest rate of asthma & chronic disease *Chronic disease self-management programs *Data collection and analysis efforts play an important role in educating and empowering people *Community health centers are a great model Summary Respiratory disease is a health issue with high disparity in Hawaii County. In general, people living in poverty are more likely to smoke and more likely to live in conditions that may trigger asthma. Residents of the Big Island in particular are more likely to smoke and live in poverty than the rest of the state. Within the county, Native Hawaiians, women, and residents of East Hawaii are more likely to have asthma. Controlling asthma is particularly important for children, whose education can be negatively affected by the disease if the school environment is not able to provide asthma medication support. Key informants praise progressive laws that have made an impact on smoking rates, and recommend chronic disease self-management programs and further data collection and analysis efforts in this area. Hawaii County s residents have more exposure to volcano-emitted gases Social Environment Core Indicators and Supplemental Information Little data was available among the core indicators that directly pertain to the social environment. A higher proportion of children in Hawaii County live in a single-parent family household than in other Hawaii counties and the nation. Other topic areas, such as economy and education, are closely linked to the social environment; there are significant concerns for Hawaii County in both of these. An additional consideration for the social environment is the inclusion of two priorities in a recent statewide needs assessment of Maternal and Child Health Needs: 14 Reduce the rate of child abuse and neglect with special attention on ages 0-5 years Prevent bullying behavior among children with special attention on adolescents age From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November

51 Key Informant Interviews Needs/Concerns *Hawaii County ranks at bottom of all 4 counties in chronic disease disparities because county is last in terms of economic prosperity *Population health is all about the social determinants *Welfare recipients doubled in Hawaii County between 2010 and 2012 *High levels of poverty, and the highest free/reduced lunch rate in the state. In Pahoa, almost all students are eligible for free/reduced lunch *High rates of domestic abuse, drug abuse, child abuse in the community. Children need emotional and physical support to reach their full potential *High rates of alcohol/drug use, even at a young age Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *People in poverty are not equipped to address health needs; have too many other pressing concerns *Need for more translators, particularly Spanish and Marshallese Opportunities/Strengths *Could encourage economic development to boost health outcomes *Community health organizations provide many services to students and people living in remote areas *Kids are self-reliant, they know how to hunt and fish, create music *Kids love to participate in sports: most Kau High students are involved in school athletics, it s what brings them together Summary Largely driven by economic insecurity, social issues such as unemployment, education, alcoholism, and domestic violence all influence a community s health. Low-income residents are most impacted by poor social environments that limit opportunities for economic and social advancement. This is a particular concern in Hawaii County, which has the highest rates of poverty in the state. Key informants highlight the many aspects of the Big Island community to be proud of, including collaborative efforts and kids ties to nature, but they also recognize that there are many issues on the island that stem from the poor local economy. Voices from the Community We need a family shelter and an inpatient psychiatric hospital in the area. More access to resources for the homeless in our area. More access to assisted care for the elderly who can not afford it Substance Abuse & Lifestyle Core Indicators and Supplemental Information Measures of substance abuse in Hawaii County indicate that there are large disparities in this area. Core indicator data includes measures of adult substance abuse and liquor availability: 50

52 The percentage of adults who binge drink is highest for Native Hawaiians (23.8%), Caucasians (20.5%), and adults ages (31.1%) The proportion of adults who smoke is 36% higher than state average of 14.5%, and does not meet the HP2020 target of 12%. Smoking prevalence is highest for adults ages (34.8%) Table 3.13: Core Indicators Substance Abuse & Lifestyle In Hawaii County in , the overall percent of hospital admissions that were associated with a substance related disorder (11.4%) was higher than the state average of 8.9%. The highest rates in the county were found in North Kona (13.8%), South Kona (13.7%), and Puna (13.3%). 15 Key Informant Interviews Needs/Concerns *Significant need in drug and alcohol addiction, and related problems like accidents and psychosocial disorders *There is no substance abuse inpatient facility for adults on Hawaii Island *There are few/no psychologists available to treat addiction and mental health problems *Overlay with mental/behavioral health: a portion of pain management patients are also drug seekers Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Low-income population particularly struggles with substance abuse issues *With Marshallese population and others, there are issues related to language and culture; need for translation Opportunities/Strengths *A medical alcohol detox program on the island is in its initial planning stages, would eliminate the need to send patients to other counties Summary Substance abuse is correlated with mental health and economic issues, all of which are areas of concern in Hawaii County. Smoking is particularly prevalent among residents of the Big Island, and certain segments of the population are more prone to binge drinking. The county s limited access to care makes 15 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Primary Care Needs Assessment Data Book 2012, July

53 substance abuse treatment more difficult, as some patients must be referred to other islands for treatment. Intervening on psychosocial disorders and other mental health issues may indirectly assist in controlling substance abuse in Hawaii County. Voices from the Community Hawaii Island suffers tremendously because of unaddressed substance abuse disorders. Prevention and treatment must be strengthened Transportation Core Indicators and Supplemental Information A reliable transportation network is essential for accessing health services and educational/employment opportunities. The largely rural environment of Hawaii County poses a challenge for residents to get around quickly or to travel without a car: The mean travel time to work in the county is 32% longer than the best Hawaii county (Kauai, 19.9 minutes) The percent of workers commuting by public transportation is lower than the state average of 6.0% The percent of workers who walk to work is also lower than the state average (4.7%), and is particularly low among those ages (just 1.8%) Table 3.14: Core Indicators Transportation Key Informant Interviews Needs/Concerns *County has expanded public transportation island-wide, but not within certain communities *Not enough buses, especially smaller ones that would be used for Impact on Low-Income, Underserved/Uninsured, Race/Ethnic Groups *Transportation issues impact the low-income and elderly most *Only a small fraction of the elderly that need transportation to doctors appointments are being reached; Opportunities/Strengths *Could try to use nonprofits vans when they are not in use, but there is a liability issue that prevents vehicle sharing *Big Island community has a very 52

54 shorter routes; trying to get federal funding to increase the fleet this affects their ability to receive care *The high cost of gas can force some low-income families to make difficult choices between going to work, the doctor s office, grocery store, etc. special sense of helping each other and really caring for each other Voices from the Community Transportation to and from medical appointments is very limited in this community. Travel distances are long. Summary Hawaii County has the largest land area, lowest population density, and highest poverty rate of any county in the state. This combination means that transportation issues are a significant concern for many Big Island residents. Low-income residents are the most impacted by limited bus routes and the high costs associated with car ownership. Transportation shortages in turn impact residents ability to get to job opportunities, as well as to receive care. Many key informants in other topic areas mentioned transportation as a barrier to accessing care on the island. Although public transportation options have expanded in recent years, additional innovative solutions are required to fully address the need. 53

55 4 Community Health Needs Summary 4.1 Findings/Conclusions The community health needs of Hawaii County span across all of the topics included in this report. Some health issues impact a larger proportion of the population, while others are of greatest impact to particular groups or sub-geographies. In order to assess the health needs of the Big Island, both objective data and subjective interviews were considered. While data gave a good starting point for determining where attention should be focused, sometimes the data was lacking in depth or breadth on important topics. Interviewing key informants who have local knowledge on the topics helped to fill in details and bring attention to data gaps. Surveying residents elicited health concerns from a small proportion of the community and added highlights to this. Planners will want to consider how to impact these areas, as many areas can be addressed concurrently with appropriate primary and holistic interventions. Several common themes emerge in this assessment that can guide community health improvement planning: All groups experience adverse health outcomes due to chronic disease and health risk behaviors While significant disparities exist, chronic diseases like heart disease and stroke, cancer, diabetes, and asthma affect many residents of Hawaii County. Moreover, key health behaviors that impact chronic disease, including optimal exercise, nutrition, and weight, need attention across all age, gender, and race/ethnic groups. Chronic diseases and their drivers are becoming more prevalent in the county. Cancer screening rates are low, obesity has been on the rise, and diabetes is going undiagnosed. Unmanaged heart disease has led to high rates of hospitalizations and deaths among residents of the Big Island. Residents of the Big Island are at special risk for chronic respiratory problems, evidenced by the unusually high asthma rates and the high rates of hospitalization due to COPD and asthma. Factors contributing to poor respiratory health include high smoking rates, high particulate pollution and exposure to unusual volcanic gases. Particularly alarming is the rise in poor health outcomes and risky behaviors among children and teens. Children in the state of Hawaii are much more likely to develop Type II diabetes than their counterparts in the rest of the U.S., partly due to the low levels of physical activity in the county among residents of all ages. Attention to this area at many levels could have an enormous positive impact on the long-term health of the community. As a chronic condition that significantly influences overall health, mental health and associated substance abuse arose repeatedly throughout key informant interviews as a concern in Hawaii County. The low-income population is particularly afflicted by substance abuse. In addition, many injury-related hospitalizations and deaths may be attributable to substance abuse, including motor vehicle collision deaths caused by driving under the influence of alcohol. In recent years, the suicide rate has increased drastically in the county. Depression induced by poor nutrition, inadequate sleep, and stressful family dynamics are detrimental to young peoples well-being and educational success, and drug use among teens further inhibits learning. Teens need more activity options that steer them away from drugs, alcohol, and teen pregnancies. Stress is also considered to have a negative effect on health behaviors, further worsening the chronic conditions mentioned above. Greater socioeconomic need and health impacts are found among certain groups and places in Hawaii County Primary data across many topic areas stressed that the low-income residents of Hawaii County are the most impacted by health problems and often also the most difficult to help. The entire county has 54

56 higher rates of poverty than the other counties in the state, and poverty is most concentrated in Puna and Kau. Furthermore, because Census estimates of poverty do not adjust for the higher cost of living in Hawaii, the number of Hawaii County residents impacted by poverty is likely underestimated. Key informants said the Big Island s underserved populations are determined by geography more than by ethnicity; however, the Native Hawaiian and Pacific Islander populations were mentioned frequently as the groups most impacted by limited access to care and a variety of chronic conditions and poor health outcomes. Some areas identified as having particularly large disparities are heart disease, diabetes, and teen birth rates. When planning for heath improvement, careful consideration should be given to highest-need groups identified geographically from socioeconomic measures. Low-income families often have limited access to healthy food outlets and recreational facilities, and are less likely to engage in healthy behaviors that can prevent chronic disease. People living in poverty are more likely to suffer from asthma as a result of poor housing conditions, and are limited to residence choices by a lack of affordable housing. Older adults are often unable to afford the transportation and living accommodations required for special health needs. Cultural and language barriers inhibit effective intervention for the most impacted populations Because of the strong correlation between poverty and race/ethnicity, some of the groups most impacted by health issues often face cultural barriers to health improvement. Language differences, including limited English proficiency, and poor health behaviors that are common within a culture are challenges that must be overcome in order to effectively prevent disease. Key informants called for improved translation services for the Spanish-speaking, Micronesian, and Filipino populations in particular. Misinformation, mistrust, and a reluctance to seek care from providers of a different culture prevent many Micronesians in Hawaii County from accessing preventative care and treatment. Differing views of pregnancy, birth control, and women s health across the cultures represented on the Big Island also impact the rates of cancer screening, prenatal care, and teen births. Key informants identified church settings as the best venue for reaching the Pacific Islander populations, but noted that this restricts the discussion of topics like family planning and STDs. See Section for further discussion of health disparities by race/ethnicity. Limited access to care results in greater health impacts Like the other Neighbor Islands, Hawaii County suffers from limited access to various types of care. The Health Resources and Services Administration has designated the entirety of the county as medically underserved ; large areas are designated as mental health provider shortage areas as well. Although the public transportation system has expanded over the years, many communities still cannot rely on public buses as their primary mode of transportation, and need to seek alternative options to get to their appointments. Issues relating to access were mentioned most frequently in the key informant interview process. Key informants commented on a loss of providers due to attrition and retirement, and noted the problem will worsen unless something is done to attract and retain more providers. The shortage of primary care providers in particular is associated with the high prevalence of uncontrolled hypertension and diabetes. Centers for cancer prevention, screening, and treatment are mostly located on Oahu. Substance abuse and mental health issues are significant in Hawaii County, but there are few resources for care and treatment on the island. Within the county, there is no substance abuse inpatient facility for adults. The shortage of mental health services means other segments of the health care system, including emergency departments and primary care providers, are overwhelmed by the large need in this area. In 55

57 addition, there are inadequate resources for the severely mentally ill. The acute shortage of providers on the Big Island is driving some residents to move elsewhere in seek of care. Community health centers and schools are key community assets for effective interventions Given the barriers described above, several key informants recommended focusing on intervention through community health centers. Locally-based care has many advantages, including the ability to bring primary care services that are culturally appropriate to rural areas. In addition, key informants noted the centers could fill some provider gaps as shortages worsen. Staffing community health centers with residents from the served community offers opportunities for economic advancement and improved social environment. Health interventions for children and teens can have a two-fold benefit of establishing healthy life-long behaviors among Hawaii s youth, as well as influencing the health of their families. Beginning health education early in life is now more important than ever, as more young people are developing diabetes or cancer and not seeking care until the disease is in a more advanced stage. Preventative services and education on health risks can be effectively delivered in school environments. Key informants often recommended interventions that are school-based or involve collaboration with Hawaii schools. Some groups are already visiting schools to provide vision and dental care, which key informants hope will expand to more schools on the island. School-based vaccination programs on the island have already seen positive results. Improved family planning education in schools could help curb the high teen pregnancy rates in the county. Childhood obesity can be addressed in school by increasing physical activity time and sports activities, an important step towards reducing future chronic disease. Schools can also play an important role in addressing substance abuse, an increasing problem among teens Disparities Highlights Although the root causes of health disparities are attributable to socioeconomics, race/ethnicity is a correlate for which data is more often available. The topic areas for which each race/ethnic group was noted to have a severe disparity (either by a key informant or for at least one indicator) are listed in Figure 4.1 below. Note that some race/ethnic categories differ between secondary data sources, and the degree to which disparities could be assessed depend on data availability. A significant finding is that Native Hawaiians and Pacific Islanders are faring worse across more topic areas than any other group. This population also has one of the highest poverty rates in the county. 56

58 Figure 4.1: Areas of Disparity for Race/Ethnicity Groups Identified Data Gaps There were four topic areas for which so little data was available that a secondary data summary score was not calculated: Diabetes, Disabilities, Older Adults & Aging, and Social Environment. Although Diabetes was further informed by hospitalization rates, more data is needed on the disease regarding children and teens. Obesity indicators, while correlated with diabetes, are not necessarily predictive of diabetes impact. Although the population affected by Disabilities was described with data from the American Community Survey, information on the specific needs and challenges of this group is lacking. The health needs of Older Adults can be further described with data from other topics such as tooth loss, immunization rates for adults 65 and older, and age-specific hospitalization rates, but data 57

59 describing the social isolation, disability, and care needs faced by this population is lacking. While some secondary data shed light on the topic of mental health, primary data brought further attention to this critical area that impacts many other health behaviors and outcomes. For Immunizations & Infectious Diseases, little sub-population data is available to examine disparities. And across most topic areas, little data specific to children and teens is available for Hawaii County. In particular, Exercise, Nutrition & Weight, Oral Health, and Injury Prevention & Safety are areas that affect children according to key informants but are not represented well in secondary data. Another area where available data does not fully describe the health needs is with new immigrant and transient populations. Primary data did highlight the populations arriving in Hawaii under the Compact of Free Association and the new challenges this growing group presents to the state s health care system. Due to this population s mobility, marginalized existence, and cultural isolation, traditional public health surveys and population statistics typically do not capture their data and circumstance. However, acute care settings are challenged to provide services and community infrastructure to support the new populations. 4.2 Limitations and Other Considerations This needs assessment is subject to limitations of the methods used for summarizing secondary data and key informant interview findings. Topic areas to which core indicators were assigned are not truly independent of each other, and the scoring system used could not account for the inherent relationships between health and wellness topics. The number of indicators available for each topic area varied, and while the scoring system numerically accounted for this variation, the impact of a given indicator on the final scoring for a topic area was greater if fewer indicators and/or comparisons were available. Nonetheless, this needs assessment utilized an extensive data set, derived from the best public health data made available by the Hawaii State Department of Health and the Hawaii Health Data Warehouse. By using the local website source for indicator data, available from the most recent, least aggregated across years, and most detailed race/ethnicity disparity data possible was considered. Race and ethnicity breakout data from this source provides information on the numerous subgroups in Hawaii (Japanese, Filipino, Chinese, Native Hawaiian, Pacific Islander), allowing this report to understand health needs and disparities for groups that together compose a majority of the population in Hawaii County. Indicators from national data sources had limitations, including combining important race and ethnic groups together and thus masking disparities. Importantly, in assessing poverty and economic measures, data sources did not account for the higher cost of living on the islands, resulting in an underestimation of poverty in Hawaii County. The variability in accuracy and precision of secondary data indicators, as well as the comparisons used, are further limitations. Some indicators, such as those from vital statistics, are based on accurate counts and are the most exact. Other indicators that are based on surveys are subject to variability due to sampling error and accuracy of self-reported data. The small number of counties in Hawaii allowed for few other in-state comparisons. Because of the varying amount of historical data available for different sources, trend comparisons were not equal between indicators. Additionally, many indicators from surveys conducted in Hawaii, including the Hawaii Health Survey (HHS) and Pregnancy Risk Assessment Monitoring System (PRAMS), could not be compared to a national value or benchmark due to lack of equivalent data. When national comparisons were available, sometimes the indicator was in an area where the nation as a whole is doing very poorly and a favorable comparison for Hawaii County did not necessarily reflect good health; examples of this include obesity and physical activity measures. Healthy 58

60 People 2020 benchmarks were used for comparisons, when available, though some of these can be ambitious targets for communities to meet. While preventable hospitalization rate indicators provided by HHIC were invaluable for their insight into the underlying health of the community at a sub-county level, it should also be considered that the variation in rates may reflect geographic differences in access and timeliness of care. Further analysis may be needed to better understand Hawaii County s preventable hospitalization patterns. One challenge in conducting this community health needs assessment was the condensed timeline. All of this work was compressed into a 5½-month time frame, overlapping the winter holidays, which impacted the primary data collection strategy. However, the key public health officials and community health leaders of Hawaii County were successfully included in the key informant process (See Appendix C for a full list of key informants interviewed). The online community survey was aimed to further complete the understanding of the local needs in Hawaii County, although the limited participation makes it difficult to assess if findings accurately reflect the broader community s perspective. While invaluable data was provided through the primary data collected for this report, a future CHNA process would benefit from a longer time horizon and would allow for expanded involvement and input from the community. Regardless of the limitations, this report provides a snapshot of the health and quality of life challenges in Hawaii County. The needs outlined provide a guide for community benefit planning, but subsequent efforts may be needed to delve deeper into specific areas of need and the most effective methods of intervention. While there are many areas of need, there are also innumerable community assets and a true aloha spirit that provide ample foundation for community health improvement activities 59

61 5 Selected Priority Areas This version of the report does not include prioritized areas. Each hospital will customize this section for its own needs in its submitted report. 60

62 Appendix A: HCI Provided Data About HCI Provided Data Healthy Communities Institute (HCI), in partnership with the Hawaii Department of Health and the Hawaii Health Data Warehouse, provides demographic and secondary indicator data on health, health determinants, and quality of life topics. Data is typically presented in comparison to the distribution of counties, state average, national average, or Healthy People 2020 targets. Data is primarily derived from state and national public health sources. HCI also provides a database of promising practices from a variety of sources, including the Centers for Disease Control and Prevention. All of the HCI content is presented in a public web platform that also serves as a publishing tool for components of Community Health Needs Assessments. Framework for Indicator/Data and Topic Selection The framework for indicator selection within the Health category is based on the Department of Health and Human Services (DHHS) Healthy People initiative. Healthy People establishes science-based national objectives for improving the health of the nation. The initiative establishes benchmarks every ten years and tracks progress toward these achievable goals. This framework encourages collaboration across sectors and allows communities to track important health and quality of life indicators focusing on general health status, health-related quality of life and wellbeing, determinants of health and disparities. The Health subcategories are based on the Healthy People framework, and multiple indicators across the health sub-topics that correspond with Healthy People targets have been chosen (based on data availability, reliability and validity from the source). Indicators in the other categories were selected according to national consensus and feedback from a wide set of advisors, public health officials, health departments, and local stakeholders from various sectors in the community. For example, the education indicators are based on the National Center for Health Research and Statistics and United Way of America, and the standards and goals they set forth to help track educational attainment in the U.S. Economic indicators were selected in conjunction with economic development and chamber of commerce input. All of the selected indicators have gone through a vetting process where HCI s advisory board, as well as stakeholders in communities who have implemented HCI systems, provide feedback to refine the core indicators in order to best reflect local priorities. The indicator selection process evolves over time with changing health priorities, new research models and national benchmarks. HCI continues to incorporate models and standards from nationally recognized institutions such HHS s Healthy People, AHRQ s PQI s, EPA Air Quality standards, National Center for Education Research and Statistics priorities, United Way, and United States Department of Agriculture s Food Atlas, among many others. Core Indicator Data Summary: Analytic Approach and Scoring Methodology As discussed in Section 2.1, the selection of topic areas for primary data collection relied on four types of Core Indicator comparisons: geographic, trend, disparity, and benchmark. A four-point system was used to evaluate each indicator on these four comparison methods, as illustrated in the examples below. Please note the data in this section is presented only to demonstrate the methodology and may not reflect data referenced elsewhere in this report. 61

63 Geographic Comparison The core indicator was assigned a geographic comparison point if it was worse than its comparison values on average: Relative to the comparison geography s value, the county value receives one of three designations, which is translated into points to calculate an average: Better/same 0 points Worse 1 point For example, this breast cancer core indicator for Honolulu County would be assigned a geographic comparison point. Much worse 2 points The following criteria were used to assign points for worse or much worse comparisons: Comparison Worse 1 point Much worse 2 points National* worse than U.S. value *or* worst 50th percentile of U.S. counties >25% worse than U.S. value *or* worst 25th percentile of U.S. counties State worse than state value >25% worse than state value HI counties worse than best county value >25% worse than best county value *National comparison uses either the U.S. value or a distribution of U.S. counties depending on data availability. An indicator with a national comparison will be compared to either the U.S. value or the county distribution, never both. Average was calculated as total points divided by number of possible geographic comparisons. If average was at least 1 (worse), then geographic comparison was considered poor for indicator. National The county value is in the worst 25 th percentile of U.S. counties 2 points State The county value is worse than the state value of cases per 100,000 females, but not more than 25% worse 1 point HI counties The county value is worse than the best county value (Kauai, at cases per 100,000 females), but not more than 25% worse Sum of Points 1 point 4 points Since the average was greater than 1, this breast cancer incidence rate core indicator was assigned a geographic comparison point. 62

64 Trend Comparison The indicator was assigned a point if the value was worsening by at least 2.5% on average. In this example of a colon cancer screening indicator, a point would be assigned because the value decreased by 7.9% on average: Disparity Analysis The indicator was assigned a point if there were large disparities among subpopulations. In this Core Indicator analysis, any indicator with a maximum disparity ratio of 4 or greater received a point. This example of an adult smoking indicator would receive a point because its maximum disparity ratio is 4: Healthy People 2020 Target Comparison The indicator was assigned a point if it did not meet a Healthy People 2020 target. In this high cholesterol prevalence example, a point would be assigned because the county did not meet the target of 13.5%: 63

65 Scoring The total earned points and total possible points were tallied for each indicator. In this example of a mammogram history indicator, four points were possible since all four comparisons were available. Out of the four potential points, the indicator earned only one point, for not meeting the Healthy People 2020 target: The total earned points and total possible points were then tallied for all indicators in a topic area to calculate the topic area summary score. In this cancer topic area example, 15 points were earned out of 38 possible points, giving the topic area a summary score of These summary scores were then ranked in descending order to help guide the primary data collection process. 64

66 Core Indicator Data Most of the core indicator data included in this report can be found on Hawaii Health Matters ( 65

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76 Appendix B: Hospitalization Data Hospital Service Areas Figure 5.1: Hawaii County Hospital Service Areas The Hawaii Health Information Corporation (HHIC) derived the Hospital Service Areas (HSAs) used in this report. These HSAs are composed of contiguous zip codes surrounding hospitals self-defined service areas, and were delineated by hospital CEOs in The following zip codes are included in each HSA: East Hawaii North Hawaii West Hawaii Hospitalization Rates Rates were provided by HHIC, and are defined by the Agency for Healthcare Research and Quality (AHRQ) as a set of measures that can be used to identify quality of outpatient care that can potentially prevent the need for hospitalization. Rates are risk-adjusted based on the Healthcare Cost and Utilization Project s State Inpatient Databases. Please see for a complete definition of indicators. Because the area of mental health was not well represented in the Core Indicator Summary, HHIC also provided unadjusted rates of hospitalization for any mental health-related primary diagnosis. For all rates, values were suppressed if based on fewer than 10 cases. Population estimates are based on the U.S. Census Bureau, Population Division, Intercensal Estimates of the Resident Population for Counties of Hawaii. Sub-county demographic counts are based on estimates/projections provided by Pitney Bowes Business Insight, Population estimates by race were provided by the Hawaii State Department of Health, Office of Health Status Monitoring, Hawaii Health Survey The tables below include risk-adjusted hospitalization rates with 95% confidence intervals for Hawaii County and all contained Hospital Service Areas for 2009, 2010, and Unadjusted rates by age, gender, and race are for 2011 only (race-specific rates unavailable at HSA level). All mental health hospitalization rates are unadjusted. Use caution when comparing unadjusted rates, as they may represent populations of differing age distribution. State values are also provided for comparison. 75

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82 Acute Composite Rate includes Dehydration, Bacterial Pneumonia, and Urinary Tract Infection Chronic Composite Rate includes Short-Term Complications of Diabetes, Long-Term Complications of Diabetes, Uncontrolled Diabetes, Rate of Lower-Extremity Amputation, Hypertension, Heart Failure, Angina without Procedure, COPD or Asthma in Older Adults (Ages 40+), and Asthma in Younger Adults (Ages 18-39) 81

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