COMMUNITYHEALTHNEEDS
ASSESSMENT
FOR THE PEOPLE AND ISLANDS OF HAWAI‘I

May 15, 2019

Healthcare Association of Hawai‘i
Produced by: Islander InstituteTABLE OF CONTENTSEXECUTIVE SUMMARY2OVERVIEW

7STATEWIDE ASSESSMENT
A COMMUNITY PRESCRIPTION FOR HEALTHSECURITYJUSTICE
LOVE
HOPE
TIME
FOOD
PLACE
COMMUNITYHEALTHY KEIKI
HEALTHY KŪPUNACARE
AVAILABLE HEALTHCAREDOWNSTREAM HEALTH EFFECTSSIGNIFICANT HEALTH ISSUES, GOALS AND PRIORITIES IN HAWAIʻI

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63
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86
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ISLAND ASSESSMENTSHAWAIʻI
STRENGTHS AND PRIORITIESMAUISTRENGTHS AND PRIORITIESMOLOKAʻI
STRENGTHS AND PRIORITIESLĀNAʻISTRENGTHS AND PRIORITIESOʻAHUSTRENGTHS AND PRIORITIESKAUAʻISTRENGTHS AND PRIORITIES

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ADDRESSING HEALTH PRIORITIESA SHARED KULEANA FOR COMMUNITY HEALTHCHOOSING PRIORITIES AND DEVELOPING STRATEGIESFACILITY PRIORITIES

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CONCLUSIONACKNOWLEDGMENTS

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APPENDIX A - SHARED KULEANA STRATEGIESAPPENDIX B - EXISTING HEALTHCARE FACILITIESAPPENDIX C - STEERING COMMITTEEAPPENDIX D - COMMUNITY MEETINGSAPPENDIX E - KEY INFORMANTS
APPENDIX F - INTERVIEWS, 2013 & 2015 CHNAs
APPENDIX G - RESOURCES UTILIZED

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EXECUTIVE SUMMARY
To truly address the root causes of health in Hawaiʻi, we need tounderstand that we are a unique people with a unique history
living in a unique place.
When Hawaiʻi people are asked to describe a healthy life, few
think that the absence of illness and the extension of life years
are the only aspects of health.
Diet, exercise, and doctors are essential—though
insuﬃcient—to improve health, but they alone are far fromcapable of providing the sense of meaning, security, loving
relationships, sense of home, happiness, quality time, and otheraspects of health that people want and deserve.
This Community Health Needs Assessment (CHNA), as required by the Internal Revenue Service for tax-exempt
hospital facilities to complete at least once every three years, culminates a yearlong eﬀort involving 19
hospital facilities; numerous community health centers and organizations; and hundreds of providers, experts,
and community members to identify and prioritize signiﬁcant health issues facing Hawaiʻi’s communities. This
reports shares the dominant themes that emerged in conversations across the islands, analyzes data sets that
impact all aspects of people’s lives, and provides statewide and island speciﬁc priorities to address the mostsigniﬁcant health issues.

2Community Prescription For HealthThe participants in this CHNA have written a new community prescription for health in Hawaiʻi, one
derived from people’s own deﬁnitions of health and the factors that contribute to attaining andmaintaining that health. These 12 factors make us healthy when we have them and unhealthy when we
don’t. To be healthy, we all need: security, justice, love, hope, time, food, place, community, healthykeiki, healthy kūpuna, care, and available healthcare. By seeing the full picture, we can begin to envisiona strategy for community health that addresses the important gaps and takes advantage of ourgreatest opportunities in order to help our people live healthy, fulﬁlling lives.

Sharing Kuleana in the Healthcare Ecosystem
In Hawaiʻi, health is a shared experience and endeavor. No single person, no single entity, and no single
industry can be solely responsible for community health. Rather than pushing responsibility back andforth between individuals and the healthcare system, it is more realistic and more consistent with
Hawaiʻi values to engage one another and share kuleana throughout the entire healthcare ecosystem.
The healthcare ecosystem acknowledges that health encompasses essentially everything; therefore
every person, family, organization, and agency has the kuleana to advance community health. Thisapproach values and strives to generate the non-sickness aspects of health, including the 12 factors in
the community prescription of health. Lastly, the healthcare ecosystem has the collective authority andpotential capability to address all the causes of poor health, including some of society’s most systemic
and stubborn issues such as discrimination, housing, and low wage jobs. It is only by sharing
kuleana—by doctors, patients, and everyone else in the ecosystem—that Hawaiʻi can adequately
address the measured and unmeasured health challenges facing our people.

Statewide and Island Priorities
Three major issues inhibit people’s abilities to achieve a truly health life: 1) A lack of foundation for
health that includes the basic things that every human being needs; 2) Loss of community, including the
aspects of place, values, culture, and practices; and 3) A poor relationship to the healthcare system,
which is seen as lacking in humanity, empathy, and availability.
While this CHNA is designed for member hospitals, any interested individual, organization, or agency
can develop plans to address the priorities most important to their constituency. The most successfulplans would include identifying existing initiatives, engaging community and other partners,
developing internal capacity, and building partnerships to strengthen existing eﬀorts and create new
ones. The 11 statewide priorities identiﬁed in this CHNA, including the ones most pertinent to eachisland, are as follows:3

STATEWIDE PRIORITIES

Hawaiʻi

Maui

Molokaʻi

LānaʻiOʻahu

Kauaʻi

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GOAL 1 - FOUNDATIONS : Provide the basic foundations so that people can have more control over their own health
1.1 Address ﬁnancial insecurity. Create coordinated andsystemic opportunities for communities and families tomake good food and housing realistically accessible,
develop workforce skills, create new economic
opportunities, build ﬁnancial assets, and reestablish active
lifestyles.

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1.2 Work together for equality and justice. Work alongsideaﬀected populations to address inequitable treatment
and opportunity.

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1.3 Strengthen families. Create the conditions andopportunities for families to be healing forces for its own
members, including addressing ﬁnancial stress that will
enable more healthy time together.

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1.4 Prepare for emergencies. Mitigate future health impacts
by engaging people, increasing understanding of the mostvulnerable populations, building food systems, andstrengthening relationships and community cohesion.
1.5 Build good food systems. Establish access to nutritious
food so that it is available to all.

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GOAL 2 - COMMUNITY : Preserve, nurture, expand, and employ the healing properties of community
2.1 Restore environment and sense of place. Better protect
Hawaiʻi’s natural resources, prepare adequately forclimate change, develop good design and integration of
the built environment, and reduce the negativeenvironmental impacts of the visitor industry.

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2.2 Nurture community identity and cohesiveness. Support
community led eﬀorts through shared activities andevents, active organizing around shared purposes, andinstilling community pride to foster greater trust andconnectivity.

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2.3 Invest in teenagers and healthy starts. Invest in healthand education at the earliest stages of life. Support
school-based structures, community-based activities, andyouth empowerment for pre-teens and teens.

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2.4 Shift kūpuna care away from “sick care.” Build a newparadigm of aging so that healthy aging is available tomore. Combat the grave threats of boredom, loneliness,
purposelessness, inactivity, and other social and emotionalhardships of aging.

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GOAL 3 - HEALTHCARE : Improve the relationship between people and the healthcare system
3.1 Strengthen trust in healthcare. Rebuild and strengthen
trust through listening, empathy, compassion, andtreating the whole person, while also paying attention to
the use of language and cultural nuances.

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3.2 Provide accessible, proactive support for those withhigh needs. Identify, develop, and strengthen outreach,
early intervention, free healthcare services, mental health,and oral health for those who are struggling withhouselessness, mental illness, and addiction.

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Important island priorities marked with “●”Highest need areas on island in RED
Note: all statewide priorities are signiﬁcant on all islands4No one patient, no matter how compliant, and no one
doctor, no matter how high quality, can achieve health in
the community. The ingredients of good health comefrom every corner of society. The likelihood of this CHNA
leading to real action in the future depends greatly on
successful communication and strong partnerships.
Each person’s story of health enlists more people into
the health conversation—farmers, caregivers, emergency
responders, judges, store managers, chefs, bankers,
environmentalists, bus drivers, architects, cultural
practitioners, teenagers, grandparents.
Everyone is together in a single health ecosystem that
determines the health of people and whether it accrues
to all or just for those with enough advantages. It calls
upon each of us to listen to one another and sharekuleana for the health of our people and place.
#5

Hurricane Lane. (Source: National Oceanic and Atmospheric Administration)

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OVERVIEW
On the north shore of Kaua‘i, a woman lost what little she had left inthe ﬂoods after experiencing a ﬁre that burned down her homemonths before. What was left of her belongings was washed out. In
the shell of what remained, she immediately began to cook all thefood she had available and pack it up. Pulling a little red wagon
through badly aﬀected areas, she passed out food to make sure that
her neighbors were okay.

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INTRODUCTION
On August 22, 2018, a hurricane warning was issued for Hawaiʻi County and Maui County as Hurricane
Lane approached from the southeast and threatened our island chain. That week, meetings that werepart of this Community Health Needs Assessment were canceled in Wahiawā, Kaunakakai, Lānaʻi City,
and Waimea, Hawaiʻi. Schools closed, work stopped, planes were grounded, and everyone waitedanxiously for Lane. When it was over, rain, wind, and ﬁre had destroyed or damaged over 200 homes.
1
Property damage totaled $22 million. Two weeks later, Hurricane Olivia stopped more work, caused
more anxiety, and aﬀected more lives.
When natural disasters strike, things we thought were important get swept aside by the things that are
truly important: Our loved ones. Our home.
The hurricanes that occurred during the making of this report were literally health events. The storms
disrupted lives, impacted physical and mental health, and made some people houseless. People are still
recovering. Hurricane Lane even took a life—a man from Kōloa was swept away after saving a dog from2drowning in an overﬂowing stream.
The storms—the preparation, anticipation, destruction, response, and recovery—are also an apt
metaphor for the health of Hawaiʻi’s people. Storms will come to our islands. It is inevitable. As
inevitable as illness, misfortune, and death. People get sick and injured, including our loved ones. We
give birth to new generations and old ones pass away. We get warning signs and frightening nearmisses. Much feels out of our control, so all we can do is stick together, wait, get news, be ready to help
others, and be open to receiving help. We worry about our loved ones, often more worried about themthan ourselves. We worry about whether we can aﬀord the costs of recovery.
Are we ready? Can we put the most important things ﬁrst, learn from the past, and apply ourknowledge? What about the most vulnerable among us? Have we met with them and listened to what
they said about the things they need and how we might help? Are we mindful of our neighbors, andtake only what we need, or do we hoard supplies like it is every person for oneself? Will we face pain
and grief with courage and kindness?
It’s all too easy to be in denial and think hard times won’t come to us, but we know better. We are island
people. Waves crash, volcanoes erupt, rain falls, and winds blow. We get hurt, we feel pain, we get sick,we suﬀer, we lose loved ones. But we are island people. These same things also bring out the best in
us—our intelligence, diversity, humility, compassion, resilience, humor, and aloha. Because we areisland people. We put the important things ﬁrst. We talk story. We stick together. We get stronger.

BACKGROUND
The Patient Protection and Aﬀordable Care Act of 2010 (also known as the “ACA” or “Obamacare”)
included a section on community health planning—Section 9007—which amended the Internal
Revenue Code by adding a requirement that tax-exempt hospital facilities complete a Community
Health Needs Assessment (CHNA) at least once every three years. This requirement is part of a familyof laws and regulations meant to ensure that hospitals bestowed with the beneﬁt of tax exemption
3
are, in fact, conferring beneﬁts to the communities they serve.

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3

Governor David Ige disaster proclamation.
Hawaiʻi News Now staff. “ ‘A Nightmare’: Kauaʻi man dies after jumping into stream to save dog.”
Internal Revenue Service. “Community Health Needs Assessments for Charitable Hospital Organizations - Section 501(r)(3).”8The general purpose of the CHNA is for hospital facilities to identify and prioritize signiﬁcant healthissues facing communities and to identify resources potentially available to address those needs. The
Healthcare Association of Hawaiʻi (“HAH”), on behalf of its member hospitals, conducted two prior
CHNAs in 2013 and 2015.
HAH aims to be the unifying voice of Hawaiʻi’s healthcare providers and an authoritative and respectedleader in shaping Hawaiʻi’s healthcare policy. Founded in 1939, HAH represents the state’s hospitals,
nursing facilities, assisted living facilities, home health agencies, hospices, and other healthcare
providers. HAH works with committed partners and stakeholders to establish a more equitable,
sustainable healthcare system driven to improve quality, eﬃciency, and eﬀectiveness for patients andcommunities.
In preparation for the creation of this report, HAH was intentional about continuing to improve its
approach to the CHNA. In January 2018, HAH released a Request for Proposals seeking a partner to
conduct the CHNA. Included in that request was this statement: “HAH and its member hospitals arecommitted to engaging in deep and transformative relationships with local communities to address thesocial determinants of health and to increase access to high quality of care.”Intrigued by the intent of HAH and its member facilities, Islander Institute responded to the request for
proposals and was ultimately selected to research and write this CHNA. Islander Institute is a local, civic
enterprise working to bring about positive social, economic, and political change in Hawaiʻi bypartnering with individuals, communities, organizations, and networks committed to island values. The
members of Islander Institute who worked on this report have combined educations and experiencesthat include public policy, public administration, strategic planning, community organizing,
community-based economic development, education, social work, child welfare, architecture, art,
folklore, mapping, ecology, urban design, emergency response, entrepreneurship, nonproﬁtmanagement, philanthropy, journalism, politics, communications, and law. To help with the project,
Islander Institute subcontracted the Hawaiʻi Public Health Institute (“HIPHI”), a nonproﬁt organization
with the aim of addressing health disparities and increasing healthy living and active living. HIPHI
provided two research assistants who helped conduct background research, organize data collection,gather quantitative data, and provide preliminary data analysis.

SCOPE
Nineteen HAH member hospitals contributed to the production of this CHNA. The names of those
hospitals follow:● North Hawaiʻi Community Hospital● Adventist Health Castle● Pali Momi Medical Center● Kāhi Mōhala
● The Queen’s Medical Center● Kahuku Medical Center● The Queen’s Medical Center –● Kaiser Foundation Hospital – Honolulu
West Oʻahu● Kapiʻolani Medical Center● Rehabilitation Hospital of the Paciﬁc
for Women & Children● Shriners Hospitals for Children –● Kuakini Medical Center
Honolulu● Kula Hospital● Straub Medical Center● Lānaʻi Community Hospital●●

Maui Memorial Medical Center
Molokai General Hospital●

Wahiawā General Hospital●

Wilcox Medical Center9

Together, the service areas of these hospitals span the totality of the islands of Hawaiʻi. In the past,
HAH produced ﬁve separate, though similar, reports: one statewide report and one per county
jurisdiction. For this CHNA, HAH agreed that Islander Institute would provide one comprehensive
report to serve all 19 facilities. The reason for this decision may be unique to Hawaiʻi. Although somefacilities serve relatively small communities, as island people who share a unique historical, cultural,social, and economic context, the story of Hawaiʻi’s entire archipelago forms the backdrop foreveryone’s community work. Common themes, challenges, and issues cut across communities, andthere is much to be learned from our shared experiences as people of Hawaiʻi. As such, the majority ofthis CHNA is written for the beneﬁt of every participating facility, with themes and ﬁndings relevant to
any work in Hawaiʻi. This single report also includes focused island-speciﬁc assessments—previously
separated into diﬀerent reports.

PURPOSE
Although some may look at the CHNA as merely an Internal Revenue Service requirement to becompleted, a brief history of the ACA’s intent is illuminating. The federal government wants to ensureorganizations that receive public support in the form of a tax exemption are creating a community
beneﬁt. But “community beneﬁt” is a broad and vague term that could include many activities if left
undeﬁned.
At the time the ACA was created, evidence was growing that individual and societal health are strongly
determined by social determinants such as socioeconomic status and environmental factors. As such,the intent of the ACA was to encourage a shift in thinking and ultimately a shift in how hospitals
4
distribute community beneﬁt dollars. In order to accomplish this, the ACA recognized that hospitals
would need to be encouraged to better understand and address community needs. Thus, the CHNA
requirement was created, and funds spent in conducting CHNAs were allowed to count toward a5
hospital’s “community beneﬁt” spending requirements.
The CHNA provides a meaningful opportunity to refocus resources and attention on eﬀective, relevant
community health needs and solutions. The ACA was passed to transform healthcare in this country on
many levels. And while details of that transformation are not speciﬁcally scripted in CHNA
requirements, those intentions can be sensed in the regulations which lay out both what is requiredand encouraged.
A recent journal article showed that many hospitals across the country have not been using their CHNA
processes to follow the spirit of the ACA. Many hospitals fail to actively engage community voicesaround issues of social determinants. Instead, hospitals identify community need by identifying andtreating disease—oﬀering medical solutions for community problems. Instead of focusing on
community health improvement, the vast majority of hospitals medicalize population health factorsthat stem from poverty and present them as treatable illnesses for which they can provide care, rather
6
than treating the root causes of ill health.
Again, HAH’s expressed desire was to use this CHNA to engage “in deep and transformative
relationships with local communities to address the social determinants of health and to increase
access to high quality of care” (emphasis added). Even though the federal government does not
speciﬁcally require it, the hospitals of Hawaiʻi, with the leadership of HAH, have explicitly embraced theintentions of the ACA. Therefore, this CHNA is meant to be a substantial step forward in addressing theroot causes of health. It is a resource to be shared with all of Hawaiʻi for the creation of new strategies
and partnerships.
45
6

Dixon, 87-89.
Internal Revenue Service, Additional Requirements for Charitable Hospitals.
Caffrey, 615-621.

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The CHNA should…

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26 CFR Part 1§1.501(r)-3(b)(6)(i)(C) - the CHNA…must include…A description of
how the hospital facility solicited and took into account input
received from persons who represent the broad interests of thecommunity it serves…lift up and listen tocommunity voice; engage withand learn from community§1.501(r)-3(b)(1)(iii) - In assessing the health needs of the community,
solicit and take into account input received from persons who
represent the broad interests of that community, including thosewith special knowledge of or expertise in public health§1.501(r)-3(b)(5)(ii) - …a hospital facility may solicit and take into
account input received from a broad range of persons located in orserving its community…aim to understand people
with the greatest needs…refocus on upstream causesof health…foster dialogue and help
hospitals forge partnerships
and take action§1.501(r)-3(b)(3) - In deﬁning the community it serves… a hospital
facility may not deﬁne its community to exclude medicallyunderserved, low- income, or minority populations who live in thegeographic areas from which the hospital facility draws its patients§1.501(r)-3(b)(5)(i)(B) - …a hospital facility must solicit and take into
account input received from…Members of medically underserved,
low-income, and minority populations in the community served by
the hospital facility, or individuals or organizations serving or
representing the interests of such populations§1.501(r)-3(b)(4) - For these purposes, the health needs of acommunity…may include, for example, the need to address ﬁnancial
and other barriers to accessing care, to prevent illness, to ensure
adequate nutrition, or to address social, behavioral, andenvironmental factors that inﬂuence health in the community§1.501(r)-3(b)(1)(v) - Make the CHNA report widely available to the
public§1.501(r)-3(b)(4) - To assess the health needs of the community…ahospital facility must…identify resources (such as organizations,facilities, and programs in the community, including those of thehospital facility) potentially available to address those health needs

METHODOLOGYWith the intent of HAH in mind, Islander Institute designed and continually adapted a process toachieve the objectives of the CHNA: a) listening to community voices; b) learning about those with thegreatest needs; c) focusing on upstream causes; and d) facilitating action through dialogue andpartnerships. This section describes all the salient features of that process.

7

IRS, Additional Requirements for Charitable Hospitals.

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Guiding Principles
Islander Institute conducted its work in accordance with the following set of principles to help ensure
integrity in the process while achieving the desired objectives:

Local style
The ﬁrst rule was to honor our home by conducting the work in accordance with the values andpractices of Hawaiʻi: to be respectful of places and traditions, to be generous with time and spirit, andto approach the work with humility, joy, and aloha. Islander Institute met people “where they were at,”and then pursued connections. So when people said, “Try talk to this person,” Islander Institute tried its
best to say, “Yeah, can,” continually expanding the study where possible.

Start with people’s lived experiences
Although there are many excellent studies and models to utilize (many of which were reviewed andintegrated into this analysis), Islander Institute did not want to impose any pre-set assumptions on thecommunity. This study starts with people’s own stories and conceptions of health, accepting the factthat what people share is their truth. Individual accounts are considered to be at least as important andreal as statistics and the opinions of subject matter experts. The intent was that all gathered
information would be able to supplement one another to uncover common themes as well as nuances,complexities, and insights.

Honor everyone’s contribution
Everyone who volunteered to participate in this CHNA cares about health in Hawaiʻi. To complete thisreport, many individual viewpoints were gathered and reviewed. Thereafter, themes were identiﬁed,
ideas organized, and conclusions drawn. So that individual ideas are not lost in the process, this reportpresents many ideas in people’s own words. When people provided thoughts that stood in conﬂict withsomeone else’s, those diﬀerences were allowed to coexist. Islander Institute made every eﬀort to haveevery voice represented in some way in this document so that they can live beyond this report as acontribution to community health.

Be open to diﬀerent narratives
In a study with such a large scope, on a subject considered many times, it can sometimes be diﬃcult tokeep an open mind. Often, data serve to harden generalizations and biases because they have been
regularly interpreted through the same lens—e.g. that certain races or places are just unhealthy or
troubled or needy; that any particular person might be “typical”; that a particular solution is always theright medicine. To avoid making assertions on false understandings, Islander Institute always tried tokeep an open mind, to deepen understandings through conversation and empathy, and to be cautious
not to reinforce commonly held beliefs without ﬁrst examining them against people’s real lives.

Keep looking upstream
Quantifying diseases and death are often where health analyses begin. And yet, disease and death arereally the points where good health ends. With guidance from community members, Islander Instituteand its partners asked about and sought the root causes of downstream health eﬀects, resisting thecommon urge to medicalize problems and solutions.

Build relationships
Throughout this process, Islander Institute and its partners looked for opportunities to strengthen
existing relationships and facilitate new ones, knowing that the likelihood of the CHNA leading to realaction in the future depends greatly on successful communication and strong partnerships.

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Steering Committee
A steering committee was formed to: a) advise Islander Institute on the factors that impact health in
Hawaiʻi and the diﬀerent communities aﬀected; b) participate in or help plan community engagement;
and c) provide input and analysis in the development of ﬁndings.
In building the committee, Islander Institute looked for a diverse group with the following collective
attributes:●●

Direct experiences conducting similar community-based research in Hawaiʻi
Experiences working across many communities in Hawaiʻi●

Direct experiences working in health research, health care provision, or public health●

Large networks spanning across the islands and including those who might be consulted as key
informants●

Understanding of grassroots politics, community organizing, government agencies,
philanthropy, economics, or academic research

The committee included a number of willing participants from HAH and member facilities, and provided
an opportunity for them to forge new relationships and shared understandings that will hopefully
beneﬁt the future implementation phases of this CHNA.
The steering committee met a total of three times in 2018 on May 21, July 27, and September 19. In
between meetings, steering committee members were called on for advice and for help in making
community connections. Some attended community meetings, and some planned and facilitatedmeetings based on their own relationships with groups. A list of steering committee members appears
in APPENDIX C.

Community Meetings
Islander Institute convened 21 community meetings in total to engage everyday people in discussions
around health in their communities. A full list of community meetings can be found in APPENDIX D.
A speciﬁc eﬀort was made to learn about the experience of health in vulnerable communities, including
disadvantaged minorities, rural residents, youth, seniors, places that are medically underserved, andpeople with low incomes. The meetings were not limited to these populations and included a diverse
sample of geographies, ages, ethnicities, and socioeconomic backgrounds. Special attention was given
to ensure the meetings were not merely extracting information from people and communities. Rather,
the purpose of the meetings was to build relationships by listening, engaging, understanding values,
and building reciprocity.
Islander Institute partnered with organizations and individuals with strong connections within theircommunities to organize and host these meetings. All the hosts work in community health, community
service and/or community building and engage on issues aﬀecting health and wellbeing. As hosts, they
played a critical role in creating a safe space and inviting the right people into the space, including
patients, staﬀ, or community members who had important stories and could feel comfortable sharing
them. The meetings were kept relatively small—between ﬁve to 25 people—and designed to maximize
everyone’s comfort level, which would allow all to meaningfully participate and for the conversation to
go deeper. Participants were told that they would not be personally identiﬁed in the report. In this
CHNA, they are identiﬁed based on attributes that might be helpful to give context to their input, suchas their area of residence or background.

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Nearly all the meetings included food, a critical part of building relationships in Hawaiʻi. Meeting
participants ate together before or during the meeting as a way to create an informal, comfortablesetting conducive to building relationships and sharing openly. In some cases, the host began themeeting with an appropriate protocol as commonly practiced by that group to honor their space andtraditions. The conversations were to be true “talk story” sessions that people of Hawaiʻi are used to in
their everyday lives.
Following introductions by hosts, Islander Institute usually began its facilitation with an overview of the
CHNA process and report. The conversations were launched with some variation of the question, “Whatis your deﬁnition of a good, healthy life?” The purpose was to allow people to enter into theconversation wherever they felt comfortable, without judgment or a feeling of being studied. Withfacilitation that honors people, does not judge, and redirects as necessary, these community
discussions regularly took deep dives into issues. Some conversations required translators to fully
include people who, in particular meetings, spoke Marshallese, Ilocano, and American Sign Language.
Other questions that were asked, depending on the direction of the conversation, included:●●

When was the last time you felt healthy?
What is something you do that makes you feel healthy?

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What makes it hard to be healthy?

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What have your experiences been like when going to the doctor’s oﬃce or to the hospital?
What is a healthy community? What does a healthy community have?

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Do you feel your community is healthy? Why or why not?

●●What are some things in your community that improve health?
What are some things you’d like to have in your community to help improve health?

The format was adapted for certain communities, in conjunction with hosts, to ﬁnd ways to best beneﬁt
and honor their community. For example, facilitators from Islander Institute went on a hike with awomen’s healing group on Kauaʻi as part of their regular learning series on Hawaiian medicine. This
helped set the tone for a day of learning, exchange, and relationship building before a lunch picnic
where the discussion on community health was held. Another example was working with the Molokaʻioﬃce of Liliʻuokalani Trust, which wanted to help build the skills of teenagers in one of theirafterschool programs. Islander Institute ran a training session for the teenagers on how to interview
their peers, family, and teachers. In a later session, the teenagers debriefed their lessons around theskills of interviewing and analyzed the responses from their surveys. The goal with each community
meeting was to create an environment of reciprocity and learning; therefore every meeting needed to
be a positive experience and valuable to each community. A key takeaway from this experience is thatpeople want to be heard, and that safe, interactive forums are necessary to truly understand what ishappening and to create action plans that have requisite legitimacy and support.

Key Informants
Islander Institute created an initial list of people who could shed light on questions of health, social
determinants, and the circumstances in various communities. The initial list included experts andauthorities with whom Islander Institute had existing relationships based on its many years of working
in Hawaiʻi. Throughout the months of conversations, people suggested others to talk to and helped
make connections. In total, Islander Institute spoke with roughly 200 people from six islands in person
or over the phone, in a one-on-one format or in small groups, and in formal or informal settings. A fulllist of key informants whose views inﬂuenced this report can be found in APPENDIX E.

14The conversations began with a few general questions, and key informants were encouraged to delve
into whatever they felt was most important to share. When appropriate, they shared about their own
personal experiences and/or professional connection to health.
Among the key informants, Islander Institute also met with representatives of each of the 19
participating hospital facilities to best understand their engagement with the CHNA and thecommunities they serve. These conversations helped illuminate interests, capacities, and missions ofeach facility and shed light on limitations and uses of previous CHNAs and the potential for this CHNA.
As part of the 2013 and 2015 CHNAs, key informants were also interviewed. A few of the same persons
participated in this year’s process, while others felt they had already shared what they had to say in theprevious process(es). Rather than re-interview many of the same people in the same positions, Islander
Institute obtained the informant interview notes from the past two CHNAs, reviewed them, andincorporated those views that were still timely into this process. A full list of the reviewed pastinterviews can be found in APPENDIX F.

Literature Review
Islander Institute reviewed past CHNAs from Hawaiʻi and other states, background information onvarious organizations and programs, numerous scholarly reports, and contemporary articles from themainstream media. Two research assistants from HIPHI did a comprehensive review of health-related
data from national, state, and local sources. That data was summarized and analyzed to help build
arguments for prioritizing issues and to understand the data resources available for advancing
community health. A full list of the resources reviewed over the course of the CHNA process is includedin APPENDIX G. These citations may be useful for future study and planning.

Quantitative Data Approach and Analysis
This CHNA begins with the lived experiences of people in their own words, and therefore depends on
the authenticity, quality, and breadth of that sharing in order to draw meaningful inferences. The focusof this CHNA is also on the upstream causes of health. Both of these aims call for a diﬀerent approach
to using the health statistics that are commonly collected and tracked.
Typically, a health assessment begins with health statistics that track medical outcomes usually in theform of morbidity rates—diabetes, heart disease, cancer, etc. These are generally the kinds of things
for which one would require medical care. Another set of statistics looks at risk factors—smoking,exercise, diet, etc. These are essentially the behaviors that aﬀect medical care. Finally, there is anassessment of medical resources—numbers of doctors, hospital beds, health insurance, etc. These are
the components of medical care.
Statistics on medical outcomes, risk factors, and medical resources are indispensable for developing
strategies to improve community health. However, when we begin with these measures, they often
become identiﬁed as the problems and the solutions, leaving out many factors that people consider tobe part of health and that go into creating health. In short, there is a tendency to aim for only thethings that are measured.
This can be problematic for two reasons. First, it may cause us to marginalize certain health challenges
and the people experiencing them when overall statistics are good. This is particularly tempting in
Hawaii which, by most traditional measures, has long been considered one of the “healthiest” states in
the nation. Second, when we use standard measures to label things “healthy” or “unhealthy,” whole15

groups of people and communities often get stereotyped and treated diﬀerently, instead of being
listened to and understood. These sentiments came out clearly in community meetings and key
informant interviews. One of the more unfortunate results of this is that we can fail to acknowledge
health strengths in particular populations because they are not measured.
Given this, Islander Institute considered the following cautions in its approach to using quantitative
data in this analysis:
1. If quantitative data are being used to learn about community, it is important to ﬁrst understandthe community’s reality and then try to view those numbers through a community lens. One
common theme is that health statistics have a tendency to emphasize medical care more thanpeople actually value medical care in their pursuit of health. Some of the factors that matter tocommunity are not measured. Some are not measurable.
2. Quantitative and qualitative should inform each other on equal planes to generate powerful
insights. With proper care in collection and analysis, neither is “more true” than the other.
3. Quantitative data without community input can sometimes reinforce untrue biases andunhelpful narratives. Statistics can be dehumanizing and can cause us to forget that individuals
experience life in uniquely human ways.
4. Quantitative rankings and comparisons can sometimes obfuscate important issues, marginalize
communities, dismiss issues that are of real importance to people, and lead to wrong
conclusions.
For this CHNA, Islander Institute tried to employ quantitative data in new ways, placing data indiﬀerent contexts based on community input. More work needs to be done to ensure more upstream
data is collected on a regular and reliable basis, and is presented in a context that sheds light oncommunity interpretations of health. For this report, some core county-level data is presented throughthe community lens that was developed from community conversations and key informant feedback.
Quantitative data was appended to the diﬀerent issues identiﬁed by community to provide further
insight, evidence, and/or corroboration. In some cases, reliable supporting data simply does not exist.
Health outcomes data is also presented in a separate section to show those downstream eﬀects in thefour county jurisdictions.
County data was used because it is a relatively stable and reliable delineation of data that is often
trackable over time. For this report, Kalawao County, which includes the Kalaupapa Peninsula, isincorporated into Maui County when data is presented by county, and is incorporated into Molokaʻiwhen data is presented by island. It should be recognized that county level data can be particularly
frustrating for the three islands of Maui County with their unique capacities and priorities. Survey
approaches that cover Molokaʻi and Lānaʻi often fail to reach large enough sample sizes to draw
accurate conclusions. County data can also mask disparities between urban and rural areas of an island,particularly on Oʻahu. Therefore, additional care and alternative approaches are needed to assemble
accurate information for smaller communities.
While new ways of seeing and presenting data are needed, and while some important factors are notcurrently measured, it should be noted that Hawaiʻi has a tremendous amount of available data
pertaining to the social and environmental factors that can contribute to a healthy life. There are also a
number of very high quality, highly accessible data resources for generating reports and maps withsubsets of data, trends, and other analyses. Some of the more useful community health research tools
examined and accessed in the course of this study are:16

Hawaiʻi Health Matters (http://www.hawaiihealthmatters.org), developed by Hawaiʻi Health Data
Warehouse (http://hhdw.org) and the Hawaiʻi Department of Health, provides access to data on healthand quality of life, data reporting tools, promising practices, and local resources.
Data USA (https://datausa.io) is a comprehensive visualization engine of public U.S. government data.
The resource was created in a partnership between Deloitte, Datawheel, and Collective Learning to
inform decision making by understanding and visualizing the critical issues facing the U.S. in areas likejobs, skills and education across industry and geography. Data for Hawaiʻi are available at multiple
geographic levels in categories including economy, health and safety, diversity, education, and housing
and living.
HealthLandscape (https://www.healthlandscape.org) is a web-based mapping tool that allows healthprofessionals, policymakers, academic researchers, and planners to combine, analyze, and display
information in ways that promote better understanding of health. The tool draws from many sources ofhealth, socio-economic, and environmental information and can be used to create maps.
HealthLandscape is a division of the American Academy of Family Physicians.
Community Commons (https://www.communitycommons.org/CHNA) provides access to thousands ofdata layers that allow mapping and reporting capabilities to explore community health. WithinCommunity Commons is a CHNA toolkit, designed in response to the IRS CHNA requirement, to assist
hospitals and organizations seeking to better understand the needs and assets of their communities.
Community Commons is managed by the Institute for People, Place and Possibility; the Center for
Applied Research and Environmental Systems; and Community Initiatives.
These resources are often updated and enhanced, and they can have tremendous value when trying toanalyze speciﬁc issues.

Mapping
One of the purposes of this CHNA is to catalyze curiosity, insight, and dialogue around community
health issues. Because health data is so readily available in regularly updated and customizable forms,
this report focused on developing alternative ways of looking at quantitative data that might sparkideas and be built upon in the coming years.
With this intention, a variety of data sets were incorporated and combined based on availability tocreate a series of maps that are included in each island’s assessment. The visualizations of the maps aremeant to help deepen and inspire the ways health is measured and approached.
Each map begins to spatialize various types of data typically associated with measuring “health” tosupport the idea that being healthy is not an outcome, but a process unique to diﬀerent communities
across diﬀerent islands. The maps serve to strengthen the spatial lens of the reader, such that in the
future, data used to measure diﬀerent indicators of health can be expanded and more place-based.
Seeing and thinking about a particular health outcome in a map aﬀords the reader a chance to visualize
in a dimensional capacity and consider how experiences of time, stress, loneliness, etc., aﬀect anddetermine community health.
Data was considered based on an island’s moku (the large land divisions based on Hawaiian wisdom andpractice), neighborhood, and zip code, which reﬂect the ways a community may understand their place.
These three layers reﬂect the ways data are collected and understood: zip code reﬂects most healthdata; neighborhood reﬂects distinctions used by the State of Hawaiʻi Department of Health reports;
and moku for the way many local people refer to their areas.

17

To spatialize the data in each map, a variety of data sets were incorporated and combined. All rates,
proportions, indicators, and raw data were collected from publicly available data sources, such as
annual reports from the Behavioral Risk Factor Surveillance System (BRFSS) published through the
Hawaiʻi Data Warehouse and the Hawaiʻi Indicator-Based Information System. Where applicable, themost recently published data was utilized. High school data was gathered from the publicly available
2016-2017 Status and Improvement reports provided by the State of Hawaiʻi Department of Education.
Each data set was then processed according to U.S. Census American Community Survey 2012-2016
Data Proﬁles, which provide spatialized geographical base layers relating to population size, race,income, household status, etc. Each base layer was then combined with additional geographic layers
regarding land use, land ownership, schools, and parks, for example, to build an appropriate base layer
upon which health data could be applied. Whereas a typical map may color-code an entire zip code, themaps in this CHNA take a more granular level analysis at the level of the census block group. The maps
are not meant to be exact representations of community health, but are intended to provide a new
example of how health can be portrayed beyond percentage and beyond zip code.
While the presentation of the maps are limited to the availability of existing data sets, the hope for thevisualization of the maps is to help deepen and inspire the ways health is measured and approached. Asaﬃrmed by qualitative data, health is not an outcome to be treated as a condition, but one that is asreal and as complex as these islands are.

Identifying Signiﬁcant Health Issues,
Goals and Priorities
Based on all collected data and analysis, this CHNA identiﬁes three signiﬁcant health issues, threecorresponding health goals, and eleven priorities that apply statewide. Almost all of these are focusedon what one might call “upstream factors” or “social determinants” of health.
All input was considered in the development of these priorities including: a) community input frommeetings, which indicated community needs and the degree of community readiness to join in forming
solutions; b) key informant interviews, which provided expert opinion on various community needs,
possible solutions, systemic factors, and/or evaluation of organizational readiness for partnerships; andc) quantitative data, which provided evidence of need, locational and population priorities, and othernuanced aspects of issues.
Based on this information, an analysis was done looking at ﬁve criteria:● Evidence of community need based on qualitative and/or quantitative data
● Community knowledge, energy and readiness to address an issue●●●

Existing or potential cross-sector partnerships for broad impact
Existence of current eﬀorts to replicate or learn from
Political will and potential resources, if known

As statewide priorities were being identiﬁed, each island was also assessed based on what was learned
through community talk stories, interviews with island residents during the assessment period, andisland-speciﬁc quantitative data where available. For each island, health priorities that are of speciﬁc
relevance to that island are identiﬁed. These lists were created using the same criteria employed forthe statewide priorities.
Finally, each participating hospital facility conducts its own independent prioritization process todetermine its own priorities. Suggested criteria and information on that process, as well as an area for18

participating hospitals to insert their own speciﬁc priorities can be found in the last section of thisreport.

Editing and Review
Islander Institute was entirely responsible for the drafting of this CHNA, including the creation of allmaps and charts. In the latter part of November 2018, a draft of the CHNA was shared with all steeringcommittee members and HAH member facilities for review and comment. All feedback was carefully
considered prior to ﬁnal editing and layout. The ﬁnal report was delivered to HAH in December 2018.

LIMITATIONSThis CHNA has ﬁve important limitations that should be kept in mind when it is put to use:
Scope and representation
Obviously this process could not accommodate every person and group that has a viewpoint to beshared. Furthermore, resources were not expended on survey methods speciﬁcally because theemphasis of this process was on obtaining a depth of understanding through dialogue. Of course, every
person and group deserves to be heard, and it is always disappointing to know that a person or groupthat wants to be part of the process could not be included at this time. Because this process is ﬁnite, aplan was devised to have depth in conversations across a strategic breadth of people and places thatwould likely generate scalable themes that resonate within and across geographies and groups.
Nevertheless, the fact that certain important viewpoints may not have made it into this report is alimitation. It is Islander Institute’s sincere hope that processes like this continue to occur so that more
people and places can have their stories heard for the advancement of community health.
Quantitative data
The scope of this report is large, which limits the extent to which it can delve deeply into speciﬁc areasor populations with quantitative data. Islander Institute continually wrestled with the conundrum of
including more detailed data while trying not to make the report too large. In the end, geographic
focused data has been provided at the county and island levels. Very speciﬁc geographic
representations of certain data have been provided in island maps. Geographic-focused numerical data
within islands is generally not included in this study even though it could be signiﬁcant tocommunity-based entities with coverage areas smaller than an entire island. The same can be said forentities that serve speciﬁc populations. The primary intent of this CHNA is to provide the themes thatare resonating across the islands. These themes and references to resources will hopefully provide abasis for continued analysis and planning for speciﬁc communities and populations.
Qualitative data
This analysis attempts to give appropriate weight to people’s opinions. Every story is authoritative as it
applies to the person telling it, and sometimes as it applies to family members and associates. However,when people made generalizations, a judgment had to be made as to whether the person was in aposition to conﬁrm that generalization. It is diﬀerent in every situation. Comments made by key
informants about issues within their sphere of experience are more reliable than their opinions on
issues for which they have no direct knowledge. As much as possible, anecdotal views were
corroborated by other people’s views and by quantitative data. Nevertheless, this approach is not

19perfect science, and Islander Institute acknowledges that all themes and assumptions that rely on
qualitative data should be subject to continual veriﬁcation.
Authority
This report suggests strategies and priorities that apply to whole communities and jurisdictions,
including the entire state. However, it should be acknowledged that the actual authority to set
strategies and priorities lies in many entities, which must consider many variables that are outside thescope of this study. All strategies and priorities within this CHNA are based on analysis of the data
gathered for this report only, and are not the decisions set forth by any individual organizations or
entities.
Expectations
It is HAH and Islander Institute’s intention that this report present ambitious ideas and goals that willlead to bettering the lives of people in Hawaiʻi. It is acknowledged, however, that change is a usuallyslow product of many factors. One of the important drivers of social change is the existence of strong
working relationships, which take time to develop. It is hoped that this CHNA will be a catalyst for morecooperation, partnership and initiative.

USING THIS REPORTThis CHNA has two sets of assessments which follow this OVERVIEW. It begins with a statewide
assessment.
The STATEWIDE ASSESSMENT begins with a detailed accounting of the dominant themes that emerged
from all of the conversations with hundreds of community members across the islands. Twelve
community health themes are identiﬁed and described along with stories in people’s own words that
illustrate those points. Together, those twelve themes constitute what will be called a community
prescription for health. Interspersed within these themes are selected quantitative data that shedlight on aspects of those themes. These data are presented at the state and county levels. The
assessment also contains a section with health status indicators in the four counties. These familiar
statistics might be interpreted as “downstream” eﬀects of the twelve themes identiﬁed by thecommunity. At the end of the statewide assessment is a description of three signiﬁcant health issues,
three goals, and eleven priorities that emerged from this study.
Following the statewide assessment are six sub-reports that contain ISLAND ASSESSMENTS for each of
the six major populated islands that were the focus of this CHNA. As with the statewide assessment,each island assessment begins with community input in the form of a written narrative summarizing
what was learned from the conversations that took place on those islands. This is followed byisland-speciﬁc data presented in maps and tables which are meant to provide new, alternative insights
into the nature and scope of health issues on each island. At the end of each island assessment is a
description of identiﬁed strengths and health priorities for that island, which can be the subject of
future discussion, planning, and action. The CHNA process is too short and the island-speciﬁcsummaries are too brief to capture the entirety of each island and all the pertinent issues its people
face. To really understand an island, one needs to live on it for quite some time. Fully aware of thislimitation, the hope is that the island reports will help accomplish two things: a) help outsiders grasp
less stereotypical, more accurate views of each island; and b) advance a dialogue on each island for
improving health.

20

After the assessments, this CHNA focuses on ADDRESSING HEALTH PRIORITIES. This section contains a
strategic framework for community health, which is presented as a shared kuleana for many
individuals and organizations. The section also contains ideas and criteria for setting priorities, and anarea where HAH member facilities insert their own information and aims of their community healthengagement plans. A list of community health initiatives that are prime examples of strategies inalignment with the ﬁndings of this report can be found in APPENDIX A. Each example can serve as amodel or, in some cases, a potential future partner.
The report ends with concluding thoughts and a mahalo to those who contributed to this report. This isfollowed by numerous appendices, including examples of current health initiatives in Hawaiʻi, a list of
existing healthcare facilities in Hawaiʻi, lists of individuals and communities who contributed to thisreport, and a list of resources used in the making of this report.
It is the ACA’s intent that a document like this would be a beneﬁt to the community by encouraging
dialogue and catalyzing collaborations. In service to that purpose, this CHNA is a public document. HAH
and its member hospitals are putting these ﬁndings forward to all potential audiences including:
HAH Participating Hospital Facilities
This CHNA meets their IRS requirements for submission once facility speciﬁc information isadded and facility priorities are chosen. The report will also hopefully spark dialogue andcollaboration among hospitals as they innovate to meet the needs of their various
constituencies.
General Public
The CHNA shows how hospitals value transparency and accountability. As will be detailed laterin this report, the relationship between people and their healthcare system has much room for
improvement. By reading this report, community members can begin to develop a sharedreality with hospitals and other health industry players. All residents have a responsibility andopportunity to ensure all voices are heard, and that ways are found for residents to contributeto better health.
Policymakers
The ideas in this report should help advance the evolving notion that a broad view of healthand healthcare—one that encompasses social, economic, and other factors—is necessary for
improving societal health. The ACA took important steps to encourage movement in thisdirection. Now policymakers in Hawaiʻi have an opportunity to take those evidence-based ideas
to the next level.
Researchers and Academics
This report attempts to lay out new and original ideas based primarily on the input of hundredsof Hawaiʻi residents engaged in concentrated conversations about health, its meaning, and its
causes. It is hoped that this report will raise new questions and inspire researchers andacademics to collect new data, develop and test new theories, and create new knowledge thatcan be parlayed into action to serve our communities.
Healthcare Ecosystem (and all its elements)
That is, all of the players that aﬀect health and wellbeing in Hawaiʻi, including youth
organizations, foundations, schools, workplaces, farmers, natural resource managers, unions,artists, caregivers, community leaders, cultural practitioners, businesses, housing developers,
government agencies, civil rights advocates, health insurers, and so many more. It is hoped that
this report makes it clear that the health of Hawaiʻi’s people, or the lack thereof, is a product ofeverything we do together on these islands. Everyone has a role.

21

STATEWIDEASSESSMENT
A Waipahu man with diabetes wants so badly to follow his doctor’s
directions and be healthy. He takes his insulin every morning andnight. He struggles to eat the right portions and the right foods. He
lives with his immigrant parents, and as a family, they know how tocook only their cultural foods—noodles, rice, and meat. It’s notalways the best for his diet, but not wanting to oﬀend orinconvenience his family, he eats it. He’s too ashamed to tell his
coworkers about his diabetes, and his work doesn’t always allow for
the frequent food breaks diabetics need to keep their blood sugar ata healthy level. So instead he eats a full portion to get by the whole
shift and deals with both the jitteriness and fatigue. Every time hevisits his doctors, he’s ashamed to tell them he slipped up and iseating full sized meals again with too much sugars, so he doesn’t tellthem the full truth. When his assigned doctor changes (and changes
again), he needs to build a relationship with yet another one andfears the judgment, the same questions, the same excuses he has togive. His family doesn’t fully understand his diabetes and why hecan’t just take care of himself. They berate him for the choices hemakes, so food—even the food he loves—has become poison and hesinks further into isolation.

22

COMMUNITY PRESCRIPTION FOR HEALTH
We all know this common prescription for health: To be healthy, you need to eat well, you need toexercise, and you need to do what your doctor tells you to do.
Through habit and repetition, we have ﬁrmly established this simplistic paradigm that personal
behavior and the healthcare system are the generators of health. But when we ask people to share
their own stories of health, this prescription breaks down in three important ways.

First, what is health?
When we look at most health reports, it is easy to conclude that health is about disease and thethings people should do to prevent it. These familiar data regularly place Hawaiʻi among themost “healthy” states in the nation. But when people are asked to describe a healthy life, few
think that the absence of illness and the extension of life years are the only aspects of health.
Instead, they talk about a sense of meaning, security, loving relationships, sense of home,happiness, quality time, and other aspects of health that they long for and deserve.

Second, what factors go into health?
Quality healthcare and personal behavior are important elements of health, but we have known
for a long time that there are many elements beyond the control of individuals and healthcare
providers that conspire to determine health outcomes. These include the so-called social
determinants, including economic stability, education, environmental factors, and community
factors that aﬀect an individual’s health status.

Third, who produces health?
Healthcare—really medical care—is not the only kind of “care” available and valuable forindividuals. Besides one’s own personal will and behavior, people also rely on families, friends,
the natural environment, community institutions, neighbors, and many others to contribute to
wellbeing. When those “health providers” are unavailable or not functioning, people can get
sick or they can take longer to heal.
Nevertheless, we continue to emphasize the mantra: the keys to good health are healthy living and thehealthcare system. This idea is the prime focus of our resource allocations, our health industries, ourhealth policy, our interventions, and our measurements of success. It is what children are taught andthe public is told. Doctors blame patients. Patients blame doctors. It is an easy prescription toremember and repeat, but it is not accurate and not helpful in getting people truly healthy.
In this CHNA, an alternative prescription emerged; one derived from people’s own deﬁnitions of healthand the factors that contribute to attaining and maintaining that health. Many frameworks andmeasures of social determinants are being developed and deployed across the nation and world tocategorize people’s needs, set their priorities, and develop strategies. But Hawaiʻi people are uniquepeople with a unique history, living in a unique place. So instead, this CHNA process simply asked
people to share their honest thoughts and experiences. Collectively, this is what they said:23

To be healthy, we all need...
SECURITYJUSTICE
LOVE
HOPE
TIME
FOOD
PLACE
COMMUNITYHEALTHY KEIKI
HEALTHY KŪPUNACARE
AVAILABLE HEALTHCARE
Taken together, the participants in this CHNA have written a new prescription for community health in
Hawaiʻi—twelve health factors that make us healthy when we have them, and unhealthy when we
don’t. By having the full picture, we can begin to envision a strategy for community health that
addresses the important gaps and takes advantage of our greatest opportunities in order to help our
people live healthy, fulﬁlling lives. We can all take part in ﬁlling this prescription.
At the same time, when we look at these twelve factors, we need to remember that each individual hasa deeply personal health story reﬂective of her or his needs and strengths. Not all factors apply to all
people, and factors apply to diﬀerent people in diﬀerent ways. People’s needs are nuanced andlayered, one on top of the other in unique combinations and in unique circumstances. Throughout thissection, people’s stories are shared in their own words to remind us of each person’s individuality. Our
health priorities and strategies need to create the conditions for good health, while also
accommodating the humanity and uniqueness of each individual.

24

SECURITY
Many people are in crisis. Whether the crisis is chronic or acute,when the situation exists, a person in crisis is often too
preoccupied to care for her or his own health. People in unstableconditions need compassion, outreach, and specialized help sothey can endure, escape, and ultimately heal. Security isprerequisite to the eﬀective pursuit of good health.

Financial Hardship“Health is survival,” was a sentiment shared by people who are living right on the edge of economic
disaster. In 2017, the United Way released an important report about families who are asset limited,
income constrained, and employed (known by the acronym ALICE). That report, which has gained theattention of many, found that 11% of Hawaiʻi households are at or below the Federal Poverty Level,
and an additional 37% of households are ALICE. This means that nearly half of Hawaiʻi households
8
struggle to aﬀord basic necessities, including housing, childcare, food, transportation, and healthcare.
Those just scraping by and perhaps a misfortune or two away from eviction or bankruptcy said they had
little or no time to think about their own health, let alone act on it.

My deﬁnition of health is staying alive while my children are still young. I
never learned what being healthy is; I only saw the doctor when I’m sick.
I want to be able to support my family and think about their future.
(Marshallese woman living in West Hawaiʻi)

I have to live in Ocean View because there isn’t any aﬀordable housing
nearby. The driving takes a toll on you. Housing is still so expensive so
you end up with no disposable income.
(Ocean View resident working in Kona)

Most high schools students have to have jobs and manage school too,
which is stressful. My parents are stressing me out about getting a job,
but I already have so much on my plate. My mom works three jobs andmy dad works one. My parents argue about who will pay taxes and who
will pay for the house. I don't want to hear it; I’m already stressed aboutschool and trying my best.
(Kauaʻi teen)

8

Aloha United Way, ii.

25

POVERTYUS

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

14.6%

10.3%

17.4%

10.0%

9.1%

9.1%

37.0%

33.5%

30.7%

30.5%

Percentage of people living below the federal poverty level (FPL).
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

INSUFFICIENT LIQUID ASSETS

36.8%

N/A

Percentage of households without suﬃcient liquid assets to subsist at the poverty level for three months in the absence of income.
(Data: 2013). Source: Prosperity Now Estimates Using Survey of Income and Program Participation and American Community Survey, 2018

ALICE + POVERTY

N/A

48%

61%

47%

44%

45%

Percentage of households Asset Limited, Income Constrained, and Employed with incomes above FPL but not high enough to aﬀord a basic household
budget + the %age of households below FPL = households struggling to aﬀord basic necessities.
(Data: 2015). Source: United Way, ALICE: A Study Of Financial Hardship in Hawaiʻi, 2017

CASH PUBLIC ASSISTANCE

2.6%

3.4%

4.4%

3.1%

3.3%

3.1%

Percentage of households receiving general assistance and/or Temporary Assistance to Needy Families (TANF).
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

About one in ten people in Hawaiʻi lives below the federal poverty level (in Hawaiʻi, the federal poverty
level in 2018 for a family of four is $28,870). This income threshold and multipliers of it are the basesfor eligibility for many government programs, but FPL is not an accurate indicator of what it takes toactually survive. Furthermore, income alone is not the only measure of economic security. Assets suchas money in a bank account or other savings is also necessary in case there is an interruption in income
as can happen in life. Because of the high cost of living, Hawaiʻi families have had diﬃculty
accumulating necessary liquid assets. The ALICE report provides a better indicator of ﬁnancial stability,
as well as insights into what families must do to cope when living below the minimum household
budget. One support is government subsidy such as cash public assistance, but only about 3% of
Hawaiʻi households receive that entitlement. The important takeaway from the data is that many more
Hawaiʻi families are severely ﬁnancially insecure than one might think at ﬁrst glance. Hawaiʻi County
has the highest proportion of people who are economically strapped.

Houseless and Hungry
Listening to people’s stories, one can start to fathom how devastating houselessness is to personal
health, and how extremely diﬃcult it is to get out of a houseless situation. Health and wellbeing arelower priorities than ﬁnding a place to stay and food to eat. In the healthcare system, people who arehouseless feel they are treated with less respect and tend to avoid seeking care until it turns into an
emergency. Hunger is a state of being that extends even to those with shelter, and is a basic need that
often must precede all others.

When I’m sitting around the waiting room, I think they (the staﬀ) thinkit’s okay to make me wait two hours because I have QUEST. Maybebecause of how I look, or maybe because our medical is not the best so
they treat us to how good our medical is. If we get QUEST, they treat us
like crap.
(Houseless woman in Hilo)26

I have a disabled patient in his mid-60s and he ended up on the street. He
gets a Social Security check every month from work that he did as ayounger man and he ends up in the hospital at least once every six weeks
because younger homeless men ﬁght him. He has been stabbed, broken
many bones, had multiple concussions.
(Maui provider)I have food. I have housing. I’m happy. I’m not sick anymore. I’m healthy.
(Deaf formerly houseless, now living in Whitmore Village, translated from American Sign Language)

HOUSELESS (per 10,000)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

18.3

55.4

70.2

69.2

49.8

61.4

13.0%

12.8%

Rate of homelessness per 10,000 population.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi Dept. of Human Services, 2017. National ﬁgure from 2015.

FOOD INSECURITY

N/A

13.7%

13.1%

13.1%

Feeding America accounts for poverty, unemployment, and median income to project the number of “food insecure” individuals.
(Data: 2014). Source: Hawaiʻi Community Foundation, Hunger in Hawaiʻi; Feeding America, Map the Meal Gap, 2016

FOOD INSECURE, % SNAP ELIGIBLE

N/A

57.0%

75.0%

65.0%

54.0%

66.0%

46.0%

34.0%

Feeding America’s identiﬁed “food insecure” individuals who live below 200% FPL and are eligible for government beneﬁts.
(Data: 2014). Source: Hawaiʻi Community Foundation, Hunger in Hawaiʻi; Feeding America, Map the Meal Gap, 2016

FOOD INSECURE, % NOT SNAP ELIGIBLE

N/A

43.0%

25.0%

35.0%

Feeding America’s identiﬁed “food insecure” individuals who live above 200% FPL and are disqualiﬁed from government beneﬁts.
(Data: 2014). Source: Hawaiʻi Community Foundation, Hunger in Hawaiʻi; Feeding America, Map the Meal Gap, 2016
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Hawaiʻi’s houselessness rates are three times higher than the national average and a serious issue
facing every jurisdiction. About one in ten Hawaii residents are deemed “food insecure,” meaning theycannot aﬀord to adequately feed themselves to live a healthy lifestyle. People with low food intake
have less energy and are linked to poor health and poor performance in school. More than half ofindividuals who are food insecure qualify for the federal Supplemental Nutrition Assistance Program(also known as “Food Stamps”). Eligibility creates more options for creatively addressing this need.
Fewer options are available for the 43% of the state who are food insecure and ineligible for beneﬁts,
which is a particular issue to consider for Oʻahu’s hungry.

Severe Mental Illness and Addiction
Some of our fellow residents have lost most or all of their personal ability due to mental illness or
addiction or both. Some have become houseless, and those who shared their stories for this report
relayed just how diﬃcult it is to want to seek help, ﬁnd help, receive help, and get to a state of stability
for any amount of time. Many shared how they have become estranged from families. Sometimes,
caring and active support is provided by friends found in shelters or in treatment programs.

I used to live in Honolulu and had a good stable job. I had friends who got
me into drugs, I lost my kid, my girlfriend left me, and now I’m here.
(Shelter resident in Hilo)27

I used to be homeless and struggled with mental health and substanceabuse. My work makes my sobriety feel more important.
(Wahiawā community worker)

FREQUENT MENTAL DISTRESSUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

15.0%

9.6%

11.7%

10.2%

8.5%

9.4%

Percentage of adults who stated that their mental health, which includes stress, depression, and problems with emotions, was not good for 14 or moreof the past 30 days.
(Data: 2016). Source: Hawaiʻi Health Matters, County Health Rankings, 2018

HEAVY DRINKING

6.5%

7.9%

11.6%

7.9%

7.4%

9.7%

Percentage of adults who reported having more than two drinks per day on average (for men) or more than one drink per day on average (for women).
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

DRUG OVERDOSE DEATHS

16.9

12.1

10.9

12.8

12.2

12.1

Death rate per 100,000 population due to drug poisoning (accidental or intentional)(Data: 2014-16). Source: Hawaiʻi Health Matters, County Health Rankings, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

There is no regularly available data on the number of people actually aﬄicted with severe mental
illness, severe addiction, and their treatment or lack thereof. Based on Department of Health surveys,
Hawaiʻi is doing better than the national average for adults who report poor mental health, such as
stress and depression, although some shared that people in Hawaiʻi may be culturally inclined to nottalk about or admit their mental illness. Hawaiʻi has higher rates of heavy drinking than the national
average. Alcohol abuse can negatively impact a person’s employment, ﬁnances, legal, and family life.
Drug overdoses in the U.S., particularly those associated with the opioid crisis, have not climbed to thesame levels in Hawaiʻi, but it is a grave concern for public health oﬃcials and could become a major
problem for Hawaiʻi in the years ahead.

Fear and Anxiety
Some people live in fear, lacking the basic safety and security that allows many of us to go on with ourlives and take care of our health. A few willing to share their traumas said terror is a special kind of
burden to carry. Many victims of physical abuse, sexual abuse, sex traﬃcking, and other crimes cannot
safely seek help, do not want to seek help, or have no help available to them. A diﬀerent, but also
debilitating kind of fear was experienced by residents in Pāhoa who were traumatized by earthquakes
and lava. For many, the reaction was helplessness and paralysis.

I’ve never felt healthy. I went through a lot of spiritual trauma and had arough childhood.
(Molokaʻi adult)

There is a widespread problem of human traﬃcking in Hawaiʻi that may
be impossible to account for.
(Honolulu attorney)

The sky was red. The stress level was high. Every morning I would wakeup wondering if there was lava at my door.
(Pāhoa resident)

28

INTIMATE PARTNER VIOLENCE-PHYSICALUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

8.6%

9.5%

11.5%

14.3%

8.3%

10.7%

Percentage of adults who report they have ever been hit, slapped, kicked, or hurt in any way by a current or former intimate partner.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2015

INTIMATE PARTNER VIOLENCE-SEXUAL

1.8%

3.6%

4.5%

5.5%

3.0%

3.8%

5.2%

6.6%

Percentage of adults who report they have ever experienced unwanted sex by a current or former intimate partner.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2015

RAPE/ATTEMPTED RAPE

N/A

5.8%

5.6%

9.1%

Percentage of adults who report that someone has ever had sex with them, or attempted to have sex with them, after they said or showed they didn't
want that person to or without their consent.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2015
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Fear and its severity is not something regularly measured. It is also not something that people caneasily talk about or reveal. Some measures exist that may indicate some of the root causes of fear. The
percentage of adults who reported being physically or sexually abused by a partner in Hawaiʻi arehigher than the national average, with Maui County reporting the highest rates. The impacts of intimate
partner violence can be lasting, resulting in physical injuries and/or emotional trauma. People may copewith this trauma in unhealthy ways such as smoking, drinking, and drug abuse. Maui County also leads
the state with the highest reporting rate of rape or attempted rate at 9.1%. All of the measures above
are self reported, which suggests the need for further analysis and understanding to know if these are
accurate estimates of the actual number of instances.

Grief and Loss
Losing a loved one is a pain that nearly everyone experiences. It too can be paralyzing, destabilizing,and disruptive to health. Similarly, over the past few years, many people in Hawaiʻi have suﬀered great
losses of life, property, opportunities, and stability at the hands of ﬂooding, lava, earthquakes, storm
winds, and ﬁre. The family of a very important community leader in the Puna District had to move for
economic reasons after lava destroyed the ﬁshing grounds that helped pay the bills. It is in times ofgrief and loss that strong families and communities can be a healing force.

I suﬀered the loss of my son and nothing takes you more into the depths
of depression than that. You need to rely on the community here on Mauiand appreciate the good things.
(Maui kupuna)I was married for 25 years and have three children. And then all of asudden, without any warnings, one day my husband woke up and hedidn’t recognize me. I felt like I was going crazy. After three weeks, hismemory came back. He was basically healthy, but he had Alzheimer’s. He
passed away after only a few years. My children are all grown up. They
left me; they’re married. I was really sad and lonely. And I was thinking
about taking my life.
(Kalihi kupuna)29

The impact of loss on individuals and a community is the underlying
factor for most of the problems in our society. Loss of relationships, jobs,
marriage, homes, not graduating, individual loss of self, all of thesethings that put people in situations of unresolved grief. Having that be
unresolved and unidentiﬁed continues to trigger choices that bring aboutpoor health—substance abuse, violence, houselessness. Loss is the root
cause.
(Kauaʻi health employer)

According to Hawaiʻi Health Matters and the National Survey on Drug Use and Health, 9.0% of adults in
Hawaiʻi reported having at least one major depressive episode in the past year compared to 14.3%
nationwide (2015-16 data). Studies show that most people with mental health issues do not receive
treatment for that illness.

30

JUSTICE
Health disparities exist, and even without seeing the statistics,
those disparities are palpable when spending time in certain
communities across Hawaiʻi. Those community members know
the disparities exist too. If we look for proximate causes ofhealth disparities, we ﬁnd disparities in income, education,
incarceration, and so on. For many who are part of a group withsystematically poor health due to their race, gender, sexual
orientation, class, national origin, age, or disability, the root ofevery disparity is an injustice. People experiencing disadvantage
and discrimination often shared that what they need to behealthy is to be free from the lingering burdens of unfairness.
The layered impacts of injustice are pervasive, cyclical, andgenerational. Injustice impairs a person’s ability to attain health,education, economic stability, and justice itself. In places where
injustice runs deep, some people express resignation that all
people like them get sick, or all people like them die early.
Rather than focusing on the disadvantages and deﬁcits thatcertain communities are facing, most of the people who talked
about this subject want something done. They want societal
wrongs to be righted.

Historical Injustice and Trauma
Many of us have ancestors who as a group suﬀered a severe historical injustice that destroyed people’s
lives—eras of colonization, occupation, forced migration, environmental destruction, systematic
oppression, genocide, or enslavement. In the absence of full societal healing and reconciliation, that
injustice can still be felt today, most acutely by those who remain at a disadvantage, lack equitable
opportunities, face crude discrimination, and are often misunderstood, judged, or discounted. Somecan themselves remember the experience—or remember ancestral stories of the experience—of that
historical collective trauma. For many indigenous Hawaiians whose ancestral lands were colonized andare now occupied, and more recently for migrants from three nations in Oceania whose islands wereused for nuclear testing (often incorrectly clumped together and called “Micronesians”), and any othersfrom throughout the world who now ﬁnd themselves in Hawaiʻi, the present-day reverberations ofhistorical injustice are real. Many feel caught up in a narrative of failure—because their group is more inprison, more dependent on government programs, less educated, more sick. At the same time,31

counternarratives of rediscovery and restoration exist as well, and many others are feeling adetermination to achieve justice, self-determination, and true health.

For a family to really break a cycle and make a change, it means most of
the time addressing a social determinant, it’s directly related toeconomy, education, income, food security, etc. What is themoʻokūʻauhau (genealogy) of chronic disease?
(Waimānalo service provider)

Historical trauma or cultural trauma…disempowerment, loss of land,
loss of resources. If you follow the trickle down of that…it goes directly
to meth. It is oversimplifying to connect it all to sovereignty…but still, it’s
all connected. If your great, great grandfather was treated poorly, it
goes from generation to generation.
(Kauaʻi physician)PART HAWAIIANUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

0.4%

26.0%

33.9%

26.7%

24.5%

23.7%

Percentage of people who list themselves as Native Hawaiian alone or in combination with one or more other races(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017Native Hawaiians are more likely to live in poverty, have higher rates of unemployment, live in crowded
and impoverished conditions, and be imprisoned. Socioeconomic factors are linked to health outcomes,
which are poorer for Hawaiians than other races in Hawaiʻi. Hawaiians have the shortest life expectancy
and higher mortality rates than the rest of the population. They have higher prevalence of heartdisease and stroke. The overall cancer mortality rates are highest for Hawaiian men and women, andthe overall incidence rates are highest for Hawaiian women. The prevalence of diabetes for Hawaiians is
9nearly double the general population when there are actual screenings as opposed to self-reporting.

There’s bullies that make fun of our skin color and culture. One said, “Didyou come from a microwave?” and another said, “Micronesian bitch,”
and another said that we are like roaches.
(Chuukese girl living in Wahiawā)

Micronesians feel unwanted, even at the community health centers andthe hospitals. They are told, “you don't comply,” “you're dirty,” and“you’re constantly moving around, so we can’t reach you.” They feel they
are seen as a pariah in the community.
(Honolulu doctor who works with Micronesian and other Paciﬁc Islander populations)

OTHER PACIFIC ISLANDERUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

0.1%

2.5%

2.7%

2.3%

2.7%

0.8%

Percentage of people who list themselves as Other Paciﬁc Islander, which does not include Native Hawaiian, Chamorro, or Samoan(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
9

Mokuau, 1-7.

32

The Compact of Free Association (COFA) is a series of treaties between the U.S. and the nations of theFederated States of Micronesia, the Marshall Islands, and the Republic of Palau. While they do not
typically self identify as “COFA,” they are sometimes referred to as the “COFA community” to describe
the residents of many diﬀerent ethnicities who have come to Hawaiʻi under this agreement. There is no
reliable population data on COFA residents, though estimates from studies and news reports ranged
between 12,000 to 18,000 in Hawaiʻi. The U.S. Census measure of “Other Paciﬁc Islander” is used here
as a proxy for the estimated percent of residents who may be from COFA nations. Many COFA residents
have left their island homes because of the adverse health and economic eﬀects of U.S. nuclear bomb
testing on their homeland. In Hawaiʻi, COFA residents are disproportionately experiencing
socio-economic hardship and poor health status, and they are the target of signiﬁcant discrimination.

Immigration, Language, and “Otherness”
Discrimination and bigotry exist in Hawaiʻi. People can sense when they are being judged, scapegoated,
perceived as a threat, or treated diﬀerently, and stories were shared in that regard. “Otherness” is asticky trait foisted upon people because in someone else’s judgment, they look, talk or act “weird” or“diﬀerent.” Immigrants, or people suspected of being immigrants, have particular fears grounded inreal government policies, which are felt regardless of their actual immigration status. The injustice ofbeing unfairly treated aﬀects people’s ability to live the healthy life they deserve to have.

When I came to the United States, my family was undocumented. I
remember how intentional we were about living in the shadows.
(Kona resident)

People talk to me like I’m stupid because I can’t speak English good. Ifthey spoke Chinese, they would know how smart I am.
(Immigrant living in Waipahu)

There is a fear to go to any institution because people don’t know who isreporting to ICE (Immigration and Customs Enforcement). Many haveissues that could beneﬁt from seeing a health provider, but they areafraid, and if issues are non-life-threatening, then people are opting to
not be seen. Being scared is an important determinant of health.
(Maui immigrant rights advocate)

Poor people go to the ER and are inadequately treated with bad attitude.
Somewhere along the line, health workers altered their thinking about
how to treat people. It upsets me that physicians are indiﬀerent topatients who need to be served. The impact is that they don't want to go
there because they're going to be ridiculed or treated as less than.
(Maui provider)

33

DIFFICULTY WITH ENGLISHUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

8.5%

12.4%

6.3%

10.5%

14.2%

9.0%

11.3%

18.6%

19.4%

16.6%

Percentage of people who speak English less than "very well"(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

FOREIGN BORN

13.4%

18.1%

Percentage of people who were born outside of the United States(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Immigrants living in Hawaiʻi report having diﬃculty navigating diﬀerent systems because of language
and cultural diﬀerences, facing discrimination in employment, and enduring general hostility because
they are diﬀerent. This also applies to COFA residents who may have diﬃculties with English and areoften the targets of Hawaiʻi’s ﬁercest bigotry and stereotyping. Undocumented immigrants, estimated10
at 36,000, also face similar language barriers on top of the fear of deportation and worse in thecurrent political climate. Oʻahu has the highest percentage and largest raw numbers of immigrants andnon-English speakers.

Age and Ability
People with disabilities and seniors whose abilities are deteriorating often feel ignored or at best, anafterthought by others for whom most of the built environment and human systems have been
designed. Seniors and people with disabilities feel discrimination and can be the targets of hostility andabuse; all of which constitutes a barrier to being healthy and well.

Ageism is a lot more rampant and insidious than people think. A lot of
seniors need paying jobs to stay aﬂoat, and some employers purposely
only advertise online or on social media to reduce the number of older
applicants.
(Specialist on senior issues in Honolulu)

We have a number of wheelchair-bound clients who have limited accessto care because they live in remote areas and don’t have transportationthat can accommodate the wheelchair. And they can’t aﬀord a taxi,
either. The result is they can’t access their doctor and they don’t have theﬁnancial resources to go either.
(Hilo provider)10

Migration Policy Institute.

34

ANY DISABILITYUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

12.6%

11.2%

13.3%

10.5%

11.0%

10.1%

3.9%

4.4%

3.8%

1.7%

1.6%

1.8%

3.8%

3.4%

3.8%

Percentage of the population that are limited in any activities because of physical, mental, or emotional problems(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

COGNITIVE DIFFICULTY

5.1%

4.5%

5.8%

Percentage of the population having serious diﬃculty concentrating, remembering, or making decisions(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

VISION DIFFICULTY

2.3%

1.8%

2.7%

Percentage of the population that are blind or have serious diﬃculty seeing even when wearing glasses(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017HEARING DIFFICULTY

3.6%

3.7%

4.9%

Percentage of the population that are deaf or have some serious diﬃculty hearing(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

One in ten persons in Hawaiʻi reports having a disability. Persons with disabilities have higher rates ofpoor health outcomes than those without disabilities, including higher blood pressure, inactivity,
obesity, and smoking. This is in addition to barriers they face in health care, education, andemployment. Hawaiʻi Island has the largest proportions of people with disabilities among the counties.

Gender
The role of gender can play out in several ways in healthcare. Transgender and gender nonconforming
individuals say they are commonly misunderstood by their doctors. Women often do not feel listened
to or trusted, and many expressed a desire for sensitivity, empathy, and understanding. Some men feel
uncomfortable with being vulnerable and admitting to needing help, so some avoid care until problems
are critical.

I told my doctor that something wasn’t right because I know my body.
But he frequently dismissed what I had to say. I think he didn’t trust me
because doctors think they understand our bodies better than we as
women do.
(Kauaʻi woman)

The trans community doesn’t feel safe in their doctor’s oﬃce. Doctors
don’t use the right pronoun. Trans people pretend to be a diﬀerent
gender to make the doctors feel at ease. They settle for subpar care.
(Health provider who also treats transgender and gender nonconforming individuals)

35

My mom passed away from breast cancer and when the delivery was
made by a male doctor, he said, “Oh yeah, you’ll die. There’s no cure, but
you can have a longer life if you want. But it’s gonna be awful because
the chemicals are not good.” She said she needed some help to hear
what she needed to hear, but protect her spirits, don’t give into a total
loss of hope. So I could do that. She did not go back with him formonitoring, but if he’d had more sensitivity, she might have consideredit.
(Maui health worker)

LGBTQ

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

4.8%

4.6%

3.4%

5.2%

4.0%

Percentage of adults who do not identify as heterosexual(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

Adults who identify as a sexual minority and transgender and gender nonconforming have poorer
health outcomes than heterosexual people. This could be a result of humiliating or harsh interactions
with the healthcare system that discourages them from seeking care. Compared to heterosexual adults
in Hawaiʻi, lesbian, gay, and bisexual adults are more likely to smoke cigarettes and drink alcohol,
experience physical and sexual abuse by an intimate partner, and have a greater prevalence of11
depressive disorders.

11

Hawaiʻi Sexual and Gender Minority Health Report, 2017.

36

LOVE
For many people, love is the reason to be healthy. Some would
even say love is health itself. Humans need meaningfulconnections with others. They need to love and be loved; tounderstand and be understood. A basic foundation of healthrequires reciprocal, healthy relationships that share familiarity,
security, happiness, trust, and intimacy, even if it is with just one
other person. When love is empty or at risk, health seems to fallaway.

Family and Friends
Although health is often framed as an individual’s responsibility, many viewed family and friends as
critical to healthy living. Loved ones impact the choices people make, such as diets, treatment options,and overall outlook. Family members and friends are often caregivers or navigators and are also heavily
impacted by a loved one’s health. That said, others shared stories of how family can also cut the
opposite way; some families can be negative inﬂuences and/or create an environment that makes it
diﬃcult to be healthy.

The last time I felt healthy? The last time I felt healthy was when I waswith my mom.
(Unsheltered man in his 60s in Hilo)

Sometimes as a native Hawaiian male, I don’t want to hear it from a
doctor—even if I know it’s true. If I hear it from my mom or my wife,
though, there’s something diﬀerent when it comes from your family.
(Kauaʻi resident)

A week and a half ago, I went camping with my family for four days. I
felt relaxed. We went ﬁshing. Being out with my ʻohana, there were no
distractions.
(Molokaʻi resident)

Most people want their family navigating for them. We might consider
how to pay for a family member to go with the patient when theyreceive treatment oﬀ island. It would give peace of mind to the caregiverand is critical to the patient, especially for rural health.
(Molokaʻi provider)37

People will be ﬂown oﬀ island for treatment and then don’t hearanything back in community until it’s a relapse or funeralannouncement. Sure, there are things to shore up on the medical side
but we need more family involvement included in the care model. All thefunds go to the patient but the family member is the one taking care of
the patient. Individualistic service delivery tends to isolate.
(Molokaʻi provider)

The closeness of our ʻohana is a double-edged sword. When there areproblems in the family, we tend to protect one another rather than dowhat’s right. Some people might describe people as “resilient” when they
are just normalizing bad behaviors or coping.
(Molokaʻi resident)

There are no regularly kept measures of the degree to which people have positive loving relationships
in their lives, nor are there good measures for when family relationships become a negative force or for
how lonely people are. Furthermore, especially in Hawaiʻi, family relationships can take many forms,
extending beyond the walls of the Census-designated household and beyond blood relations.

Caregivers
One of the beautiful things about Hawaiʻi is the willingness of so many among us to put others aheadof themselves. People shared how they are giving everything to care for a dependent loved one at thecost of their own health and wellbeing. Some of Hawaiʻi’s caregivers sacriﬁce their own stability,
putting themselves at risk of poor health for lack of an alternative that can both ease their burden andmeet their obligations.

I haven’t been to the doctor’s for myself since my postpartum check up. I
take my daughter to all her doctors’ appointments and make sure she ishealthy.
(Mother of a young daughter in Honolulu)

Catching a bus for two hours for a doctor’s oﬃce or taking care of
grandma at home? People will choose to take care of their grandma.
(Waiʻanae resident)

Some of our patients are not healthy because their priorities are notright at that stage of their lives. They come with diabetes, mental healthissues, oral health issues. How the families are oriented, if one family
member is out of sync, they all get out of sync. They need to take care ofthemselves so that they can take care of others rather than always
taking care of others.
(Maui provider)38

A 2015 study by AARP-Hawaiʻi estimated there are about 154,000 family caregivers in Hawaiʻi whowere helping an adult loved one carry out daily activities. This number does not include the number of
12parents caring for children, and particularly those with special needs.

Screen Time and Social Media
Some feel pervasive technology has been a boost to their quality of life and health. Technology enables
them to stay connected with people, form online communities, and ﬁnd important information onmatters of health. However, the majority of views on technology and screen time were negative. In fact,screens were frequently brought up as one of the biggest barriers to good health, often equated to akind of addiction that is ruining relationships and lives. Many teenagers mentioned this factor, not justfor how it is aﬀecting themselves and their peers, but also how screens are impairing adults. Others
seemed a little ashamed to admit they are spending too much time on their phones, and not enough on
the things that really matter to them.

My mom tells me to get oﬀ my phone, but then right after that she’s
playing a game on my sister’s phone.
(Kauaʻi teen)

Kids spend all day on their phones, which is rotting our brain. It’s anaddiction. It becomes dangerous when you pick your phone over family
time, like beach or hiking.
(Molokaʻi teen)

The amount of time we spend in front of a screen can prevent us fromdoing what is needed. Like when a parent asks a kid to go cut the grass,but you don't because you're in front of a screen. There are so manythings we don't know how to do because we’re in front of a screen.
(Kauaʻi teen)

Being a teen, we were raised into technology. Day by day, they’reincluding more tech in our schools. But it’s still important to learn social
skills, and technology is still not a reliable resource for communication.
You can miscommunicate a lot of things through social media. Reducing
the use of tech would be ideal.
(Kauaʻi teen)

While there are some measurements for children’s use of screens (covered in the section on Healthy
Keiki), there are no consistent measures for adult screen time, use of social media, and any negative
impacts that may result from this use. Further study on screen time is recommended as this issue wasoften mentioned as one of the biggest, growing threats to positive relationships.

12

AARP Hawaiʻi.

39

HOPE
One of the most mentioned factors for living a healthy life washope—the desire and belief that one deserves to be healthy andcan be healthy. How people feel about themselves, though
diﬃcult, if not impossible to reliably measure, seems to be oneof the most important requirements for living a healthy life.
Over and over, people shared stories of loved ones who lost
hope and fell to depression, addiction, and even suicide.

Identity and Purpose
A central part of having hope is having an identity and purpose. Many people in Hawaiian communities
shared the impacts of a resurgence of positive Hawaiian identity, particularly among children. The
restoration of Hawaiian culture and practice has been a positive force for many people, including
among non-Hawaiians. Others ﬁnd inspiration and purpose in their responsibility to family members, incommunity service, and in their gardens.

I didn’t want to go to the doctor and hear negative stuﬀ. I thought I
would die early like my dad at 56. But my family is everything and my
grandkids are our pride and joy. I can prevent my health from going thewrong way. After two years, I went from not walking to eight miles perday. I lost 31 pounds from January to August with exercise and eating
better. This program changed our lives and we want to help our family,
friends, and church.
(Hawaiian man enrolled in a diabetes prevention program in West Hawaiʻi)

Prevent bad health? We gotta teach our kids the culture. But we have to
do it now because the older people with the knowledge are all passingaway.
(Kaʻū resident)

I learned that if you live for yourself, you’ve lived for nothing... Health isserving my community.
(Volunteer in Pāhoa)There are no regularly collected quantitative measures of how people feel about themselves, theirstrength of identity, and their personal sense of purpose.

40

Fate and Future Prospects
A big part of having hope is being able to imagine a better future with a sense that it is attainable.
Many wanted their kids to be able to grow up healthy, have an opportunity for good education and agood job, and to live in their community if they wanted to. But in some communities, there is little
sense of hope. People shared how their goal of making enough money to provide for their family andlive a healthy life has never been realized despite working hard. Because of their family histories andsystemic disparities, many feel they are fated to illness and early death.

In the Hawaiian community, they don’t understand that diabetes isreversible. A lot of our family would say, “We’ll just take insulin when we
get diabetes.”(Hawaiian woman living in Kona)

With the Hispanic community, we think that if our grandparents havediabetes that we think we’re going to get it too.
(Hispanic woman living in West Hawaiʻi)

Most of us will never aﬀord a house in Lahaina on minimum wage. That’s
why you get multiple family members in one household. That's why
people need to move somewhere cheaper.
(Lahaina hospitality worker)

SUICIDE DEATH RATE (per 100,000)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

13.3

12.9

20.4

15.9

10.3

14.6

Age-adjusted death rate due to suicide (ICD-10 codes *U03, X60-X84, Y87.0).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

There are many reasons why someone might resort to taking one’s own life. Here, it is presented as one
possible indicator of people losing all hope. This ultimate choice has grave eﬀects on families andcommunities. The suicide rate on Hawaiʻi Island is the highest of all the counties and nearly double thatof Oʻahu.

41

UNEMPLOYMENTUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

3.9%

2.2%

2.7%

2.1%

2.1%

2.4%

7.9%

8.6%

8.2%

73.7%

66.0%

71.8%

$72,762$80,078$72,330

Civilians, 16 years of age and over, who are unemployed as a percent of the civilian labor force.
(Data: 2018). Source: Hawaiʻi Health Matters, US Bureau of Labor Statistics, 2018

NO HS DEGREE, adults

12.7%

8.4%

7.7%

Percentage of people aged 18 years and older who do not have a high school diploma or a GED.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

NO BACHELOR DEGREE, age 25+

69.1%

68.0%

71.4%

Percentage of people aged 25 years and over who have earned a bachelor's degree or higher.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

MEDIAN HOUSEHOLD INCOME$57,652$74,923$56,395

Median household income. Household income is deﬁned as the sum of money received over a calendar year by all household members 15 years andolder.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

HOMEOWNERSHIP

56.0%

49.4%

52.0%

44.7%

50.0%

46.4%

$316,000$569,100$626,400$520,100

22.3%

24.6%

10.1%

26.3%

26.9%

32.2%

27.3%

26.6%

Percentage of all housing units (i.e. occupied and unoccupied) that are occupied by homeowners.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

MEDIAN HOUSING VALUE$193,500$563,900

Median housing unit value.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

VACANT HOUSING UNITS

12.2%

14.9%

Percentage of total housing units that are vacant(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

SEVERE HOUSING PROBLEMS

18.8%

27.8%

Percentage of households with at least one of the following four housing problems: overcrowding, high housing costs, lack of kitchen, or lack of
plumbing facilities.
(Data: 2010-14). Source: Hawaiʻi Health Matters, County Health Rankings, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Many people measure their life success around the “American Dream,” which includes getting an
education, ﬁnding a good job, owning a house, and providing better opportunities for the next
generation. While there are few measures of how one feels about their prospects in life, there aremany measures of surrounding economic health that are likely to aﬀect how one feels. The economic
measures that report Hawaiʻi’s low unemployment, high median income, and higher rates of highschool education do not tell the full story of the economic reality of living in Hawaiʻi. A high cost ofliving and limited job prospects are causing many to leave Hawaiʻi and frustrating those who stay. And
while many economists interpret high housing values as a positive sign of economic prosperity; forpeople in Hawaiʻi, it marks the growing impossibility of owning a house in the place they call home. The
median cost of a home in Hawaiʻi at $563,900 is nearly three times the national cost. As so many people
are houseless or struggling to pay rent, people are frustrated to know that so many housing units are
empty, particularly on the neighbor islands. The quality of housing is also low compared to national
standards, with greater than one in four Hawaiʻi households dealing with overcrowding, high costs, lackof plumbing or lack of a kitchen. There are obviously many other aspects of hope than economic
prospects, but these factors are telling as to why so many people on the middle and lower ends of theeconomic spectrum feel stuck on a treadmill, just getting by with little energy or motivation for theirown health.

42

TIME
Many stories revealed an interesting relationship between timeand health. People need time to build and maintain their health:time for healthy activity, healthy relationships, preparing
healthy meals, going to the doctor or pharmacy, getting
adequate sleep, and more. Some people literally have no time,with multiple jobs to make ends meet and long commutes towork. Others say they feel busier than ever and are crushed withthe stress of life, while admitting maybe it is a matter ofchanging priorities and ﬁnding the time to be healthy. And
ﬁnally, a few stories were shared of too much time, where theidleness of unemployment or retirement is causing adeterioration of health. A unifying factor in our relationship totime is the economy, including the jobs we have (or don’t), thethings we spend our money on, and the infrastructure on whichthat economy runs.

Multiple Jobs
People in Hawaiʻi often need to have more than one job to make ends meet, particularly when so manyjobs are seasonal, temporary, part-time, and/or pay the minimum wage or close to it. According to the
ALICE report, 62% of jobs pay less than $20 an hour, with more than two-thirds of those paying less13
than $15 per hour. It reports, “the state now faces an economy dominated by low-paying jobs.” At one
community meeting with service workers in Lahaina, the group was asked to raise their hands if they
only had one paying job. No one raised their hand. When people are running from one job to the otherwhile also juggling multiple priorities, there is little time and space for healthy activity.

When we’re so busy with kids and working multiple jobs, there’s no time
for meal prep and eating healthy. I’ll try to whip something together orget drive through at Taco Bell or Panda’s. When people work multiple
jobs, we lose sleep, which impacts our thought process. I’m not sure how
I get home all the time. I’m afraid I'm going to fall asleep at the wheel.
(Lahaina hospitality worker)

It is not clear how many people in Hawaiʻi have multiple jobs, but based on what was shared incommunity meetings, one would think the number is quite high. According to the Bureau of Labor
13

Aloha United Way, 42.

43

Statistics only about 5% of the U.S. workforce has more than one job. But according to the Federal
Reserve, about 30% of U.S. adults participate in the “gig economy” doing contract work and other side14
endeavors to supplement income.

Commuting and Traﬃc
Many people are spending more time in their cars or on the bus in long commutes. Traﬃc congestion is
no longer just an Oʻahu phenomenon, as residents of Kauaʻi, Maui, and Hawaiʻi Island spend more timewith more cars on the roads, exacerbated by increasing tourism and development. Commuting is tiringand stressful and it chews up time and energy that could otherwise be put to productive and healthy
activity. According to the ALICE report, “Hawaiʻi’s economy is dependent on jobs that pay wages so low
15
that workers cannot aﬀord to live near their jobs even though most are required to work on-site.”

In a healthy community, people would live closer to their jobs and spend
less time driving all over the island. There would be more time to exercise
after work and have a healthier lifestyle. If they live in Wailuku but they
have to work in the hotels, they spend two hours commuting, so when
they get home from their jobs they have much less time to do anything
but sleep.
(Maui immigrant rights advocate)

Most employment opportunities are in Kailua-Kona or even
Waikoloa—traveling from down south to Kailua is easily an hour’s drive
one way. This takes much time away from home and family andincreases the hazards related to automobile related accidents. There’s ahigh number of traﬃc fatalities in West Hawaiʻi due to infrastructure
and the amount of time spent on the road.
(West Hawaiʻi resident)

MEAN TRAVEL TIME TO WORKUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

26.4

27.4

25.3

21.2

29.1

22.4

17.3%

12.0%

21.4%

13.4%

11.7

5.1

7.9

Average daily travel time to work in minutes for workers 16 years of age and older.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 201745 MIN OR MORE COMMUTE

17.0%

19.4%

Percentage of workers 16 years of age and older whose average travel time to work is 45 minutes or more.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

MOTOR VEHICLE DEATHS (per 100,000)

11.5

6.3

10.6

Age-adjusted death rate due to unintentional motor vehicle crashes including deaths to automobile occupants, motorcyclists/moped riders,pedestrians, and bicyclists who were struck by a motor vehicle(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

14
15

Federal Reserve Board, 15.
Aloha United Way, 43.

44

Traﬃc has long been an issue on Oʻahu, which has the longest commute of all the islands with one inﬁve people spending 45 minutes or more to and from work. But traﬃc is increasingly becoming an
issue for commuters on the neighbor islands, and just as one West Hawaiʻi resident noted in acommunity meeting, Hawaiʻi Island does have a high rate of traﬃc fatalities, as does Maui.

StressStress steals time and energy. And the people of Hawaiʻi—certainly those who participated in thisstudy—are feeling really stressed. Personal health is just not a priority for people worried about work,
money, kids, partners, parents, friends, world events, or whatever else is causing stress in their lives.
Under stress, many ﬁnd coping relief in the convenience of fast food or the distraction of screens.
Sometimes, stress unleashes even greater problems, such as mental health struggles, substance abuse,struggles at work, or domestic violence.

When there is a lack of funds for food, with increased family stress anddrugs, it triggers much of the domestic violence.
(Honolulu medical provider)

It is a beautiful thing that people want to move to Kīhei. But what
happens is that people want to get away from what they left, but thenthey bring it to Kīhei. It’s so commercial now, prices have gone up andnow you have a more stressed out community.
(Kīhei provider)

SINGLE PARENT HOUSEHOLDSUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

33.0%

29.1%

37.7%

33.8%

26.5%

30.9%

Percentage of children living in single-parent family households (with a male or female householder and no spouse present) out of all children living infamily households.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

NO PHYSICAL ACTIVITY

23.3%

20.8%

18.8%

19.6%

21.6%

16.7%

Percentage of adults who did not participate in any physical activity or exercise outside of work during the 30 days preceding the survey.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

INSUFFICIENT SLEEP

34.8%

42.8%

37.6%

38.8%

44.9%

40.1%

Percentage of adults who did not report getting 7 or more hours of sleep in an average 24-hour period.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Stress is particularly high for people working and raising children by themselves, which leaves little time
for healthy activity. Hawaiʻi Island has the highest percentage of single parent households, which areassociated with adverse health problems, such as emotional and behavioral problems for adults andchildren. Children of single parents are also more likely to abuse alcohol, smoke, and develop
depression. Physical activity and sleep are important parts of health, yet many in Hawaiʻi are not able toadequately do either. Physical activity reduces the risk of health conditions like obesity, heart disease,diabetes, and high blood pressure. Hawaiʻi is doing worse than the national average for sleep
deﬁciency, which is associated with health conditions including heart disease, high blood pressure,stroke, depression, and anxiety. Oʻahu has both the highest percentage of people with no physicalactivity and with insuﬃcient sleep.

45

FOOD
More people of Hawaiʻi seem to be expressing their love andreverence for food, to say nothing of the fact that without good
food, we cannot have health. Because so many people in Hawaiʻihave deep cultural connections to food, more people are sharing
their desire to rebuild a positive relationship to food, produce
more of it locally, and ensure that everyone has access to good
food. Many positive stories of food were shared, but many of
those harkened to a time past. Other stories told of poor food
options and ultimately harmful food decisions, poor nutrition,and ill health.

Cultural Connection to Food
Food can be a powerful force for good health, far beyond the chemical nutrients it contains. And
Hawaiʻi is lucky to have many people and organizations leading this rediscovery, much of which isembedded in our diﬀerent cultural practices in producing, preparing, sharing, and eating food. At thesame time, some are learning that the foods they are accustomed to, whether from long standing
traditions or relatively recent ones, can be harmful to them. In the end, a strong re-connection tofood—a connection infused with meaning—is what many are seeking in order to obtain better health.

In poverty, we started to eat plenty rice. We shared canned spam, andthen we start to lose the healthy ways. When you have generations ofthat, it’s hard to break. My grandparents were eating ﬁsh and poi. But
my parents were eating poverty food. Now that I have great
grandchildren, I watch what I eat around them.
(Hauʻula resident)

I love the food we ate in the Philippines… especially the bagoong, it’s sogood. We were poor back then, but now I can go store and get it here.
But then I learned that if I eat too much, I can get sick. So I have to keep
learning how to eat not so much, because I still want to have it.
(Kalihi kupuna, translated from Ilocano)Two kids named foods they remembered and missed including bobo
(coconut and rice balls), breadfruit, coconut water, pancake with meat,icy juice, and mei breadfruit.
(facilitator notes from a talk story with Marshallese children in Wahiawā)46

The degree to which people feel connected to their food is generally not measured. As such, it is ahidden asset in many communities that produce and prepare elements of their traditional diets.

Farming, Hunting, Fishing
People who grow or capture their own food often shared how important this activity is to their health.
Besides knowing where the food was from and what is in it, people also feel a sense of satisfaction,
pride, and conﬁdence when producing food. Producing food also requires physical activity that engages
people in the outdoors. Sharing that food is a powerful act for Hawaiʻi people. Mango, avocado,
tangerines, lychee, eggplant, kalo, ﬁsh, tako, deer meat—so many things are exchanged, which form
stronger interpersonal bonds while spreading the consumption of good food. People feel as though
there is momentum around the issue of food, with more organizations and young people devoting timeand energy to gardening, ﬁshponds, loʻi, the business of farming, and other food production activities.

When there’s akule, the akule ʻohana opens nets to everyone. The senseof community opening net is a big part of health. The net has to get
patched and everyone who are skilled in net making helps to patch.
Everyone else helps to open the net, teaching the kids about how toharvest the ﬁsh.
(Hāna provider)

In plantation days, every family had a hunter and a ﬁsher but now we’regetting away from that. We still have about 400 to 500 licensed hunters,
which is decent, but without people who hunt, it means less voice andit’s even easier to lose hunting areas.
(Longtime Lānaʻi resident)

Pretty much everyone grows everything. And if you don’t you know
someone who does. Even homeless people here eat pretty well.
(Hāna health provider)

Subsistence activity in Hawaiʻi is generally unmeasured and often unrecognized. Given all the positive
impacts of food production and sharing, it may be useful to gain a better understanding of this activity,
particularly in communities where it is still a signiﬁcant practice.

Availability and Aﬀordability of Good Food
Nearly everyone talked about good food as a major part of a healthy life. But good food is understoodas more expensive, and the time spent buying good food and then cooking food is another added costto people’s day. Getting good food is diﬃcult for those who have no grocery stores in theirneighborhood or who ﬁnd it too expensive. For many, it can be diﬃcult to switch to a healthy diet. But
there is a growing food movement to eat local and eat healthy that has made it easier to get better
food. This includes more farmer’s markets and organizations building food systems (including
production, processing, distribution, consumption, and waste systems) in communities.

47

Look at poi versus rice. One pound poi is 10 dollars and 15 pounds of ricefor the same amount. It’s more economical to get the rice.
(Kauaʻi resident)

Everything is expensive. Healthy food is expensive and the processedstuﬀ is cheaper. Am I going to pay my electric bill or get healthier food?
(Kauaʻi resident)

The barge comes once a week and determines whatever we get here andthe variety. Quality is impacted. Often things arrive already expired; isthat due to an oversight or just not caring? I end up having to returnthings to the store.
(Lānaʻi resident)

LOW-INCOME, LOW ACCESS TO GROCERYUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

N/A

13.3%

8.2%

5.2%

10.7%

Percentage of the total population in a county that is low income and living more than one mile from a supermarket or large grocery store if in an
urban area, and more than 10 miles from a supermarket or large grocery store if in a rural area.
(Data: 2015). Source: Hawaiʻi Health Matters, U.S. Dept. of Agriculture, 2017

FARMERS MARKETS (per 1,000)

0.03

N/A

0.16

0.06

0.04

0.19

Number of farmers markets per 1,000 population. A farmers market is a retail outlet in which vendors sell agricultural products directly to customers.
(Data: 2016). Source: Hawaiʻi Health Matters, U.S. Dept. of Agriculture, 2017

GROCERY STORES (per 1,000)

N/A

N/A

0.23

0.25

0.19

0.31

Number of supermarkets and grocery stores per 1,000 population. Convenience stores and large general merchandise stores such as supercenters andwarehouse club stores are not included in this count.
(Data: 2014). Source: Hawaiʻi Health Matters, U.S. Dept. of Agriculture, 2017

ADULT FRUIT/VEG CONSUMPTION

N/A

19.8%

22.9%

21.2%

18.4%

22.8%

Percentage of adults who eat ﬁve or more servings of fruits and vegetables per day.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2016
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Low-income and rural communities often have fewer options of stores that sell healthy food, but in
Hawaiʻi, rural communities potentially have good access to fresh food even if they lack large
supermarkets. The data relating to food access on Kauaʻi and Hawaiʻi Island may show thisphenomenon. On one hand, their lower-income residents have less access to grocery stores. On theother hand, they have a higher ratio of farmers markets to people. Generally speaking, the density ofgrocery stores is related to the diet and nutrition of residents; availability and aﬀordability of healthy
food options increase the likelihood of a nutritious diet. One in ﬁve adults in Hawaiʻi is eating ﬁve
servings of fruits and vegetables a day; Hawaiʻi Island and Kauaʻi have higher rates. Eating a variety offruits and vegetables is linked to reducing the risk of chronic disease.

Nutrition and Diet Information
One of the challenges to eating better is that people have a diﬃcult time knowing what is and isn’t
good for them. People can be confused by the often conﬂicting or jargon-ﬁlled nutrition information
put out by diﬀerent sources on social media, websites, TV, and from doctors and peers. Key informants

48

shared that many doctors lack nutrition education along with an ability to eﬀectively communicate
information to their patients.

As far as eating, community gatherings can be a detriment. A lot of
people come in with gout after festivals.
(Hāna health provider)

People don’t know what it means to be healthy. They don’t know thatthey shouldn’t give their kids sugary cereals; they think that it’s healthy
for the kids to have breakfast.
(Wahiawā health employee)

USE CALORIE LABELS IN RESTAURANTSUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

20.8%

17.7%

20.7%

21.6%

16.2%

Percentage of adults who report that, when calorie information is available in a restaurant, they always or most always use the information to help
them decide what to order.
(Data: 2012). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2015
RED = of signiﬁcant note; YELLOW = positive compared to other counties

About 20% of people in Hawaiʻi say they use the calorie labels when they’re available at foodestablishments, which is part of a growing national eﬀort to increase understanding of healthy eating.
It would also be helpful to track the degree to which people understand nutrition, nutrition educationin schools, and nutrition information shared during doctor visits and other settings.

49

PLACEFor many people in Hawaiʻi, our relationship to our home islandis the most important relationship of all. Our land and sea aremembers of the community. The health of our naturalenvironment aﬀects human health directly and indirectly. Ourbuilt environment has a direct impact on what we do and how
we live. People ﬁnd special places where they go to heal andfeel healthy. In so many ways, our place aﬀects who we are andhow we feel about who we are. It aﬀects what we know, what
we eat, what we do, our physical activity, our bodies, ouremotional health, and spiritual health.

Connection to Place
The spiritual and cultural connections people have with their places help ground a person’s identity andgives people that knowing feeling of a home. This connection seems much stronger on the neighborislands, although there are places on Oʻahu where the connection remains, and there are people onneighbor islands who feel that connection slipping away.

When we talk about aloha ʻāina, people think of picking up trash.
They’re missing the point that ʻāina is about ourselves. We take care ofthat ʻāina and we become better. Like uncle learning the plants,
teaching us the connection between mountains and sea. Learning ourhistory and genealogy.
(Kauaʻi resident)

I looked all over the world for a place to be healthy. This place is ahealthy place – we have fresh, clean air, no vog. You can eat out of yourgarden every day. You are not tempted to go to McDonaldʻs because we
don’t have it here. We have a nice farmers market.
(Hāwī resident)

50

Most Hawaiians don’t consider themselves minorities the way lawmakers
might use that language in health policy. You can ﬁnd that Hawaiians
today are very educated about what they want for the entire communityand land is always gonna come in. They think about what is happening
with the resources, the food, plants, ﬁsh.
(Molokaʻi service provider)

Connection to place is not something measured, and therefore is often not seriously taken into
account. And yet many people in Hawaiʻi see it as vitally important to health. This is particularly true forthe rural communities and the Hawaiian community.

Environmental Health and Climate Change
Many participants in this CHNA expressed concerns about the health of our environment, noting
overcrowding with visitors, development pressures, land use practices, solid waste concerns, and otherissues. Climate change experts shared additional risks coming our way including heat-related deaths,“Super” El Nino events that bring stronger and more frequent storms, wildﬁres, invasive plants that canlead to asthma, sewage overﬂow than can lead to infections, and changes to soils that could aﬀect thequality of our food. The eﬀects of climate change will also create social and economic burdens likely todisproportionately fall on the most disadvantaged populations, further exacerbating health disparities.
The Fourth National Climate Change Assessment released in November 2018 contains a chapter on
impacts to human health, and a chapter speciﬁcally on Hawaiʻi and U.S.-aﬃliated Paciﬁc Islands, which
details serious threats to water supplies, ecosystems, coastal communities, ocean resources, and16
indigenous cultures.

We are seeing the overuse of particular geographic areas andenvironmental resources. The number of visitors at public parks are
increasing and people are coming by the bus load. It is currently beyond
the capacity of our community. It’s actually detrimental to theenvironment and impacts all of the community.
(Waimānalo resident)

Hospitality and tourism from a business perspective…it’s important forour economy. But there’s a diﬀerence between locals and tourists. A
diﬀerence in appreciation for the land. There’s a lot of pollution causedby visitors. They leave, and it means we have to go and clean it up on our
own time.
(Kauaʻi teen)

We need healthy land for healthy people, and the deer and sheep are
wrecking land, and we’re standing by to allow it. It’s wrecking the
productivity of the reef when the ﬁshpond could be food providing.
(Lānaʻi resident)

16

Ebi, Chapter 14.

51

UNSATISFACTORY AIR QUALITY (days)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

254

254

0

0

0

1,632

717

61,7620

Number of days per calendar year in which the Air Quality Index (AQI) value was over 100.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH State Laboratories Division, 2014CARCINOGENS RELEASED (lbs)

N/A

64,111

Quantity (in pounds) of reported and recognized carcinogens released into the air. The quantity is based on fugitive and point source emissions of 179
recognized U.S. Occupational Safety and Health Administration carcinogens.
(Data: 2017). Source: Hawaiʻi Health Matters, U.S. Environmental Protection Agency, 2018

PBT RELEASED (lbs)

N/A

120,783

30,318366

90,0990Total net pounds of reported PBT (Persistent, Bioaccumulative, and Toxic Chemicals) released. These data only reﬂect releases and other waste
management activities of chemicals, not whether (or to what degree) the public has been exposed to those chemicals.
(Data: 2017). Source: Hawaiʻi Health Matters, U.S. Environmental Protection Agency, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

With an active volcano, Hawaiʻi Island is the only island with unsatisfactory air quality days. These
pollutants can include particle pollution, carbon monoxide, sulfur dioxide, and nitrogen dioxide, andcan harm people with asthma. Poor air quality contributes to the development of respiratory disease.
Carcinogens, which can induce cancer, impact Oʻahu the most. Chemicals like lead and mercury cancause harm to people and the environment. Other important environmental data to study includes thedisposal of solid waste, biodiversity, health of streams and reefs, water quality, shoreline erosion, andmany others that have impacts on human health.

Access to Healthy Places
Most participants in this CHNA, when asked about the place they go to be healthy, could name a special
place. Some people’s healthy places are private, like their homes. But many have public healthy places
like hiking trails, beaches, and parks. They jump in the water or tend to the garden. For many, access to
those places is crucial for maintaining health.

Health is mauka to makai. We used to swim at the wharf where our dad
used to swim when he was keiki. Families did pūlehu down at the beach.
Everybody was happy. As much as we want to keep it that way, we see
reality: rock walls going up keeping us from accessing hunting andﬁshing, ʻāina being purchased by rich people.
(Hāna resident)

We need more open space and parks and access to more hiking, ﬁshing,biking, running, walking. Our community grew so much faster thanpeople expected; it was poor planning and now it is hard to catch up.
(Kīhei resident)

When things get really bad, we go to the ocean to go get groundedagain. It's part of our healing.
(Molokaʻi resident)52

We have people ﬁghting for places to go ﬁshing, but that is getting
harder and harder because of condos taking away our right of way.
(Kīhei advocate)

URBAN ACREAGEUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

4.9%

2.1%

4.2%

26.3%

4.2%

40.6%

56.2%

Percentage of total acreage classiﬁed "Urban" by the Hawaiʻi State Land Use Commission, and regulated by the counties(Data: 2017). Source: 2018 State of Hawaiʻi Data Book, Hawaiʻi DBEDTCONSERVATION ACREAGE

N/A

48.0%

50.7%

39.2%

Percentage of total acreage classiﬁed "Conservation" by the Hawaiʻi State Land Use Commission, including areas for protecting watersheds; preserving
scenic and historic areas; providing park lands, wilderness, and beach reserves; conserving indigenous or endemic plants, ﬁsh, and wildlife; preventing
ﬂoods and soil erosion; forestry; etc.
(Data: 2017). Source: 2018 State of Hawaiʻi Data Book, Hawaiʻi DBEDTFOREST ACREAGE

N/A

24.0%

21.8%

19.2%

33.1%

45.2%

Percentage of total acreage that is either state-owned or privately-owned lands in the forest reserve system, or private forest land within theconservation district.
(Data: 2017). Source: 2018 State of Hawaiʻi Data Book, Hawaiʻi DLNR, Division of Forestry and Wildlife

SAFE BEACH DAYS

N/A

95.9%

93.0%

96.6%

96.3%

97.8%

Percentage of days that beaches are open and safe for swimming. Total available beach days are the sum of the length of each state/territory's beachseason multiplied by the number of beaches in the state/territory. Notiﬁcation actions are reported as the number of days under advisory or closed.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BEACH Program, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

The availability of healthy natural spaces is partly a function of land use designations. Oʻahu is the mosturban of all the islands, but still has a relatively large amount of land in conservation and forests.
Hawaiʻi’s forests, which total to about a quarter of the land, contain many of the best hiking trails, andare critical to the overall health of streams and oceans. Hawaiʻi experiences a high rate of safe beachdays, though beaches are closed typically when there is sewage or chemical runoﬀ that can cause
infection and illness. Many people said their healthy places are being crowded out by visitors who havebecome aware of these places through social media and commercial promotion. It would be useful to
track this phenomenon and its impact on resident health.

Land Ownership and Control
Whoever controls land has considerable power over the health of island residents, whether they areconscious of that fact or not. Many residents expressed frustration with the way land is being used in
Hawaiʻi, believing that many of these uses are having adverse eﬀects on human health.

(Someone) bought by Leho‘ula, one of the ﬁrst ﬁshponds and the
freshwater spring. We lost access. Now we have to decide whether tostay out or jump over the wall to “trespass.” This raises anger incommunity. … People become unhealthy, stressed out, and feel a senseof hopelessness. There’s no future for the kids. That’s when there’s drugs
and drinking. All you hear now, “how it used to be” and “only one ﬁshover there now”… it’s depressing.
(Hāna resident)

53

There’s fear on this island of continued development, diﬀerent
communities really questioning whether we were right to give permits todevelopers. Why didn’t we learn from Maui and Oʻahu? There is sadness
for our young people believing that they have to leave to better
themselves. It is unhealthy for people to feel they have to leave.
(Kauaʻi resident)

It seems that if major landowners don’t see a beneﬁt ﬁnancially, they’re
not going to do it. For example, they could spend money to plant grass or
foilage where it’s needed to stop erosion, but they decide to spendmoney on something diﬀerent that has immediate ﬁnancial returns.
(Lānaʻi resident)

Developers’ resources are going into the housing but leaving issues likepoor infrastructure and social and economic issues like homelessness tocommunity to ﬁgure out. And in new developments, there are so manytransplants; there’s very little stake in the place—unlike Waiʻanae or
Waimānalo where you have generations of people tied to and invested in
the place.
(State employee, Oʻahu)

Owing to our unique history, one unusual feature of Hawaiʻi is the number of large private landowners
and the signiﬁcant impact that their land use decisions can have on everyday residents. On Oʻahu, thetwo largest private landowners own 32% of all private land. On Hawaiʻi Island, the two largest own
45%. Four large landowners own 50% of the private land on Maui and three own 55% on Kauaʻi. Single
17
landowners control 46% of Molokaʻi and 99% of Lānaʻi.

Built Environment
People mentioned the built environment as a factor in their health in four ways: what’s in it, how it’s
designed, how one gets around, and how it looks. These factors can have profound impacts, sometimes
unknowingly, on many aspects of a person’s life.

There’s no transportation here. The bus doesn’t come or it doesn’t drop
you oﬀ in front where you need to go. You have to walk a mile to go to
the bus, and it’s always raining here.
(Houseless person in Hilo)

17

State of Hawaiʻi Department of Business, Economic Development and Tourism, Hawaiʻi Data Book, Table 06.07.

54

The roadways are unhealthy in this area. No safe sidewalks or paths
along the roadway. A lot of people are against sidewalks because they
will take away the country feel, but the kids can’t walk or ride bike toschool.
(Waimea, Hawaiʻi resident)

Everything around us is brown. We need to change the way Wahiawā
looks. What if we planted trees along the main drag?
(Wahiawā provider)

COMMUTE BY PUBLIC TRANS OR WALKUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

7.8%

11.2%

3.4%

5.2%

14.0%

3.7%

0.4%

0.8%

1.2%

0.5%

Percentage of total trips to work made by walking or public transit.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

COMMUTE BY BICYCLE

0.6%

1.0%

Percentage of total trips to work made by bicycling.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Commuting by public transportation, walking, or by bicycle beneﬁts the environment by removing carsfrom the road and can add to an individual’s physical activity. Oʻahu is doing better than the national
average for these commutes, while only a small number of people are doing so on the neighbor islands.
County governments are increasing dialogues around public transportation and safe streets foralternative commuting, however not all places have good infrastructure or realistic
options—particularly across the vast distances of Hawaiʻi Island or in rural communities. Furthermore,
many people do not have the luxury of a job that is within walking or biking distance from their home.

55

COMMUNITY
A community really isn’t a community unless the people show
signs of trust, caring, and interdependence. When those things
exist, the community bestows tangible and intangible beneﬁts
upon the people within it. People feel safer and less anxious.
They seek help, share information, and try to educate one
another. They provide valuable goods and services to one
another at no charge. They feel friendship, hope, fun, andpurpose where there otherwise would be none. These are thehuman connections that produce health and are health. Forcesthat create division and isolation are an ongoing threat.

Community Identity
People on every island have stories of community identity and pride. These narratives are not imposed
upon them from the outside, rather they come from the accumulated life experiences of people within
the community. They are original, authentic stories about generations past, special places, sharednorms and protocols, and historic events. This sense of identity is central to having a strong, connected
community. This identity, however, can be fragile if not actively nurtured. Many communities are seeing
an exodus of young people who feel they have no realistic opportunities to pursue their careers or
make an adequate living in their hometowns. In communities seeing an inﬂux of visitors, particularly
into residential areas, people are going to their local stores and seeing fewer familiar faces. As
communities become more transient, it is sometimes diﬃcult for residents to keep track of who iscoming and going. Continuity is disrupted, and shared experiences become more a thing of the past.

One thing that’s not healthy is that Lahaina is a tourist destination.
There’s traﬃc and it’s dangerous. We have to travel so far for simple
needs if you want cheap price. The stress adds up. Tourists have takenover way too much on this side of the island.
(Lahaina resident and worker)

I worry about the impact of military in the area...both the stress that
longtime residents are feeling and the health of the military personnel
and their families.
(North Shore Oʻahu resident)

56

People come to Hāna to leave it all behind, get away from it all. But
locals feel like those people are in their elbow room. When newcomers
take what locals feel belongs to them, the dynamic leads to unhealthy
relationships.
(Hāna health provider)

I wish the cost of living wasn’t so high. I would love to entice more of our
local people to come home because they would understand us and knowhow people are. The graduates move away and wait to come back, but
we need a way for them to come back.
(Kauaʻi resident)

HOMES SOLD TO NONRESIDENTSUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

27.3%

42.9%

51.7%

15.3%

45.2%

14.6%

11.7%

Percentage of total homes sold to non-residents including buyers from continental U.S. and foreign countries.
(Data: 2008-15). Source: Hawaiʻi Appleseed, 2018; Hawaiʻi DBEDT, Residential Home Sales in Hawaiʻi, 2016

PEOPLE MOVING INTO AREA

14.6%

13.1%

11.6%

12.8%

Percentage of people who moved into an area within the last year; either from a diﬀerent location within the county, from another county in the state,from a diﬀerent state, or from abroad.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

VISITORS PER DAY PER RESIDENT

N/A

0.15

0.16

0.37

0.10

0.35

Number of visitors per day divided by the number of residents in each county(Data: 2017). Source: 2018 State of Hawaiʻi Data Book, Hawaiʻi DBEDT Annual Visitor Research Report 2017; U.S. Census, American Community Survey
5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

A large number of homes on the neighbor islands are being sold to nonresidents, and yet thepercentages of people moving into neighbor island counties are actually lower than on Oʻahu. Thissuggests the homes being bought are not being occupied by owners but are either investment
properties or second homes. Nevertheless, some people lamented about so many people moving in andout of their neighborhoods. It may be that inﬂuxes of new residents are happening in speciﬁc
communities while populations are more stable in other towns. People may also be feeling crowded intheir own neighborhoods because of an inﬂux of visitors, not new residents. Finding data on short-term
rentals is diﬃcult since much of that information is held by private companies. However, the number oftourists coming to Hawaiʻi is at an all-time high. For Maui and Kauaʻi, on average, one in every threepeople on island is a visitor. With more residences being used for tourist accommodations, local
neighborhoods may start feeling less connected and familiar.

Kindness and Generosity
Aloha is real when it is practiced. The core manifestations of aloha in communities are acts of kindness
and generosity that people selﬂessly perform for one another—friends and strangers alike. People give
each other rides, share food, look out for each other’s kids, give money even when there isn’t much to
give, and more. During this assessment period of threatening hurricanes, participants shared story after
story of residents looking out for one another. However, it is also a common feeling across Hawaiʻi that
communities are changing and the practice of kindness and generosity is being eroded by more people
and a mass culture that follows a more individualistic and self-centered ethos.

57

What works in Hawaiʻi is the extended family, including hānai. If you
want to call it aloha spirit. Whether it’s family, friends, neighbors, ourcommunities are just more inclined to take care of each other. Still
stemming from the Iniki experience is this feeling that we can rely oneach other.
(Kauaʻi physician)I see new vans sitting in (that organization’s) parking lot unused, and I
deal with so many kūpuna who can’t ﬁnd a way to their doctor’s
appointment. We have to be better at using our collective resources tohelp each other out.
(Kaʻū resident)

I was really touched by how many tourists who were strangers came tohelp us. It reminded me to not just lump people into one group that I
usually label one way.
(Kauaʻi resident about April 2018 storms and ﬂooding)

Measures of generosity in a community tend to focus on charitable giving and volunteerism, both ofwhich fail to grasp the valuable generosity and kindness in Hawaiʻi communities, particularly those inwhich residents lack the kind of money, time or institutional connections that lead to the recording andmeasurement of charity and volunteering.

Collective Activity
Community-wide activities provide good evidence of the existence of human connection in acommunity, while simultaneously generating more of that connection. Events and activities instill prideand can promote healthy living. On Molokaʻi, teens talked about service days cleaning the beach atMoʻomomi as a healthy activity and a way for them to connect with the broader community. Others,
particularly those in small communities, said they look forward to community-wide events that create
excitement, cement a unique identity and perpetuate cultural practices and values. School activities,
competitions, festivals, concerts, holiday events, and others make irreplaceable contributions tocommunity health.

Here we have taro festival and ulu festivals that bring the community
together. It draws everyone out of their nooks and crannies. Events thatare fun and enriching. Cultural events are important for generational
knowledge transfer.
(Hāna health provider)58

When it comes to being healthy, so many people are still embedded in
sports, especially at high school. If you go back to the older generations,they were pretty active and they lived oﬀ the land. Lots of them still holdthat value.
(Lahaina worker)

DRIVING ALONE w/LONG COMMUTEUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

34.7%

40.3%

34.2%

27.2%

44.3%

36.0%

6.4

6.5

6.3

8.8

Proportion of commuters who drive alone to work and commute for more than 30 minutes.
(Data: 2012-16). Source: Hawaiʻi Health Matters, County Health Rankings, 2018

SOCIAL ASSOCIATIONS (per 10,000)

N/A

6.5

Number of organizations per 10,000 population. Includes membership organizations such as civic organizations, golf clubs, ﬁtness centers, sports
organizations, political organizations, labor organizations, business organizations, and professional organizations. Social Associations does notmeasure all of the social support available within a county.
(Data: 2015). Source: County Health Rankings, 2018

RESIDENTS PER COUNTY PARK

N/A

1,947

939

1094

3,334

961

Total number of residents divided by the number of oﬃcial county parks as of 2017
(Data: 2017). Source: 2018 State of Hawaiʻi Data Book, County parks and recreation departments; U.S. Census, American Community Survey 5-year
estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

44% of Oʻahu commuters drive long distances alone, and a third on the other islands do the same.
Driving alone taxes the environment and public infrastructure, as well as the driver’s body. But it also
indicates a society much less interactive, and it amounts to an opportunity cost that diminishes thesocial capital of the islands. County Health Rankings makes an attempt to measure social associations
by looking at the number of organizations in a particular locale. Based on this measure, Kauaʻi County
does better than others. However, this is not a complete measure of how people interact. For many
people without access to private spaces, public parks are important gathering places, but these areparticularly scarce for the people of Oʻahu. It would be helpful to have more stable measurements ofcommunity gatherings, the quality and accessibility of gathering spaces, community events, and actual
participation in communal activity.

Workplaces
When thinking of workplaces and health, many might associate the two with so-called “workplace
wellness” programs increasingly being implemented to encourage employees to adopt behaviors that
may ultimately alter healthcare utilization and reduce costs. This type of program did not arise ininterviews or community meetings. However, what did come up is that some workplaces can essentiallybecome strong communities of people with supportive relationships and positive team identities. Thiscan happen organically, or in some cases, employers work hard to intentionally develop that kind oftrust and closeness among colleagues.

59At our company, the culture is very important... recognition, incentives,
big parties like UB40. That for me is the baseline of creating a healthy
department overall. Communication is key, knowing where people arecoming from. If employees feel like their opinion doesn’t matter, thatspreads and it becomes negative. Giving opportunity to have a say. They
feel empowered to make decisions.
(Lahaina worker)

To the extent that workplaces may be replacing place-based communities, more information is needed
to know how much workplaces are serving as positive, supportive communities, and how they can beintentional in this capacity. The same kind of investigation may be necessary to evaluate the strengths
and weaknesses of online social networks.

Community Stress
As much as a community can make one feel secure, it can also make one feel scared, vulnerable, andanxious. Criminal activity and violence impact a community, increasing stress, seeding distrust, andencouraging greater isolation. In a number of neighborhoods, people talked about their fear of goingout, and doing the normal things that one expects to be able to do in a community such as walking
around at night and engaging with neighbors. Some shared about places that they knew were sites ofcriminal activity such as gambling, sex traﬃcking, drug distribution, and ﬁghting. Because calling thepolice may lead to retribution or doesn’t seem to stop the problems, people feel powerless. Instead,the community gets hijacked and becomes a liability for community health.

There’s an illegal game room right here in our community. The politicians
all know about it, law enforcement knows, but nobody is doing anything.
Our residents are trying to get their lives together, recover, and heal.
And there’s violence next door, and sex traﬃcking. People are afraid. Ourcommunity is corrupt. That’s why our community stays the way it is.
(Waiʻanae transitional housing resident)

One of our kupuna lived next to a vacant house that had a squatter, who
was a drug addict, living there. He was always too afraid to call thepolice for fear of retribution. One day, he came home to the squatter’shouse on ﬁre and they still live there today. This adds stress to thecommunity and people fearing for their safety.
(Pāhoa resident)

I also live in Ocean View and where you live can make it hard. I want tojog but there are no sidewalks, dogs are always chasing you, people arescreaming.
(Ocean View resident)

60

INDEX OFFENSES (per 10,000)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

325

274

377

333

233

Number of Index Oﬀenses per 10,000 population. Index Oﬀenses include murder, rape, robbery, aggravated assault, burglary, larceny-theft, andmotor vehicle theft. Does not include arson.
(Data: 2016). Source: 2018 State of Hawaiʻi Data Book, Hawaiʻi Dept of the Attorney General, Uniform Crime Reports 2016; U.S. Census, American
Community Survey 5-year estimates, 2016

PART II OFFENSES (per 10,000)

N/A

703

684

1522

579

566

Number of Part II Oﬀenses per 10,000 population. Part II oﬀenses include other assault, disorderly conduct, driving under the inﬂuence, drug abuse
violations, embezzlement, forgery and counterfeiting, fraud, gambling, liquor laws, manslaughter by negligence, oﬀenses against the family andchildren, prostitution and commercialized vice, sex oﬀenses, stolen property, vagrancy, vandalism, and weapons oﬀenses. All traﬃc cases are
excluded.
(Data: 2016). Source: 2018 State of Hawaiʻi Data Book, Hawaiʻi Dept of the Attorney General, Uniform Crime Reports 2016; U.S. Census, American
Community Survey 5-year estimates, 2016
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Hawaiʻi has a relatively low rate for serious crimes, called “index oﬀenses,” such as murder, rape,
aggravated assault, larceny-theft, etc. The rates are nearly doubled for lower level crimes, called “part II
oﬀenses,” which include assault, disorderly conduct, drug abuse, sex oﬀenses, etc. Maui County has thehighest rate for both these levels of crime.

Community Based Solutions
In communities deemed to be “disadvantaged,” outside organizations are often driving eﬀorts to help“ﬁx” them. From the perspective of communities, these eﬀorts can provide much needed resources,
but they can also be the source of great frustration as programs come and go. New concepts seem toarrive every year or so, and these have to be adopted in order to get funding. Help often comes in
disconnected silos—funding for health, funding for education, funding for culture, funding for capital
improvements, etc. In this mode, it is diﬃcult for a community to build leadership and capacity forsustained improvement. Advocates point to the need for community-based solutions grown and driven
by those with the greatest stake in success—the residents themselves. Communities become stronger
by engaging in dialogue and strengthening relationships within the community, forming the terms ofpartnership with outside allies, and coming up with solutions that ﬁt their own people and place.

For something to be successful out here in this community, it takes yearsof continual dedication and passion for the cause. The guy running the
local rugby club puts all of his free time and energy into it, like a second
work shift but it’s not paid. He comes home from work and coaches boys
and girls rugby in the community six afternoon/evenings a week. He
brought four of the girls to the mainland to provide some exposure andthey each secured college scholarships in rugby.
(Kahuku provider)

61

The Waimānalo co-op grew over time. The health center partnered withthe co-op to provide talk story sessions for patients and the community.
The patients enrolled received free membership to the co-op andinformation about produce and cooking. Farmers would come in with
diﬀerent dishes to taste. Instead of cabbage alone, they tried somethingelse to make, like kim chee. We wanted to expand people’s knowledge.
We learned what we could create with alternative produce and use whatis available in this community.
(Waimānalo provider)

The work being done at Waipā—with the vision of creating sustainableahupuaʻa—has community taking ownership and actively involved. Go
on Thursday and clean kalo with kūpuna and you see that exchange of
information and the connection to the land. For kūpuna especially, allthose hands have worked in the lo‘i. It is a celebration of place. From theyoungest learners to the kūpuna… ʻāina, ahupuaʻa, science, biology… it
all creates a very healthy community.
(Kauaʻi community leader)

The most important measures to track community building may be the steady improvement of target
indicators over time and their correlation with an increase in community-based capacity, such as
leadership development, successful community-based entities, civic participation, good jobs, andsenses of empowerment. Eﬀorts to help communities develop their own evaluation criteria andresearch capacities have also been gaining traction as positive steps toward sustainable, community-led
solutions.

62

HEALTHY KEIKI
A common story of Hawaiʻi’s past is that everybody looked out
for each other’s kids. There are still some communities in
Hawaiʻi today where many adults feel a responsibility for thesafety of neighborhood kids. This special status of our keiki is a
deep-rooted value of Hawaiʻi. In this CHNA, young people
shared their stories to give adults the opportunity to see things
through their eyes. Those who participated provided some of
the most lucid and complete descriptions of Hawaiʻi’s healthneeds. They see and share almost all of the same challenges andconditions of their adult counterparts. Children experience
discrimination and trauma, struggle without basic needs,
navigate healthcare services, operate in the same physicalenvironments, beneﬁt from connected communities, often feel
isolated and alone, and thrive when their self-identities arestrong. In fact, many of the teens in this CHNA have beenprematurely thrust into the roles of adulthood, needing to ﬁnd
their own food and shelter, caring for younger siblings, andworking to support their households. But for most young people
in Hawaiʻi, in addition to all other health needs described in thisreport, a unique set of factors apply in the establishment ofgood health. In conversations with teenagers, children, parents,
teachers, youth workers, and neighbors across the islands,
speciﬁc health-related challenges and opportunities associatedwith growing up in Hawaiʻi arose.

A Healthy Beginning
Educators, health care workers and others emphasized the great future beneﬁts realized by investing ina healthy start to life—both mothers and their children. Research has shown that the very beginning is
18
the most important stage in a person’s lifetime for impacting future health outcomes. Supports andpractices for a healthy start include help for high-risk pregnancies, prenatal care, infant care and18

Center on the Developing Child at Harvard University.

63nutrition, quality childcare, and preschool. Awareness, availability, and quality of these services varyacross the islands. While there are more programs becoming available for some communities, many
parents must fend for themselves. A group of new mothers told us how they found information andsupports online via Facebook and websites so that they might learn how to provide the best care for
their newborns.

My picture of community health is building a village. Without a village,
it’s hard not to feel isolated. That initial isolation when I ﬁrst had mychild was stiﬂing and anxiety producing.
(New mother in Honolulu)

INTENDED PREGNANCYUS

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

60.0%

54.8%

52.8%

56.8%

54.8%

55.3%

Percentage of intended pregnancies among live births. An intended pregnancy is one in which the mother reported that she wanted to be pregnant
sooner than or at the time of conception.
(Data: 2011). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Pregnancy Risk Assessment Monitoring System, 2013

TEEN BIRTH RATE (per 1,000 teen girls)

26.5

20.6

29.5

22.1

17.8

28.8

67.3%

72.7%

81.4%

Rate of live births to resident mothers between the ages of 15 and 19 years.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017; National ﬁgure from 2013

EARLY/ADEQUATE PRENATAL CARE

66.8%

70.8%

59.6%

Percentage of women with a recent birth who had adequate prenatal care according to the Adequacy of Prenatal Care Utilization Index.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Pregnancy Risk Assessment Monitoring System, 2017

MOTHER SMOKED DURING PREGNANCY

9.0%

4.3%

7.0%

2.1%

4.0%

7.3%

32.8%

29.7%

23.5%

28.4%

1.4%

1.1%

1.3%

1.1%

5.4%

4.6%

9.3%

4.7%

Percentage of births to mothers who smoked during their pregnancy.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2015

C-SECTION BIRTHS

26.9%

25.6%

Percentage of births to resident mothers delivered by a cesarean delivery, or a C-section.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2015

EARLY PRETERM BIRTHS

1.5%

1.3%

Percentage of births to resident mothers in which the baby had 32 to 33 weeks of gestation.
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

LOW BIRTH WEIGHT

8.1%

8.3%

Percentage of births to resident mothers in which the newborn weighed less than 2,500 grams (5 pounds, 8 ounces).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Mothers who engage in unhealthy behaviors during pregnancy, like smoking or drinking alcohol, andthose who do not receive adequate prenatal care, have greater risk of complicated deliveries andbabies who are premature or born with low weight. Babies who are premature or low weight are likely
to require special medical care and can face infant death or lifelong health conditions. Hawaiʻi falls
within the national average in most of these categories. Hawaiʻi Island and Kauaʻi have higher rates ofmothers who smoked during their pregnancy and higher teen birth rates.

64

INFANTS SLEEPING ON BACKUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

78.5%

78.6%

78.0%

82.3%

78.7%

70.0%

Percentage of women with a recent birth who report they most often lay their babies down to sleep on their backs.
(Data: 2014). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Pregnancy Risk Assessment Monitoring System, 2017

CHILDREN w/o HEALTH INSURANCE

5.7%

2.5%

2.7%

3.2%

2.4%

2.6%

10.2%

11.9%

10.0%

10.1%

8.2%

47.6%

43.7%

51.7%

48.5%

35.8%

Percentage of children under 19 years who do not have health insurance.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

CHILDREN w/ASTHMA

9.2%

Percentage of children under 18 years of age that currently have asthma.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

EARLY CHILDHOOD EDUCATION

47.5%

Percentage of three- and four- year olds enrolled in school (public or private).
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

In the early stages of life, it is important for children to have knowledgeable parents and access toneeded care. Nearly 80% of mothers say they lie their baby on their back to sleep, which is associatedwith preventing sudden infant death. Health insurance for children is high compared to the national
average, but it can be a huge risk for those 2% to 3% who lack coverage. Asthma in young children is aserious public health problem that can result in limitations on their activities, missed school days,
emergency room visits, and hospitalizations. Finally, making sure that children receive quality earlyeducation remains elusive with only about half of 3 and 4 year olds enrolled in school.

Children and Families With Signiﬁcant Needs
Children with complex behavioral and developmental problems might not get the intense, quality carethey need and deserve. It is a challenging experience for parents to navigate these unfamiliar and often
unique healthcare journeys, from evaluation, to getting accurate diagnosis, to securing services andcare management, to dealing with schools and other agencies. Often, children are misdiagnosed orundiagnosed, which can create grave trauma for them and their families. Care they need can becomplicated and complex, with nutritional therapy, language therapy, occupational therapy, and otherservices, all of which need to be coordinated. During these stressful and scary times for parents andchildren, many need a safe space to get help, and a go-to person with knowledge of these issues.
Unfortunately, many ﬁnd that these supports are unavailable.

My daughter’s pediatrician didn’t know how to talk about my daughter’svision impairment. I wanted to know what her condition was andwhether we needed to see a specialist. Her pediatrician was so awkward
about it and couldn’t really help. So I went online and found acommunity of resources. My doctor couldn’t help me but the Internet
could.
(Mother of a young daughter who is blind)65

I had no idea how broken the system was until I had a child who needed
urgent help. We survived our very stressful early weeks with the system
by putting everything else in our lives on hold. I had to stop work and goafter the help I needed to keep my son alive and our family intact. All
along the way I saw kids who didn’t have a parent who could put thingsin their lives on hold to deal with the crisis at hand. It’s devastating
what’s at stake in this. And the path to good outcomes is grueling. I had
to ﬁght hard to get responses to calls, appointments, competent help
and basic information.
(Mother in Windward Oʻahu)

Last year our daughter had speech delays and signs of being on theautism spectrum. I feel like we only got the high quality services our childneeded because of the steady stream of advocacy and follow up I had to
do as the parent. From obtaining a referral from the doctor andfollowing up with agencies and staying on top of a schedule that
required me or a caregiver to be home at certain times for our daughter
to receive the home based services, it was quite a process. She did so wellonce she had the services she needed, but I’ve had other parents tell me
their kids aren’t receiving the services they need and some did not evenknow about how to access help.
(Mother in Windward Oʻahu)

CHILDREN W/DISABILITY <5 YRSUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

0.8%

0.5%

0.3%

0.6%

0.6%

0.7%

3.5%

4.1%

3.8%

2.9%

Percentage of children less than 5 years old with any disability(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

CHILDREN W/DISABILITY 5-17 YRS

5.4%

3.7%

Percentage of children 5 to 17 years old with any disability(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Children with disabilities make up a relatively small percentage of all children in Hawaiʻi, but in ourconnected island communities, many people are connected to a child and family with signiﬁcant needs,
whether through blood relation or friendship. Data is needed to better understand how informationand services can ﬂow better to families in need.

Healthy Schools
Hawaiʻi’s schools are the settings where—whether with intention or not, and whether for good or forbad—young people eat many meals, learn about health, develop relationships, adapt to the norms of acommunity, develop their sense of self, observe peers and adults, and engage in some or all of thephysical activity they might get for the day. Of course, the primary purpose of school—education
itself—should also set children on a course for healthy and fulﬁlling lives. So there is no denying the66

central role that schools play in the health of children. Comments about schools were divided among
those who are quite critical of schools, and those who are hopeful about local successes, such as peer
health education and having health professionals in schools.

School is not a safe place. There are lots of bad inﬂuences and peerpressure.
(Teen in substance abuse program)Research has shown that when kids feel school spirit and pride, andwhen there’s space for mindfulness and helping kids be aware of what
they’re feeling, they don’t act out; it helps their behavior. We have aschool in Līhue that has been very inclusive, they’re involved in theSpecial Olympics program, they take a trauma-informed approach, and it
has made a big diﬀerence. Generally kids who are acting out aren't just“bad;” there’s more meaning behind it.
(Kauaʻi provider)

We had a plan to bring counselors to work with middle schoolers on safe
sex and smoking, but health and PE were replaced with math andEnglish for state testing requirements. So a lot of those kids didn’t get ahealth class until high school, which was too late.
(Former teacher, Leeward Oʻahu)

The Hawaiʻi Department of Education collects wellness indicators, in which participating schools report
whether their school has the required health education classes, physical education class, more than 20
minutes of recess time, etc. Some schools have also made concerted eﬀorts to improve health, such as
creating school gardens, implementing diﬀerent challenges and games to increase physical activity,and cooking healthy meals together among other activities. An annual School Quality Survey by HIDOE
asks members of the school community, such as teachers, support staﬀ, students, and parents, about
their safety and wellbeing. These measures demonstrate part of the potentially large role schools playin developing a student’s health. With nearly all students having working parents, schools play a majorrole in developing and raising healthy children.

Youth Diet
The stereotypical youth diet is a bad one consisting of too many processed snacks, sugary drinks, fast
food, and caﬀeine. Teens and adults alike conﬁrmed these assumptions. At the same time, there aresuccess stories of farm-to-school eﬀorts, school gardens, and nonproﬁt organizations focusing on
healthy food, and reducing sugar intake. These eﬀorts are gaining traction and can become more
widely impactful with additional investment of time and eﬀort.

The last time I felt healthy was when I was three years old in Micronesia.
I ate healthier foods, and things weren’t so complicated.
(Wahiawā pre-teen)

67

There is a Foodland on one end, but people who live in the ‘hood don't go
there. Kids end up eating musubis from the convenience store, from themanapua man, and from Jack in the Box and Taco Bell.
(Wahiawā worker)

One thing for Kailua, where people supposedly like to eat healthy foods,
7-Eleven is where students stop by for snacks and high school students
go there because it is right there.
(Windward Oʻahu Public Health Nurse)

STUDENTS ELIGIBLE FOR FREE LUNCHUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

42.6%

40.1%

58.3%

40.7%

36.1%

38.4%

13.6%

14.1%

Percentage of students eligible to participate in the Free Lunch Program under the National School Lunch Program.
(Data: 2015-16). Source: Hawaiʻi Health Matters, National Center for Education Statistics, 2018

TEEN FRUIT/VEG CONSUMPTION

22.3%

14.2%

15.6%

15.6%

Percentage public school students in grades 9-12 who ate fruits and vegetables ﬁve or more times per day during the seven days preceding the survey.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

About one in eight Hawaiʻi students are eligible for the federal free lunch program. For some, schools
meals may be their only consistent meals throughout the year. Hawaiʻi’s teens fall below the national
average for consumption of fruits and vegetables, with only about one in seven reporting they ate ﬁve
or more servings a day.

Stress Growing Up
Each generation seems to think the previous one has no idea what it is going through. Today’s
generation of teens actually have a point. Cyber-bullying, social media exposure, school shootings,
e-commerce, the price of college and student debt, and other modern realities are unprecedented
developments that are on teen minds. Many young people feel stressed out. Teens shared about thepressures of academic success, college entrance, and social stressors making life unbearable for many.
Family stress is also ﬂowing onto the children and some are being asked to pick up the slack as careproviders and wage earners. Young people aren’t getting much sleep, and they say there is moreanxiety and depression leading to addiction and thoughts of suicide. Just one youth suicide isintolerable, and the tragedy reverberates throughout families and communities with painful eﬀect.
Suicide attempts and thoughts of suicide are likewise deeply troubling. So it is not surprising that teensuicide was brought up as a grave concern in Molokaʻi, Kauaʻi, North Shore of Oʻahu, Maui, andpractically every community visited. A lack of hope, inability to deal with stress, bullying, isolation, andnowhere to go, are some of the reasons given for this crisis.

It is so stressful with maintaining grades and participating in sports andclubs that I need for college. I have no time for myself.
(Kauaʻi teen)68I’m helping my mom by trying to learn how to run one of her businesses
so she has less things to worry about.
(Molokaʻi teen)

Seeing peers having to get jobs at 14 or 15 to support theirfamilies…Playing is part of being a kid and we’re missing a piece by not
being able to do that.
(Kauaʻi teen)

A lot of adults say we have it a lot easier than they did back in the day,but they have that wrong. Dad says he used to have to walkeverywhere…but nowadays, we can’t walk around without fear ofsomething bad happening.
(Kauaʻi teen)

PARENTS WORKINGUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

70.7%

73.4%

73.8%

79.1%

71.7%

81.5%

23.7%

11.6%

11.2%

8.3%

26.6%

21.8%

22.2%

23.8%

59.2%

63.5%

Percentage of households with children 6-17 years old and all parents in the family are in the workforce(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

CHILDREN BELOW POVERTY

20.3%

12.9%

Percentage of people under the age of 18 who are living below the federal poverty level.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

TEEN w/SUFFICIENT SLEEP

27.3%

22.8%

Percentage of public school students in grades 9-12 who got 8 or more hours of sleep on an average school night.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

TEEN <2 HOURS SCREEN TIME

58.3%

59.3%

61.3%

55.3%

Percentage of public school students in grades 9-12 who play video or computer games or use a computer for something that is not school related fortwo hours or less on an average school day.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

TEEN EATING DISORDER

N/A

20.8%

18.1%

23.4%

21.0%

19.9%

Percentage of public school students in grades 9-12 who went without eating for 24 hour or more, took diet pills, powders, or liquids without adoctor's advice, or vomited or took laxatives to lose weight or keep from gaining weight in the past 30 days.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2017

TEEN SUICIDE ATTEMPT

2.8%

2.4%

3.5%

3.1%

2.1%

3.4%

Percentage of public school students in grades 9-12 who reported at least one suicide attempt that required medical attention in the past 12 months.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

By now, it should be considered the norm that most children do not have a parent whose sole jobs areto be a parent and manage the home. Few children have that luxury, and in ﬁnancially-strappedhouseholds in Hawaiʻi, it seems many of these parents have more than one job, leaving even less time
for parent-child interaction. On Maui and Kauaʻi, roughly four out of every ﬁve children have all parents
working . Hawaiʻi Island at 23.7% is the only county with higher than U.S. average of children living
below poverty, which is linked to a higher likelihood of physical, behavioral, and emotional problems.
The percentage of teens in Hawaiʻi getting enough sleep has declined slightly from 2013 (state averageof 26.8%) to 2017 (22.8%) and time on screens remains an issue. Eating disorders and suicide attempts
can be the result of low self-esteem, depression, and other mental health conditions. Those at greaterrisk of suicidal thoughts can be teens going through traumatic life events, such as parents’ divorce,moving, ﬁnancial changes, and bullying.

69

Trusted Adults and Role Models
Adults have the potential to guide young people away from risky behaviors like substance abuse,violence, and sex. Most importantly, they can provide safety and security for the children in their care.
Even youth who have run away from their homes expressed a desire and need for trusted adults in theirlives. This intergenerational connection is vital to the health of young people. Finding that trusted
adult, especially for those in distressed families or without structured activities, can be diﬃcult. In thestrongest communities in Hawaiʻi, people trust that most of the adults are looking after each other’schildren.

My healthy place was being at my grandma’s house because she loved
me even when I screwed up and loved me the way my parents should
have.
(Teen in substance abuse treatment)

I always go to my friends ﬁrst. If not, then a trusted adult.
(Kauaʻi teen)

TEEN w/ADULT THEY CAN TALK TOUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

81.9%

84.4%

81.7%

81.5%

81.3%

Percentage of public school students in grades 9-12 who report they have an adult or teacher they can talk to about things that are important to them.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

A relatively high percentage of teens report having an adult “they can talk to about things that areimportant to them.” Additional data would be helpful to understand whether youth have deeper
connections with adults, where those connections are made, and how they can be strengthened.

Positive Activities
Activities for youth are valuable, but there are not enough out there to meet community needs. At themost basic level, all youth need places to go that are safe and pique their interests, whether sports,
arts, community service, academics, or recreation. Without structured care or activity, children areunsupervised and susceptible to engage in the high-risk behaviors that often lead to poor health. At
their ﬁnest, youth activities help young people develop skills, a sense of service, leadership, healthy
friendships, and a sense of community. Occupied, engaged, connected young people are more likely to
become healthy adults.

Our island is small and “healthy” means looking after the youth. We help
with elementary kids, clean beaches, showing teenagers how to help
with community. Staying in community service is a good activity forhaving something to do and being a good role model. We can be good
leaders in the future and have the ability to serve the community.
(Kauaʻi teen)70

Athletics, youth and adult, are important. I see a lot of success with Pop
Warner football, youth baseball, soccer. The West Side has basketballcamps that have been successful. The county could do a better job of
supporting sports through park management.
(Kauaʻi physician)We need more safe spaces for our teens and middle schoolers…we don’t
have a lot to keep them busy to keep them from having bonﬁres at thebeach and getting drunk.
(Kapa‘a provider)

Now that they have the ku‘i program at Hāna School, I see that as big
time health—kids harvesting kalo, cooking, learning how to pound it,right there everyone eating them. It’s so rich in culture.
(Hāna provider)

TEEN BULLIEDUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

20.2%

18.4%

21.3%

21.7%

17.1%

19.9%

Percentage of public school students in grades 9-12 who were bullied on school property in the 12 months preceding the survey.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

TEEN CYBERBULLIED

15.5%

14.6%

15.1%

16.4%

14.0%

16.1%

Percentage of public school students in grades 9-12 who were electronically bullied, including bullying through email, chat rooms, instant messaging,
web sites, or texting, in the past 12 months.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

TEEN TRIED VAPING

N/A

42.3%

49.6%

50.7%

39.0%

45.3%

Percentage of public school students in grades 9-12 who have ever tried an electronic vapor product (e.g. e-cigarettes, vaping pens).
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

TEEN ALCOHOL USE

32.8%

24.5%

32.1%

32.8%

21.0%

30.1%

Percentage of public school students in grades 9-12 who had at least one drink of alcohol on at least one day in the past 30 days.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018

OFFERED DRUGS AT SCHOOL

21.7%

25.4%

26.8%

26.5%

25.3%

21.4%

Percentage of public school students in grades 9-12 who were oﬀered, sold, or given illegal drugs on school property in the past 12 months.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2016

TEEN METH USE

3.0%

4.8%

5.7%

6.2%

4.3%

5.4%

Percentage of public school students in grades 9-12 who have used methamphetamines (also called speed, crystal, crank, or ice) one or more times
during their life.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Organized activity and positive role models can help direct youth away from behaviors like bullying andcyberbullying. Engaged youth can also reduce the chances of picking up addictive behaviors, such as
tobacco, alcohol, and drug use. Nearly half of high school students tried vaping or an e-cigarette, aconcerning national trend linked to adult tobacco addiction. It would be beneﬁcial to regularly collect
more positive measures of engagement to see what kinds of activities youth are engaged in and theimpacts those activities are having on their lives.

71Youth Voice and Power
Peer inﬂuence is often assumed to be a negative force, but there is a positive side that can be
activated. Across the islands, teens are successfully holding down jobs, leading peer support eﬀorts,
organizing community service initiatives, growing food, and advocating for healthier schools. In places
where youth are being heard, respected, and empowered, great opportunities have appeared forsuccessfully navigating the unique challenges of growing up healthy in Hawaiʻi.

What I wish people knew about me is that I have dreams and goals.
(Mililani teen in rehab)

A few years back, people would say that teens are clueless and don’t
have a voice but now with the problems we see, we’re getting better atvoicing thoughts and opinions. And there’s more understanding that
we’re not as clueless as people thought.
(Kauaʻi teen)72

HEALTHY KŪPUNA
Having reverence for elders is a core value of many cultures.
Woven together over the generations, this obligation to honor
kūpuna has become a ﬁrmly established societal value of
Hawaiʻi. But attitudes toward seniors in society are changing
with the times for at least two reasons. First, in many people’s
minds, growing old has become synonymous with having a
medical condition. And indeed, much of society’s healthcare
resources are directed at and consumed by the senior
19
population with higher per capita costs. Second, there are
more seniors than ever in history because people live longer and20
larger cohorts of people are entering older age. This means
more care is needed, and it also means more active older adults
are playing an unprecedented role in society. In these changing
times, how does the community live up to its value of honoring
our kūpuna and what will that look like in the coming decades?
Conversations with Hawaiʻi seniors and the people who care forthem helped to shed light on the issue.

Reason to Live
Loneliness, hopelessness, and boredom are the three enemies of growing old, according to a local
leader in kūpuna health services. Many physical problems have some known medical treatment, butsocial and emotional challenges require diﬀerent supports. Kūpuna shared stories about their children
moving on, their friends and loved ones dying, and their feeling of being less needed by their family andsociety. However, most of the kūpuna who participated in this CHNA had bright outlooks on life, as
many of them are connected to organizations working to decrease isolation and help kūpuna ﬁnd their
purpose, through the intentional creation of strong relationships and meaningful community activities.

19

Centers for Medicare and Medicaid Services.

20

U.S. Census Bureau. “Older People Projected to Outnumber Children for First Time in U.S. History.”73

I have a close family and a lot of good friends and my dog. My dog
always knows when I nap and when I wake up he is there and he makes
me so happy...When we are sad, he is sad but always happy when wecome home.
(Maui kupuna)You have to pursue a goal. I’m a gardener. That’s my goal. I tell myplants, “I want you to make ﬂowers and fruits for me,” and it works. And
I share all my fruit and ﬂowers with my neighbors.
(91-year-old Kalihi resident)

We’re pretty isolated here on Lānaʻi. People sit at home, or they crochet,sew, and garden. Hobbies are pretty important.
(Lānaʻi kupuna)To realize how lucky you are to be a human being and to be alive, and I
can still think and imagine at 94! The world is so beautiful andcomplicated so I am fascinated by life. It is good to be here and everyone
here who is so healthy amazes me.
(Maui kupuna)As long as kūpuna care focuses on sick care, most measurements of health status are focused on thephysical aﬄictions and medical care of seniors. It would be helpful to have a better understanding of
how seniors are viewing their lives, what gives them purpose, what frustrates them, and what kinds ofservices and interventions can improve emotional and mental wellbeing.

Activity
Most health information aimed at seniors revolves around “sick care,” which shapes the narrative in
people’s minds (including their own) that growing old is about treating disease, slowing down, andeluding death. But the reality is that many kūpuna are still quite busy. A new and potentially expandingrole is that more grandparents are becoming necessary full- or part-time caregivers to grandchildren.
This intergenerational connection is an important community function. Other activities in both formal
and informal settings provide physical activity, mental challenges, and social connection. Many seniors
shared how meaningful activity was essential medicine for their physical and mental health.

I have felt healthiest since I had my ﬁrst grandchild and now I have seven
grandchildren. People say, “Aunty, how you stay slim?” My grandkids
keep me always moving. But at the same time, I have to work, and when
I come home from work, I’m tired.
(Waiʻanae grandmother)74

I get bored at home, so I come here. We dance, we exercise, we interact
with other people, we learn things about how to be healthy. I come here
even when I don’t feel well because coming here makes me feel healthy. I
hope that I will have good health for a long time.
(Kalihi kupuna at Kōkua Kalihi Valley Gulick Elder Center)

About a year and a half ago, I got involved in a program with Hui No Ke
Ola Pono. Insurance covered a program for staying well. What they oﬀer
for people is really wonderful. If you’re in the category of being eligible
ﬁnancially, there’s a program for water aerobics, gym, massage…nomatter the color of your skin, they are equitable. Many of us are retiredage, we encourage one another, when we’re doing our ﬁtness, we push
one another on. They’ve got a wonderful thing going in the community.
(Kahului kupuna)65+ RESPONSIBLE FOR GRANDCHILDRENUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

1.2%

1.8%

2.6%

1.7%

1.6%

0.9%

7.9%

11.8%

12.1%

10.0%

19.1%

22.7%

19.7%

21.7%

22.5%

17.7%

20.0%

17.7%

Percentage of residents 65 years or older who are responsible for grandchild(ren)(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ LIVING w/GRANDCHILDREN

5.1%

11.3%

Percentage of residents 65 years or older with grandchild(ren) in their household(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ EMPLOYED

16.8%

20.1%

Percentage of residents 65 years or older who in the labor force and employed(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ WHO ARE VETERANS

19.4%

20.0%

Percentage of residents 65 years or older who are veterans(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Hawaiʻi seniors are probably more integrated into families than in the rest of the nation. Besides thefact that fewer live alone, Hawaiʻi seniors care for their grandchildren at slightly higher rates, with
Hawaiʻi Island at the highest, and a higher percentage of seniors living with their grandchildren. One inﬁve Hawaiʻi seniors is employed, and one in ﬁve is a veteran, suggesting the kinds of engagement andactivity available to kūpuna.

Kūpuna Access to Care
Many kūpuna in Hawaiʻi are on ﬁxed income from pensions, retirement plans, or social security, which
do not rise to meet the steady rise in the cost of living including medical care, and in particular the costof prescription drugs. Across the islands, stories were shared about seniors who ration
medications—taking less than the prescribed dosage—to save money. Seniors who live in poverty areamong the most vulnerable in society, experiencing or at risk of isolation, hunger, and injury. For many,leaving their homes is diﬃcult as their mobility is limited.

75

Many of our older patients make appointments for many, many things.
Sometimes it might be because they’re lonely, but there are a lot oflayers to get through. As social workers, we try to see the diamond in therough. Under all the complaints, it might be someone who needs more
hand holding than they realize.
(Honolulu provider)

One ﬁercely independent father in his 90s saw the doctor recently, andthe doctor said he needed to look ahead and ﬁgure out long term care if
he couldn’t ﬁnd anyone to help him at home when the time comes. He’s
so independent that he wasn’t going to ask around for help and is now
selling his house that has been in his family for more than 50 years so hecan aﬀord long term care.
(Waiʻanae service provider)

We can’t ignore the treatment needs that are out there. What is thestate going to be doing about the boomers or older? That’s going to be apotential ﬁnancial problem because there’s no money to pay for adultdental unless people are privately insured.
(West Oʻahu provider)

65+ BELOW POVERTYUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

9.3%

8.0%

9.4%

8.4%

7.7%

7.9%

13.4%

22.7%

26.9%

19.5%

8.2%

15.0%

21.2%

13.0%

50.0%

56.0%

59.9%

53.4%

63.1%

72.8%

64.0%

Percentage of residents 65 years or older who are below 100% FPL(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ FOREIGN BORN

13.4%

24.0%

Percentage of residents 65 years or older who are not born in the US(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ LIMITED ENGLISH

8.7%

18.1%

Percentage of residents 65 years or older who speak English less than "very well"(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ FLU VACCINE

58.2%

56.9%

Percentage of adults aged 65 years and older who received an inﬂuenza vaccination in the past year.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

65+ PNEUMONIA VACCINE

73.4%

67.6%

56.7%

Percentage of adults aged 65 years and older who have ever received a pneumococcal (pneumonia) vaccine.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Seniors living in poverty have greater likelihood of negative health outcomes and they may not havethe means to aﬀord healthcare, and thus they may skip appointments and forgo treatment. A quarterof Hawaiʻi’s seniors are immigrants with the most on Oʻahu, which also has the highest percentage whohave limited English proﬁciency. This could limit their ability to communicate with and understand theirhealthcare providers. As a possible indicator of how easily seniors are accessing care, we can look at
vaccination rates where the state is behind national averages.

76Aging at Home
Many kūpuna want to live in the comfort of their own home, in a familiar place and near their family.
Kūpuna want to be independent and not a burden on their loved ones to care for them. Some kūpuna
aren’t able to because they have higher needs of care than their home or community can provide, orthat their means can aﬀord. For many, this can be a terrible choice and a diﬃcult transition at a mostvulnerable time in life.

In our area there’s a care home that cost $10,000 per month, which is askilled nursing facility. That’s a big stretch…There are no aﬀordable
services for end of life.
(Waimea, Hawaiʻi resident)

I don’t want to die among strangers, with the sterilization and smells;
you only go to the hospital for emergency. How can we help people athome who don’t want to die in a sterile environment?
(Molokaʻi kupuna and former provider)

I wish I could die on Lānaʻi. I love this place. But my wife needs
healthcare that she can’t get on island, so we’ll likely have to move.
(Lānaʻi kupuna)65+ LIVING ALONEUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

42.9%

33.9%

35.9%

34.8%

33.4%

32.5%

21.3%

21.9%

25.6%

24.8%

Percentage of residents 65 years or older who is a householder living alone(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

65+ WIDOWED

24.9%

24.5%

Percentage of residents 65 years or older who are widowed(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

A third of Hawaiʻi’s kūpuna are living alone and a quarter are widowed. Living alone can be a choice andis no doubt preferable to some seniors. But living alone can also be an unsafe proposition without
adequate and available social and medical supports. The time for baby boomers to swell the ranks ofthe senior population is upon us. For kūpuna who lack suﬃcient ﬁnancial resources, viable solutions areneeded to ensure that all can have the safety and support needed to live out the rest of their lives withpurpose, dignity, and security.

Kūpuna Status and Engagement
One kupuna in Hawaiʻi, who happens to be an expert on aging issues, said his goal is to “live long anddie fast.” As more baby boomers enter the kūpuna ranks, some are trying to shift the narrative awayfrom sickness and toward engagement including volunteerism, paid work, taking classes, caregiving,community leadership, and teaching. There are challenges. Some seniors face discrimination in hiring,
many lack requisite skills in technology, and others whose status was tied to their pre-retirement work
have diﬃculty adjusting to something new. Nevertheless, many seniors are restoring the positive77

connotations of “kūpuna status” away from disability and inactivity, and back to an integrated
community position of value and honor.

I live Hale Mahaolu. When I ﬁrst moved in there, there was kind of astigma about living in low income housing. You didn’t have all of thethings you want to have. But that is not so in the housing. As a memberof the Hale, I get to join a group that discusses ways in which we canhave the best of life. We get to have people come by and talk with us
about health insurance companies, how we can apply for food stamps. It
makes our living that much easier. I like the way the senior citizen
housing has been organized because it caters to the older senior citizens.
I wish more of our local people would apply to become part of the Hale.
(Maui kupuna)

Positive measures are needed to better understand the tangible and intangible contributions made byseniors across the islands. By tracking and encouraging these social beneﬁts, we may begin to see aging
in a new light more appropriate to these generations and this century.

78

CARE
Often lost in the shuﬄe of paying for and receiving healthcare is
the actual exchange of care. People shared stories of being
satisﬁed with their healthcare, and some shared stories of very
positive experiences. But many others, primarily those facing
the most disadvantages, have had bad experiences withhealthcare: experiences that cause them to get insuﬃcient or
deﬁcient treatment; experiences that create confusion andmisinformation; experiences that make them suspicious anddistrusting of doctors and medicine; and experiences that cause
them to avoid interaction with the healthcare system as much as
possible, which often leads to more dire and expensive healthproblems.

Dislike or Fear of Doctors and Medicine
For some people, perhaps more than we might suspect, going to the hospital or seeing a doctor is ahorrifying or terrifying experience. People shared stories of trying to get in and out of appointments asfast as possible. Some said they avoid doctors at all costs because they are so scared of hearing bad
news, even if they know it means things could get worse in the future. Some are wary of medications,unsure of what they do, how they interact, and why so many are prescribed.

With my family history, my fear is that if I go through with the test,
they’re going to tell me things I don’t want to know.
(Hilo resident with a family history of diabetes)

Our community thinks, “I no like go. I no need go. I’m okay.” So then they
self diagnose and they don’t take the medicines.
(Pāhoa resident)

Lately when I go to the doctor, right from the beginning, the person at
the desk is all stressed out and yelling at you…it gets everything oﬀ on
the wrong foot(Waimea, Hawaiʻi resident)

79

The important thing is stay as healthy as you can so that you don’t haveto endure the healthcare system.
(Waimea, Hawaiʻi resident)

No public data was available to help analyze people’s negative views of healthcare, particularly those inpopulations that face health disparities. Based on community conversations, one might theorize thatnegative views of healthcare are passed down to generations and spread among communities topoison the relationship between people and their healthcare, or cloud the reputations of certain
healthcare providers and facilities.

Shame
Shame is a mainstay of many of the cultures of Hawaiʻi, and it revealed itself in the way people talked
about their interactions with healthcare. Some people simply feel unworthy of being helped. Or they
are ashamed of their poor health and do not want to talk about it and feel judged. Often it plays out in
subtle ways. People might nod when asked if they are doing what the doctor said to do when in reality
they haven’t. The intent here is not to lie, rather it is to internalize the shame of letting someone down.

Pride is a big barrier. When I was a Community Health Worker, I would
tell people about public programs, “This is what your mother paid into,
your grandmother paid into it…it’s like a savings account…use it!” Prideand shame is a challenge for some. For some, there was “macho” man in
the house who just lost his job, have to know how to communicate toconvince them it's ok. They say they don't need that kind of help.
(Maui provider)

I notice a lot of clients coming in for things like SNAP applications, or
needing employment, or needing medical insurance—but their pride is
everything, they’d rather not take advantage. Families have so muchpride, they'd rather not access services and usually wait until it is toolate. One aunty went into ER last night because she couldn't breathe; she
has lung cancer. But often they don't want to burden anybody else,“don't like bother,” “ﬁgure you're too busy,” “they going ﬁnd all kinds ofthings wrong; I’d rather just wait”(Hāna provider)

By its nature, shame is likely a diﬃcult factor to measure. In a safe and comfortable environment,
people may be willing to talk about their shame, but in a phone survey or focus group, it would be
extremely diﬃcult to discern how many people are too ashamed to communicate openly with theirhealthcare providers.

Community Competence
Knowing the people in a community—their cares, customs, healthy places, cultural practices, foods,
communication styles, and all the other nuances that people have—is critical to providing good
care.

80

Ideally, the healthcare providers in a community would know these things either because they wereraised in the community, or because they have worked there with an open mind and have the ability tolearn and change. But many communities, particularly small and rural ones, lack degree-qualiﬁedpeople from the community or community-qualiﬁed people with requisite degrees. For people in needof healthcare, this competency makes a big diﬀerence.

I love my doctor. She’s a local girl, born and raised, and knows the
struggle that we go through.
(West Hawaiʻi resident)

There is a greater understanding and comfort for patients when we go
into their community and home settings. From there, you can see thereasons why they still have asthma or other illnesses. We need people
from the community who understand our community and make getting
healthier easier. The system should think more about loosening rigid
rules about hiring individuals with degrees and hire morecommunity-minded people.
(Pāhoa resident and former community health worker)

Seems like when you ﬁnd a doctor who was born and raised in thecommunity, they know better how to work with people here. We need tohave more homegrown doctors who know the community.
(Waimea, Hawaiʻi resident)

I’m surrounded by people from Niʻihau. They’re so comfortable whensurrounded by their native language. When they go to a doctor, it makes
such a diﬀerence when doctor speaks the language.
(Kekaha resident)

Hospitals now employ hospitalists...“rent a docs.” They don’t live in thecommunity, don’t run into their family and patients at the grocery store.
It used to be that doctors would advocate for their patients. Now all thework gets undone because the patient doesn’t have the supports outside
the hospital.
(Kauaʻi physician)There are no publicly available measures of the degree to which healthcare providers are attuned totheir constituencies.

Attitudes Toward Non-Western Medicine
Though non-Western medical treatment has become more common, it still largely lacks respect andunderstanding by those in the healthcare system. Cultural practitioners said they approach healing bytreating the whole patient—they talk story and listen to all their concerns, understanding that physicalproblems can be manifested from emotional and mental issues, and vice versa. But most also recognize

81when there are limitations to their treatment and will refer patients to Western doctors when it
requires certain medications or treatment. They said they wish there could be greater harmony andmutual respect for each other’s practices.

Health is inner connection to being, in relation to everyone aroundme—family, second family at work, gatherings like this, ability to hangon to old values, old style of living, which would mean how I eat, having
the ability to feel connected to my food, connected not in the sense oflooking at it in a restaurant, but being connected to it, being as one withthe universe, knowing when my body is responding. When I do feel sick,what do I do? When do I go to the doctor or when can I just keep takinglāʻau lapaʻau? I tune into the signs... getting a headache when not
drinking enough water...feeling stressed. Being aware of that is health tome.
(Kauaʻi resident and cancer survivor who chose traditional healing)

I provide health insurance for all of my employees. None of them use it
because they don’t trust Western medicine.
(Native Hawaiian employer)

It’s important not to leave out the traditional healers. My mom, forexample, she couldn’t stand the medical community; she didn’t trust.
They had 10 minutes to spend with her, they didn’t want to know her
story, she was uncomfortable. But traditional healers spend a long timetalking. These become gatekeepers or at least connectors to health. We
should consider not stigmatizing, if not including, them. We need tomake them partners at the table; they are seeing people who are notgoing to doctors.
(Maui health worker)

A puʻuhonua approach would have a warm atmosphere conducive tohealing and a person-to-person element. It would be patient centeredand not hospital centered where a person can be more comfortable,
someone can listen to their needs and advocate.
(Molokaʻi resident)

There has to be an understanding from mainstream medicine thattraditional healing practices work. You are led to believe that they(Western doctors) know what will work. If they (patients) don’t believe init, all the talking in the world won’t convince them. Going to traditional
healers gives people a sense of control.
(Kauaʻi resident)82

Aloha ʻāina, mālama ʻāina…we need to treat culture as asset, not achallenge. Stop seeing culture as a risk factor.
(Honolulu advocate)

Trust
Some people said they have inherent trust in their doctors because of all the schooling and training
required to become a doctor. And yet many people also said that they do not think their doctors trustthem to do what they need to do. This important aspect of trust is fragile. One experience of mistake,or news of a mistake, or rumors of a mistake can tear down the trust that is so important in therelationship. Managing expectations in compassionate ways is also an important process that does notalways occur. Some believe doctors and insurance companies are only in it for the money—a notion
which, true or not, corrupts the sacred relationship between patient and healer.

I just lost my husband in December to cancer. He didn't use chemo until
the end of his life. The oncologist kept on saying that “we have a better
chemo.” But it was the nurse practitioner who told him the truth. The
nurse practitioner said, “what do you want, quality or quantity of life?”
Right there, (my husband) made a decision, “I am done.” The oncologist
continued to try to convince him. All it took was the nurse practitioner
telling him the truth. Sometimes with doctors, it’d be better they just tell
you the truth. Doctors have their own commission for diﬀerent
treatments. When I saw the bill, I was totally shocked about how much
one treatment cost. Never would I be able to pay that bill without
insurance.
(Kauaʻi resident)

We need people who understand that we need to treat the person andnot just the wound. For some people to get help, it takes seeing a trusted
provider regularly before they disclose or accept help.
(Waiʻanae community member and advocate)

We have given away the power of health to doctors. I do not understand
why we are not completely invested in preventative medicine. Our
government and Congress side with the pharmaceutical industry. We
have the worst healthcare system with the worst outcomes, and it is themost expensive.
(Maui kupuna)83

For native Hawaiians, when they ﬁnd a doctor who will take them andthey secure transportation to get to their appointment, now it’s about
the relationship they have with the doctor. Today’s current “in and out
the door” style of business is a barrier. They need relationships in order tobe receptive to the care being provided. If they don’t feel like the doctor
knows and understands them, they may not trust the doctor’s
instructions or the medication they prescribe. Then we hear that our
native Hawaiian clients look like noncompliant patients, and once they
get that message, they don’t want to cause a problem to the doctor andthey don’t want to be a burden, so then they stop going to see that
doctor. They become very reluctant to go back.
(Native Hawaiian health services provider in Hilo)

How do we switch from competition mindset to cooperation
mindset…it’s not hospitals’ strength because they were trained under acompetition mindset. We need to help reset the baseline. No matter how
you cut it, capitalism and healthcare don’t go together.
(Honolulu advocate)Eﬀort and Empathy
Patients are not illnesses or diagnoses to be treated. They have stories and histories that need to beunderstood in order for them to feel cared for. With the rise of electronic records, some talked about
how their doctors are only looking at computer screens throughout an examination. Patients wantdoctors who take the time to understand their lives—their experiences that make it hard to follow the
doctor’s orders, their family situations that can hinder or support their healing processes, and otheraspects that make their lives uniquely theirs. People shared how they want their doctors to trust themand their opinions. They want to feel empowered to take care of themselves. This requires dialogue
and a mutual commitment to building a relationship. It takes time, listening, and empathy.

The CNAs (certiﬁed nursing assistants) who cared for my mom...they
cried when she passed. That was so important to me.
(Health Services Administrator)

I have a new doctor every three or four months. Some are good, some are
not so good. (Question: What does “good” mean to you?) Good means heremembers who I am.
(Kalihi kupuna)I went to a new doctor I hadn’t seen before. She didn’t look at me, she
asked if I was new here, she had an attitude, she didn’t order the correct
X-ray. Teaching doctor empathy is a big issue.
(Hāwī resident)

84Language barriers are not as important as caring barriers. Even if you
don’t speak my language, I can tell from your body language and thetime and patience that you give me that you care—and then we cancommunicate.
(Kalihi kupuna)

I would like to see more doctors helping patients be able to help
themselves. We’re our best doctors. Don’t discount what people aresaying, rather they should acknowledge them and empowering people toknow their bodies.
(Kauaʻi woman practicing lāʻau lapaʻau)

I’m afraid that the caring doctors are the old ones who are retiring.
Doctors don’t do tough love anymore. New doctors don’t seem to havethat deep love of caring. I see the younger doctors on their devices... they
only give you ﬁve minutes. When you call, nobody answers. Nobody calls
you back.
(Waimea, Hawaiʻi resident)

ROUTINE CHECK UP IN THE PAST YEARUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

70.8%

72.0%

67.9%

65.1%

74.4%

66.1%

53.2%

55.7%

57.4%

51.3%

Percentage of adults who have had a routine medical checkup in the past 12 months.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

DIABETICS w/DIABETES EDUCATION

N/A

56.0%

Percentage of persons aged 18 years and older with diabetes who report they have taken a course or class in diabetes self-management. Persons withpre-diabetes, borderline diabetes, and women with gestational diabetes are excluded.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

FLU VACCINE RATE (18-64)

33.6%

34.5%

25.8%

24.0%

38.3%

27.0%

29

21

31

Percentage of adults aged 18-64 years who received an inﬂuenza vaccination in the past year.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

PREVENTABLE HOSPITALSTAYS-MEDICARE

N/A

23

26

Hospital discharge rate for ambulatory care-sensitive conditions per 1,000 fee-for-service Medicare enrollees. Ambulatory care-sensitive conditions
include: convulsions, chronic obstructive pulmonary disease, bacterial pneumonia, asthma, congestive heart failure, hypertension, angina, cellulitis,
diabetes, gastroenteritis, kidney/urinary infection, and dehydration.
(Data: 2015). Source: County Health Rankings, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Without much publicly available data on patient perceptions, satisfaction, and trust of their healthcare
providers, a few data points might serve as proxies for the degree to which people feel comfortablewith their healthcare. For example, one can look at how many people went to get a routine check up,received some kind of health education, or got a ﬂu vaccine. Data on preventable hospital stays may
indicate whether patients (in this case, Medicare patients) sought care at an appropriate or optimal
time. However, one should be cautious with these measures since they could also be inﬂuenced by how
physically or ﬁnancially accessible services are to people. Better indicators of the strength of therelationship between people and healthcare are needed to create joint solutions to the problems
shared by CHNA participants.

85

AVAILABLE HEALTHCARE“Access” has become a common term used by the healthcare
industry, but it isn’t a term that holds much meaning in thecommunity. At the most basic level, people want to be able tosee their doctor when they need to. However, this gets much
more diﬃcult to achieve when factoring in transportation, thediﬀerent ways that healthcare is paid for, the diﬀerent systems
for diﬀerent types of healthcare, the availability of medical
professionals, and whether people have the help they need toknow how best to utilize healthcare.

Getting There
For many people, getting needed healthcare involves hours on roads, or a half day on the ferry, or fulldays of airplane travel. One idea is that isolated areas need more providers and more healthcare
facilities. There are certainly strong proponents of that. Others in rural areas shared an understandingthat by living in isolated areas, they are making a tradeoﬀ between healthcare convenience and living in
the places they call home, although access to emergency care is still a necessity. For people who live faraway from healthcare resources, adding new resources is only half of the picture. Another way to see itis that it is even more important for remote areas to have investments made in improving the social
determinants of health to ultimately reduce the demand for medical care; things like access to healthy
food, preservation of healthy spaces, strong community ties, good paying jobs, ﬁnancial supports, andeducational opportunities.

The lack of transportation on the Big Island makes it diﬃcult to go toappointments. People are not going to get on a bus for two hours, go to
Hilo for a doctor's appointment, and take two hours coming back.
(Pāhoa resident)

Another problem is if you need to go to a specialist doctor. I don’t havesomeone to drive me. For Kaiser, you have to go to their places. They pay
for you to go…but you have to get your body there.
(Waimea, Hawaiʻi resident)

We may not have everything we need, but people take care of each other
here. We may have to go oﬀ island for certain things, but it’s hard to
imagine anything better than this community.
(Lānaʻi resident)

86It’s hard on this side because we don’t have clinic that's open past 8
o’clock. Traﬃc to go to the other side is crazy. I had to take an employee
to Kaiser but because it was an accident that happened on the job andwe had to go to (a speciﬁc place). If there was an emergency, this side of
the island has to fend for itself.
(Lahaina employer)

A set of measures could be developed to look at healthcare consumption for those who are the longest
distances away from healthcare. Of course, travel may need to be adequately subsidized to ensure
people can realistically access the care they need. But other measures might look at people’s demandfor healthcare and how strategic upstream investments might help lower that demand in the ﬁrst
place. This kind of eﬀort would need to be a shared eﬀort among multiple parties.

Aﬀordable
For people living on the edge of poverty, the cost of healthcare can drive it lower on the priority list
than it ought to be. Many people choose to skip the doctor’s oﬃce or medications because of cost.
These costs go beyond the co-payments, and include the cost of missing work and transportation costs.
In lieu of going to the doctor’s oﬃce, some will look online to self-diagnose or self-medicate. Some
talked about how free or subsidized programs saved their lives.

During coﬀee season, most of the men work from 6 am to 6 pm and justhave time to take a lunch break. They think, “I cannot be sick because I
need to work.” They turn to pills.
(Hispanic resident living in West Hawaiʻi)

There’s a need for free programs. People already overcome so many
barriers for wanting to quit smoking. When there are programs for them,sometimes they require payment or they’re only available on anotherisland. Bay Clinic found a way to partner with organizations to ensurethat all tools and parts of the program were free and available toparticipants.
(Pāhoa resident)

NO DOCTOR VISIT DUE TO COSTUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

12.1%

7.4%

9.9%

8.6%

6.5%

8.4%

9.0%

8.3%

5.6%

8.4%

30.1%

20.8%

16.2%

20.4%

Percentage of adults who report not seeing a doctor in the past 12 months because of cost.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

ADULTS w/o HEALTH INSURANCE

14.8%

6.6%

Percentage of adults aged 19-64 that do not have any kind of health insurance coverage.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017

PUBLIC HEALTH INSURANCE ONLY

22.3%

18.9%

Percentage of persons who have public health insurance only. Public health coverage includes the federal programs Medicare, Medicaid, and VA HealthCare (provided through the Department of Veterans Aﬀairs); the Children’s Health Insurance Program (CHIP); and individual state health plans.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

87

As has been the case over the decades, compared to the U.S., Hawaiʻi residents are more likely to have
health insurance. Neighbor island residents are more likely to forgo doctors visits because of cost andmore likely to be uninsured. Both situations mean that they are at higher risk of failing to detect andtreat conditions before they get more serious. Hawaiʻi Island has the highest percentage of people with
only public health insurance at 30%.

Comprehension
Medical language and scientiﬁc concepts are diﬃcult to comprehend. Sometimes doctors do not takethe time to explain information in ways their patients can understand. This lack of comprehension is nosmall matter—it can erode a patient’s self conﬁdence, deter people from seeking additional care, andat worst prevent someone from beneﬁting from the health care they need. Essentially, healthcare
becomes inaccessible. For those who speak a language foreign to their doctor, the comprehension
challenge is even more steep and can be more consequential. Although the common healthcare
paradigm assumes the patient is responsible for complying with doctor’s orders, when there is nocomprehension, the doctor ends up holding all the cards, and perhaps more responsibility than isreasonable to expect.

Regarding medication, for patients who have trouble with English
language, you have to be able to show shapes and colors and tabs
instead of names; you have to be able to spend a lot of time. Patients aregoing to smile and nod and not complain. Sometimes they just want toplease the doctor.
(Kauaʻi physician)We all just say “yes doctor” even if we no understand. If you no speak
English or have a diﬀerent culture, even worse.
(Maui kupuna)

Conversations with community members suggest that medical literacy among the general public is
fairly low. Also, many are seeking information online or from peers rather than interacting with theirdesignated healthcare providers. The degree to which this is happening, the quality of information
being conveyed, and the ultimate eﬀects could not be discovered in the course of producing thisreport.

Technology
The rise of technology in healthcare may give people more access to doctors and programs, but it is notalways an eﬀective solution according to some who have experienced it. Some talked about theadvantages of technology, such as automated reminders about appointments and summaries of theirvisits. Other cautioned that technology cannot replace the human connection needed in health.
Technology doesn’t convey the same sense of trust that a person can, and some say they are unsure of
the safety of their data and privacy. Many are also not as tech savvy, especially those whose ﬁrst
language isn’t English, seniors, and those without stable access to technology.

88

We did a telehealth program for diabetes. It worked a little, but it doesn’t
replace the face-to-face interaction people need to really change.
(Molokaʻi health worker)

They’re developing telehealth for East Hawaiʻi to bring specialists to thepeople. It’s a heavy lift but they had funding from the legislature. There
are so many people going to Oʻahu on a daily basis, spending so muchmoney, to access specialists.
(Hilo hospital worker)

This tele-medicine nonsense has to stop. People think that you can dothings telephonically. You cannot. You need to hold their hands. The
navigators know how important it is when you physically hold hands andbring them on.
(Honolulu physician)Access to good mental health care is lacking here. I wish we could do
telehealth, though it’s not the same as seeing therapists in person.
(Hāna provider)

More information is needed to determine what applications of technology are eﬀective with diﬀerent
communities. There seems to be a disconnect between the promises and hopes of those deploying
technology and community experiences with and attitudes toward technology aided access solutions.

Availability of Medical Professionals
A 2018 survey by the University of Hawaiʻi John A. Burns School of Medicine found there is a doctor
21
shortage across Hawaiʻi. Healthcare employers say they have a hard time recruiting medical
professionals, particularly in small communities where wages aren’t as competitive and communities
lack conveniences of bigger cities. Patients feel it too with the lack of available doctors andappointments as well as the high turnover of doctors in their communities.

I had to wait three months to see a doctor to get my knee replaced. I
ended up having to go to Oʻahu, and I suﬀered for it.
(Maui kupuna)

The choice of providers is really limited geographically. It is hard to bringspecialists to our area, and there is a fair amount of turnover at ourhealth center.
(Hāwī resident)

21

Consillio.

89What does buying a home here symbolize? Commitment. If you areserving so many people, the more attractive place to service is Oʻahu.
You couldn’t keep a doctor here. A doctor buying a home showscommitment to our community and to staying.
(Kohala resident)

It’s hard to hire qualiﬁed and dedicated people on Molokaʻi. There aremany people whose spouses don’t want to come over and don’t want to
do long distance marriages.
(Molokaʻi health employer)

It can be very challenging for a physician's family members to adapt orlive on a rural island with no, or very limited, access to a big city.
(Lānaʻi provider)

ADULTS w/USUAL SOURCE OF
HEALTHCAREUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

78.2%

84.7%

82.2%

78.5%

86.8%

83.4%

90

72

Percentage of adults that report having one or more persons they think of as their personal doctor or health care provider.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

PRIMARY CARE PHYSICIANS (per 100,000)

N/A

87

74

94

Number of primary care physicians including non-federal, practicing physicians (M.D.'s and D.O.'s) under age 75 specializing in general practice
medicine, family medicine, internal medicine, and pediatrics per 100,000 residents(Data: 2015). Source: County Health Rankings, Area Health Resource File, 2018

NON-PHYSICIAN PCP (per 100,000)

81

53

38

43

58

43

Non-physician primary care provider rate per 100,000 population. Primary care providers who are not physicians include nurse practitioners (NPs),
physician assistants (PAs), and clinical nurse specialists.
(Data: 2017). Source: Hawaiʻi Health Matters, County Health Rankings, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Most Hawaiʻi adults say they have at least one person they think of as their personal healthcare
provider. People without a regular source of healthcare may not receive the care they need, which canlead to missed diagnoses, untreated conditions, and bad health outcomes. They are also less likely to
get routine checkups and screenings. In general, Oʻahu has more health resources available to its
residents than people on the neighbor islands. Conditions are much more tenuous in speciﬁc areas: theFederal Health Resources & Services Administration currently designates Lahaina, Kula, Kīhei, andHāna/Haʻikū on Maui, all of Molokaʻi and Hawaiʻi County as Primary Care Health Professional Shortage
22
Areas.

Mental Health Services
As understanding of mental illness grows and as the occurrence of mental illness feels more ubiquitousand socially understood, the demand for mental and behavioral health services continues to grow.
Furthermore, since the outcomes of mental illness can be just as devastating as illnesses of the body,
people have a diﬃcult time understanding the fact that the healthcare system seems to treat the
22

U.S. Department of Health & Human Services. “Health Professional Shortage Areas.”90

conditions so diﬀerently. In some places, the needs are at a critical level, with trauma, substance abuse,stress, depression, and other conditions wreaking havoc on the fabric of community, further weakening
a core foundation of community health. Untreated mental and behavioral health issues spiral into manybad outcomes. This crisis of care is an issue of concern across the islands.

There is a severe shortage of mental and behavioral health, especiallyaround inpatient and outpatient substance abuse treatment. Everythingthat we hear from our stakeholders is that spots are full and there’s awaitlist.
(Honolulu advocate)

It was really hard to ﬁnd culturally relevant help for our son. Being
Hawaiian and living in a rural area with other Hawaiian families, you’dthink there would be resources for mental and behavioral health derived
from our cultural practices and knowledge. There weren’t cultural
programs for this and there weren’t any other kind either. We spent somany hours in the car and it looks like there will be many more hours
spent getting to and from the help we need.
(Mother in Windward Oʻahu)

Behavioral health is super hard work when paddling upstream. Maybe
there are plenty of eligible people to do this work, but why would anyonechoose to do it? Burnout and exhaustion is high. Our main role is tosupport the patient and that takes a constant eﬀort to justify andexplain to counterparts.
(Honolulu provider)

MENTAL HEALTH PROVIDERS (per100,000)US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

227

286

154

227

189

Number of mental health providers including psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists,
mental health providers that treat alcohol and other drug abuse, and advanced practice nurses specializing in mental health care per 100,000 residents(Data: 2017). Source: County Health Rankings, National Provider Identiﬁcation Registry, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Connecting people in need with quality mental health care is a continuing challenge. It is widelyreported that many people are not receiving the treatment that they need, although current publicdata was available. The Federal Health Resources & Services Administration currently designates
Hana/East Maui, Molokaʻi, Hawaiʻi County, and Kauaʻi County as Mental Health Professional Shortage
23
Areas.

23

U.S. Department of Health & Human Services. “Health Professional Shortage Areas.”91Oral Healthcare
Dental care is often overlooked when it comes to overall health, and yet it has far reaching impact on a
person’s life. Poor dental health can cause debilitating pain. It can aﬀect the ability to chew, causingdigestive problems and aﬀecting diets. It can negatively aﬀect self-esteem and hinder a person’s ability
to get a job. But oral healthcare is implemented diﬀerently from other types of medical care, andproblems arise for people trying to get the services that they need, particularly for those who are mostvulnerable. As with mental health services, this lack of parity with oral health care creates confusionand frustration particularly for those who see no diﬀerence between treatment inside the mouth andthe rest of the body.

Dental problems are preventable. But if I’m living in tent on the beachwith no running water, where do I put my toothbrush, where do I go tobrush teeth? These daily logistics of taking care of yourself are taken for
granted by people living in a house.
(West Oʻahu provider)

If I had my back teeth, I’d eat carrots.
(Houseless person in Hilo)

Neglecting the oral health of our people has terrible consequences. It isdiﬃcult to say but, with government not supporting the dental care ofthose most in need, we are creating a generation of adults who don’t
have any teeth.
(West Oʻahu provider)

DENTISTS (per 100,000)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

85

65

62

94

64

72.7%

65.0%

66.3%

75.6%

73.0%

Number of dentists per 100,000 residents(Data: 2016). Source: County Health Rankings, Area Health Resource File 2018

DENTIST VISIT

66.3%

Percentage of adults who have visited a dentist or dental clinic for any reason in the past year.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Hawaiʻi does slightly better than the national rate of people visiting their dentist, though Hawaiʻi Islandand Maui County have lower rates than the state’s average. The Federal Health Resources & Services
Administration currently designates Hawaiʻi County, Kalihi-Pālama on Oʻahu and Hāna/Haʻikū on Maui24
as Dental Health Professional Shortage Areas.

24

U.S. Department of Health & Human Services. “Health Professional Shortage Areas.”

92

DOWNSTREAMHEALTH EFFECTS
The following are important downstream health eﬀects seen in the four counties. By employing a social
determinants of health framework, these measures can be seen as, in large part, outcomes of the more
fundamental social, political, economic, and environmental upstream causes mentioned above.

Life and Death
LIFE EXPECTANCY - FEMALESUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

81.5

83.9

83.2

83.7

84.1

83.9

78.4

78.6

78.3

572.7

558.3

561.4

Total number of years a female person can be expected to live if current mortality rates continue to apply.
(Data: 2014). Source: Hawaiʻi Health Matters, Institute for Health Metrics and Evaluation, 2017

LIFE EXPECTANCY - MALES

76.7

78.4

77.3

Total number of years a male person can be expected to live if current mortality rates continue to apply.
(Data: 2014). Source: Hawaiʻi Health Matters, Institute for Health Metrics and Evaluation, 2017

ALL CAUSE MORTALITY (per 100,000)

733.1

571.3

645.2

Age-adjusted death rate due to all causes.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Life expectancy measures a community’s general health. Life expectancy and the death rate varies
between race and ethnic groups, and they reﬂect the health disparities in the community, public health,and medical care. Hawaiʻi is doing better than the U.S. average, though Hawaiʻi Island has the lowest
life expectancy and highest death rate among all the counties. Death rates of Native Hawaiians andother Paciﬁc Islanders are three times the overall rate.

CancerCANCERUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

---

9.4%

10.7%

12.7%

8.7%

10.8%

Percentage of adults aged 18 and over who have ever been told by a health professional that they have any type of cancer, except skin cancer.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2018

DEATH - CANCER (per 100,000)

158.5

131.4

140.1

139.9

128.2

126.6

129.7

125.7

140.6

119.6

20.1

21.7

15.5

14.0

49.2

56.7

100.0

98.2

Age-adjusted death rate due to all forms of cancer (ICD-10 codes C00-C97).
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

BREAST CANCER (per 100,000 F)

124.7

136.1

Age-adjusted incidence rate for breast cancer in cases per 100,000 females.
(Data: 2011-15). Source: Hawaiʻi Health Matters, National Cancer Institute, 2018

DEATH - BREAST CANCER (per 100,000 F)

20.3

18.7

Age-adjusted death rate due to breast cancer among females (ICD-10 code C50).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

PROSTATE CANCER (per 100,000 M)

109.0

86.9

Age-adjusted incidence rate for prostate cancer in cases per 100,000 males.
(Data: 2011-15). Source: Hawaiʻi Health Matters, National Cancer Institute, 201893

DEATH - PROSTATE CANCER (per 100,000 M)

18.8

15.4

14.4

18.5

12.9

15.5

44.6

44.7

47.3

39.4

30.1

31.7

32.0

26.9

Age-adjusted death rate due to prostate cancer among males (ICD-10 code C61).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

LUNG CANCER (per 100,000)

60.2

46.2

Age-adjusted incidence rate for lung and bronchus cancers in cases per 100,000 population.
(Data: 2011-15). Source: Hawaiʻi Health Matters, National Cancer Institute, 2018

DEATH - LUNG CANCER (per 100,000)

40.5

31.3

Age-adjusted death rate due to lung cancer (ICD-10 code C34).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

One in eight women will be diagnosed with breast cancer over the course of a lifetime, making breast
cancer the most common type of cancer among women. For men, prostate cancer is the mostcommonly diagnosed cancer. Lung cancer is the most common cancer that people die from. Cancer
rates are highest among the elderly and Caucasians. However, cancer death rates are highest among
Native Hawaiians and other Paciﬁc Islanders.

Diabetes
PREDIABETESUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

---

14.6%

13.7%

14.4%

15.2%

10.3%

10.2%

11.7%

Percentage of adults without diabetes who have been told by a health care professional that they had prediabetes.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

DIABETES

10.5%

10.5%

11.5%

11.5%

Percentage of adults that have ever been diagnosed with diabetes. Women who were diagnosed with diabetes only during the course of theirpregnancy were not included in this count.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

DEATH - DIABETES (per 100,000)

21.3

14.4

14.8

17.0

14.7

14.2

Age-adjusted death rate due to diabetes (ICD-10 codes E10-E14).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

One in ten Hawaiʻi adults has diabetes, which disproportionately aﬀects minority and elderly
populations. Diabetes also leads to other complications, including cardiovascular disease, blindness,stroke, and kidney disease. The cost of diabetes goes well beyond medical costs as it leads to lower
productivity and creates caretaking needs. As with other disease, even though incidence rates do notappear to be any higher for Native Hawaiians and other Paciﬁc Islanders, and even though Native
Hawaiians have the highest rates of receiving formal diabetes education, their death rates due todiabetes are the highest.

Heart Disease and Stroke
HIGH BLOOD PRESSUREUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

30.9%

32.0%

31.6%

27.1%

33.4%

32.6%

Percentage of adults who have been told they have high blood pressure. Normal blood pressure should be less than 120/80 mm Hg for an adult. Bloodpressure above this level (140/90 mm Hg or higher) is considered high (hypertension).
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2016

HIGH CHOLESTEROL

36.3%

36.3%

35.4%

35.8%

36.8%

36.9%

Percentage of adults who have had their blood cholesterol checked and have been told that it was high.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 201694

CORONARY HEART DISEASE

4.1%

3.6%

4.7%

3.5%

3.3%

4.4%

76.9

72.8

64.5

51.2

13.7

10.0

14.3

12.3

3.1%

1.7%

3.2%

3.7%

28.9

34.0

38.1

Percentage of adults who have ever been told by a health professional that they had coronary heart disease.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

DEATH - CORONARY HEART DISEASE (per 100,000)

108.3

66.1

Age-adjusted death rate due to coronary heart disease (ICD-10 codes I20-I25).
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

DEATH - CONGESTIVE HEART FAILURE (per 100,000)

19.9

14.4

Age-adjusted death rate due to congestive heart failure (ICD-10 code I50).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

STROKE

3.0%

3.0%

Percentage of adults who have ever been told by a health professional that they had a stroke(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

DEATH - STROKE (per 100,000)

37.6

37.4

43.7

Age-adjusted death rate due to stroke (ICD-10 codes I60-I69).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

High blood pressure, often called the “silent killer,” contributes to stoke, heart attacks, heart failure,and kidney failure. Nearly one third of people with high blood pressure are unaware they have it
because there are no symptoms associated with it. Strokes aﬀect mainly the elderly population and canlead to long-term disabilities and death. Although not more likely to have high blood pressure, highcholesterol, or coronary heart disease, Native Hawaiians and other Paciﬁc Islanders are much more
likely to die from heart disease, heart failure and stroke.

Other Factors and Ailments
ARTHRITISUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

25.5%

21.9%

25.1%

25.7%

20.8%

23.7%

11.0%

10.6%

8.9%

6.1%

5.8%

5.1%

Percentage of adults aged 18 years and older who have ever been told by a doctor that they had arthritis.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

ASTHMA

9.1%

10.7%

12.7%

Percentage of adults who have been told by a health care provider that they currently have asthma.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

COPD (45+yrs old)

6.2%

6.0%

7.4%

Percentage of adults aged 45 years and older who have ever been told by a health care professional that they had chronic obstructive pulmonary
disease (COPD), emphysema, or chronic bronchitis.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

DEATH - COPD (45+yrs old)(per 100,000)

115.1

50.0

68.7

65.4

43.1

49.0

Death rate due to chronic obstructive pulmonary disease (ICD-10 codes J40-J44, and excludes asthma) among persons aged 45 years and older.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

OBESITY

30.1%

23.8%

26.9%

24.3%

23.3%

24.0%

Percentage of adults aged 18 years and older who are obese according to the Body Mass Index (BMI). A BMI >=30 is considered obese.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017

KIDNEY DISEASE

2.8%

3.7%

3.2%

3.0%

4.1%

4.1%

Percentage of adults who have ever been told by a health care professional that they had kidney disease (not including kidney stones, bladderinfection, or incontinence).
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017SMOKING

17.0%

13.1%

16.3%

15.2%

11.9%

15.1%

Percentage of adults aged 18 years and over who have smoked at least 100 cigarettes in their life and who report smoking some days or every day.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 201795

DEATH - CIRRHOSIS (per 100,000)

10.8

8.0

10.4

11.2

5.8

5.9

50.9%

44.5%

39.0%

45.8%

Age-adjusted death rate due to cirrhosis (ICD-10 codes K70, K73-K74).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017

ONE OR MORE TOOTH EXTRACTIONS

43.4%

41.5%

Percentage of adults who have had at least one permanent tooth extracted due to tooth caries or periodontal disease.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2017
RED = of signiﬁcant note; YELLOW = positive compared to other counties

Arthritis, aﬀecting more than one in ﬁve adults in Hawaiʻi, is the most common disability that impacts
people’s daily activities. Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases
that cause breathing related problems and whose symptoms include wheezing, chronic cough, andshortness of breath. Obesity is an indicator of the overall health and lifestyle of a community andincreases the risks of many diseases and health conditions. Kidney disease is caused primarily bydiabetes and high blood pressure, and people feel generally unwell or lose their appetite. Unhealthy
activities, such as smoking and heavy drinking, can contribute to a number of diseases, poor healthconditions, and early death. Four in ten adults have had a tooth extracted due to poor dental health,with Hawaiʻi Island at 50%. Missing teeth can aﬀect health and nutrition.

96

SIGNIFICANT HEALTHISSUES, GOALS AND PRIORITIESIN HAWAIʻI
After engaging with people across Hawaiʻi to learn about their lives, their struggles, and theirinteractions with the healthcare system, and after reviewing a sampling of data that help to deﬁne thescope of challenges and who in society might be facing the biggest challenges, three major healthissues emerge. These issues point us to the most signiﬁcant health priorities in Hawaiʻi, particularly
those that can help the most needy in society—those who are often bearing the brunt of thedownstream eﬀects of poor health including disease, shorter lives, and poorer quality of life.

ISSUE 1: Many individuals in Hawaiʻi lack a foundation for
health—security, justice, hope, love, time, good food—thebasic things that every human being needs to have areasonable chance at assembling a truly healthy life.
It is a common belief that poor health is the result of people making poor decisions. In conversations
across the islands, Islander Institute met people making conscious, well-reasoned decisions. The
problem is that many people have poor options. People in Hawaiʻi are making tradeoﬀs at the expenseof their own health and the health of the community. They have to choose between an extra job to pay
the rent or the chance to spend time cooking good meals for their kids; between the time it takes tocare for an aging parent or the money it takes to pay someone else to care for that parent; between
money for a car payment to get to work or money for out-of-pocket expenses to see the doctor;
between an unfulﬁlling job that provides health insurance or a personally fulﬁlling job that doesn’t.
And if they are facing discrimination or unfair disadvantage, their options are even worse. If they arelacking a multitude of the health basics, the options are worse still.
Many people cannot simply “live healthy.” They need the support of family, friends, community,
workplaces, organizations, and society to obtain the basics for healthy living. When this foundation is inplace, many of the upstream factors get addressed, which should subsequently mitigate the expensive
and painful downstream impacts. Understanding community needs and working with people to address
priorities are much more strategic than waiting to treat their poor health outcomes in an already taxed
healthcare system.

ISSUE 2: Many feel that Hawaiʻi is losing its sense ofcommunity—including aspects of the place, values, culture,and practices—and this loss is diminishing health itself.
Community is becoming a tired word. What does it mean? More signiﬁcantly, what does it mean in
Hawaiʻi? Talk with enough people, particularly in rural Hawaiʻi, and the pillars of community start tocome into focus. The foundation was set by the genius of the indigenous people of these islands. At thefoundation of community, we have our land that provides everything we need to live. The people ofthis place work together for the beneﬁt of all, including two sacred obligations—to nurture the keiki97and to honor the kūpuna. And many generations of migrants to these islands have added ﬂavor to thatreciprocal relationship among people and place. But as much as we have added to community, we also
do many things to diminish it. In the eyes of many in Hawaiʻi today, we are losing healthy places,
creating more disconnection to our land, putting the needs of visitors ahead of residents, and losing
our sense of community. It already feels lost in parts of Oʻahu, and people across the islands feel iteroding away. People long for the healing power of community. Community makes health, it has health,and it is health.
Hawaiʻi’s people and place form a powerful healing force that is currently underutilized and steadily
being diminished. By building healthy environments and strong communities that meet our obligations
to keiki and kūpuna, we set the stage for good living and bring more power to bear on addressing the
upstream determinants of health.

ISSUE 3: For many in Hawaiʻi, particularly those with thegreatest needs, the relationship to the healthcare system is apoor one, often seen as lacking in humanity, empathy, andavailability.
Receiving healthcare is a highly personal and deeply involved human interaction. It often carries thehighest stakes of any interactions that people will have in their lives. So it is diﬃcult to square this withthe fact that healthcare has been largely reduced to a three-way economic transaction between aconsumer, a provider, and a payer. Most participants in the CHNA shared how they are not satisﬁed withthe products and services in these transactions, and many questioned the very premise of reducing
healthcare to money issues when what they really need is help from other human beings. People
shared stories of discrimination, medical mistakes, lack of listening, lack of caring, and other negative
experiences with such frequency that one would conclude that bad healthcare is the norm. Of course,
some stories may be exaggerations or misperceptions that are part of a generally negative narrative
about healthcare. But the fact that these impressions exist is a problem in itself. Furthermore, there isgood reason to believe that the things people shared in a safe, comfortable community meeting will
not be shared directly with their healthcare providers in the form of feedback, because local
people—out of shame, fear, respect, or resignation because they have no healthcare options—often
won’t call a supervisor or ﬁll out a feedback form.
The relationship that Hawaiʻi people have to their healthcare system is a core factor in the state ofcommunity health. With all the talk of social determinants, the fact is that healthcare will always be
essential to good health. Walling oﬀ personal health with the rules of individual privacy is not
personalization. What people really want are compassion, empathy, and heartfelt human connection in
their relationship to healthcare. Improving this aspect of quality will ensure that people—especiallythose in greatest need—can and will seek, access, and beneﬁt from healthcare.
SIGNIFICANT HEALTH GOALS AND PRIORITIES.
Given these three core issues, a three-part strategy emerges that focuses on three signiﬁcant goals.
Each goal is divided into priorities that were determined by a review of all input including: a) community
input from meetings, which indicated community needs and the degree of community readiness to join
in forming solutions; b) key informant interviews, which provided expert opinion on various community
needs, possible solutions, systemic factors, insights into political factors, and/or evaluation oforganizational readiness for partnerships; and c) quantitative data, which provided evidence of need,locational and population priorities, and other nuanced aspects of issues.

98Based on this information, an analysis was done looking at criteria including:●●

Evidence of community need based on qualitative and/or quantitative data
Community knowledge, energy and readiness to address an issue●

Existing or potential cross-sector partnerships for broad impact●

Existence of current eﬀorts to replicate or learn from●

Political will and potential resources, if known

GOAL 1: Secure the basic foundations so that people can havemore control over their own health
FOUNDATIONS Priorities
1.1 Address ﬁnancial insecurity. Roughly half of all households in Hawaiʻi are living lives conducive topoor health because of ﬁnancial constraints. There is not enough charity to change the living conditionsof every other household in Hawaiʻi. Communities and families need coordinated and systemic supports
to make good food and housing realistically accessible, develop workforce skills, create new economic
opportunities, build ﬁnancial assets, and reestablish active lifestyles that are giving way to economic
pressures.
1.2 Work together for equality and justice. At the root of health disparities are historical and current
injustice. Instead of addressing the health consequences of that unfairness, society needs to become
increasingly more inclusive and work alongside aﬀected populations to address inequitable treatment
and opportunity. Comprehensive approaches to support the advancement of Native Hawaiian healthcould very well improve the health of all people in Hawaiʻi. And eﬀorts must be made to stamp out
prejudice and unjust treatment of Paciﬁc Islanders, immigrants, non-English speakers, people withdisabilities, elderly, transgender and gender non-conforming individuals, and any others whose lack ofprivilege becomes an upstream cause of economic hardship, life traumas, poor healthcare, and poor
health.
1.3 Strengthen families. People of Hawaiʻi value their families, but ﬁnancial pressures and stress taketheir toll. We need to create the conditions and opportunities for families to be healing forces for its
own members—preventing domestic violence and trauma before it happens, eating healthy together,
spending adequate time with one another, being the primary role models for keiki and primary
caregivers of those in need.
1.4 Prepare for emergencies. Natural disasters are on people’s minds, and for good reason. Working with
community to prepare for these emergencies will not only mitigate future health impacts. It is acommunity building activity that can engage people, increase understanding of the most vulnerable
populations, build food systems, and strengthen relationships and community cohesion.
1.5 Build good food systems. Hawaiʻi has the ingredients to ensure that nutritious food is available andconsumed by all. Farming, subsistence expertise, grocery stores, farmers markets, cultural practices,culinary arts, prices, time, food waste—all of these factors must be thoughtfully organized to disrupt
unhealthy aspects of our food consumption and establish access to good food, particularly for those
whose health will beneﬁt the most.

99

GOAL 2: Preserve, nurture, expand, and employ the healing
properties of community
COMMUNITY Priorities
2.1 Restore environment and sense of place. The natural environment is the health resource in Hawaiʻi. It
is a critical provider of healthcare and health-risk prevention for the people of Hawaiʻi, particularly for
those without access to medical care. For many people, the sense of connection to these islands ishealth itself. Eﬀorts should be made to restore Hawaiʻi’s sense of place with better protections of
natural resources, adequate preparation for climate change, good design and integration of the built
environment, and reducing the negative environmental impacts of the visitor industry.
2.2 Nurture community identity and cohesiveness. Strengthening communities means actively working
against forces leading people to feel more divided, isolated, and unfamiliar with the people and places
around them. Greater trust and connectivity within community can be built through shared activities
and events, active organizing around shared purposes, and instilling community pride. These eﬀorts are
more likely to be successful when they are led from communities themselves.
2.3 Invest in teenagers and healthy starts. With almost all of the adults tied up with work, too many of
Hawaiʻi’s children are ill-equipped to lead healthy lives. Investment in health and education at theearliest stages of life needs to expand. But in addition, there is a large void of support for pre-teens
and teens who are not getting enough physical activity, sleep, healthy food, positive relationships withadults, and positive social engagement with one another. Many spend more waking hours at school orwith their peers than they do with their parents. Therefore, school-based structures, community-based
activities, and youth empowerment are three critical targets for investment of time and resources.
2.4 Shift kūpuna care away from “sick care.” According to many accounts, the focus on medical care forseniors pulls attention away from boredom, loneliness, purposelessness, inactivity, and other social andemotional hardships of aging. A new paradigm of aging must be built so that healthy aging is available
to more than just the few who can aﬀord those supports and activities.

GOAL 3: Improve the relationship between people and thehealthcare system
HEALTHCARE Priorities
3.1 Strengthen trust in healthcare. Health disparities are caused in part by people not receiving the
beneﬁts of healthcare, which is in part a function of people’s attitudes toward healthcare. We may not
be able to know the full extent of people’s fear or mistrust of healthcare, but based on community
accounts, it is high. Trust needs to be strengthened, and in some cases rebuilt, through listening,
empathy, compassion, and treating the whole person. Healthcare workers need to be able to meet
people where they are at in terms of language, culture, and community. And information needs to beshared in plain language that can engage people and eﬀectively convey information.
3.2 Provide accessible, proactive support for those with high needs. People with great needs, including
those who are struggling with houselessness, mental illness, and addiction as well as those who arephysically distant from healthcare require more proactive services, including outreach, earlyintervention, free healthcare services, mental healthcare, oral healthcare, and other preventative
services.

100

ISLANDASSESSMENTS

Image of Hawai‘i at night shows the extent of urbanization. Source: NOAA

101

HAWAIʻI ISLANDHILOHĀMĀKUA

Hilo

Pa‘auilo
Hāwī

Pāhoa

WaimeaPUNA

KOHALA

Waikoloa
PāhalaNā‘ālehu

Kailua-Kona

KA‘Ū

KONA
Ocean View

96780
96727
96755
96755 96719

96728

96773 96783
96774
96776
96764 96710

96781
96749
96760

96720

96743

96771

96738

96778

96785

96740

96750

96777

96725
96726
96726

96704

96772
96737

Above: Hawai‘i place names. Bold indicates moku district. Below: Zipcodes

102

In May 2018, the eruption of Kīlauea and the lava it spewed into residential areas launched community
members into action. The Bodacious Women of Pāhoa (“Bodacious”) is a community-based group thatstarted with three women seeking connection and grew to dozens of volunteers who provide food andemergency supplies to their isolated, rural community. The fear and uncertainty during this time waspalpable; in the words of one resident, “The sky was red. The stress level was high. Every morning I
would wake up, wondering if there was lava at my door.” Bodacious was ready—they organized throughnetworks of trust; passed out food, water, and supplies; created ready-to-go survival kits in orange
buckets for residents to leave in their vehicles; coordinated with county, state, and federal agencies;
and maintained a sense of security and calm.
The ability to positively contribute to their community and their passion to fulﬁll a greater purpose are
central to Bodacious members’ view of a healthy life. Yet they recognize that their community faces
tremendous challenges in being healthy. Like in other areas outside of Hilo and Kona, transportation isa major challenge aﬀecting Hawaiʻi Island residents’ everyday quality of life. This notion was repeatedin Kaʻū, Pāhoa, Ocean View, Kona, Kamuela and Hāwī. For some, doctor appointments take an entire
day when factoring in car rides or unreliable public transportation and often take lower priority whencompared to other obligations in life. Some decide it is better to self-diagnose and self-medicate. For
those with long commutes to work, there is little to no time to spend with family, make healthy meals,
exercise, get enough sleep, or do much of anything outside of work or school.

LIFE EXPECTANCYCOMPARED TO STATE AVERAGE
ABOVE

BELOW

With the vastness of Hawaiʻi Island, it is easy for people and problems, like houselessness, severe
mental illness, and substance abuse, to remain hidden and forgotten. Several houseless individuals andworkers from a Hilo-based nonproﬁt spoke about their experience in shelters and seeking healthcare.
They shared stories of shelter residents with untreated open wounds and conditions like
Methicillin-resistant Staphylococcus aureus (MRSA). Some prefer not to go to the doctor because they
don’t trust them, they feel disrespected and discriminated against, and they lack the money needed forprescriptions. Many just wait until the point where they are sent to urgent care or the emergency room.
A diﬃcult and common barrier is returning to the doctor for follow ups, which often does not happen
because of the inconvenience and cost of the bus or medical taxis.

103

Across the island in West Hawaiʻi, at a dinner gathering, residents from Hawaiian, Marshallese, andHispanic communities found commonalities in their experiences as people working hard to just get byin a world that often isn’t amenable to their cultural perspectives. Those cultural norms include areluctance to share about stress and vulnerability, causing many to just keep pushing through diﬃcult
times. In the Hispanic community, especially for those who are undocumented, they are afraid to seek
healthcare services. Because of the costs of healthcare and not having insurance, they are careful inselecting which visits are essential and which can wait. “During coﬀee season, most of the men workfrom 6 am to 6 pm and just have time to take a lunch break. They think, ‘I cannot be sick because I need
to work.’ They turn to pills,” one person said. “We don’t recognize the stress. There’s this mentality thatyou have to suck it up, don’t be a coward, and there’s no time to cry.”Further south in Kaʻū, the diverse communities of Nāʻālehu, Ocean View, and Pāhala ﬁnd themselves
lumped together by outsiders in government and nonproﬁts who want to “help” them because they arelabeled poor and needy. Residents said most of these outside eﬀorts typically don’t last, as programs
and resources come and go. It is easy to understand why some feel used, and that there is no realcooperative investment to create hope and futures for the children. They point to a need forcommunity grown and driven solutions, particularly practices that ground families in their culture andidentity.
Up north in Waimea, during a talk story at Tūtū’s House, residents shared about the healthy aspects of
their community—a playground, a nature park, an informal network of alternative medicine
practitioners, options for kūpuna care, and farmers markets. But some recognize there are disparities
within the community, such as hidden poverty that reveals itself in the schools. In Hāwī, they spoke
about how rural isolation impacts their choice when it comes to doctors and food. In rural areas,
doctors who are from the community are the ones most successful in treating people because they
understand patients on a deep level. But more common is the frequent turnover of doctors—whether
because of the low pay, isolation, or diﬃculty integrating into the community.
The statistics point to Hawaiʻi Island as having some of the biggest challenges in the state when it
comes to the socio-economic factors often associated with poor health outcomes. This includes thenumber of people in poverty or otherwise struggling economically, lower educational attainment, andhigher unemployment. These social determinants seem to play themselves out with Hawaiʻi Island
residents having higher than average engagement in risky behaviors like smoking and drinking, which inturn may have to do with higher rates of cardiovascular disease, and a generally shorter life expectancy.
Those upstream economic issues are troubling and worthy of attention, but those challenges aren’t the
total picture.
Hawaiʻi Island has bigness, but it is also has closeness. There is cohesion in its many towns around theisland—each with its own character, history and strengths. It stands in contrast to Oʻahu which is
crowded, but in many ways not as close. With its closeness, Hawaiʻi Island feels capable of coming
together to make positive things happen in community. With its bigness, Hawaiʻi Island has what seems
like abundant natural resources and human connection that are the irreplaceable ingredients tocommunity health. The people of Hawaiʻi Island are not only ﬁnding solutions for their own people.
Just as the island’s famous aliʻi, Kamehameha and ʻUmi-a-Līloa, once did, Hawaiʻi Island has thepotential to generate innovations that will spread across the islands. Government, organizations, andcommunity have been working diligently and are coming together to innovate around healthy foodsystems, clean energy, disaster preparedness, sustainable waste management, and many other social
needs. Close people in a big place can get a lot done.

104Population

POPULATION DENSITY
LOWER

200000

POPULATION GROWTH SINCE 1970
THERE ARE 3 TIMES MORE PEOPLE
ON HAWAI‘I ISLAND TODAY THAN 1970.

HIGHER

POP: 196,325
POP: 185,079

150000POP: 148,677

POP: 120,317

POPULATION

100000POP: 92,053

POP: 63,468
50000
YEAR: 1970

1980

1990

2000

2010

2017

1 OUT OF 6 PEOPLE
ON HAWAI‘I ISLAND
ARE VISITORS:

105

Keiki & KūpunaPOPULATION DENSITY(CHILDREN UNDER 18)
LOWER

HIGHER

POPULATION DENSITY(ELDERLY OVER 65)
LOWER

HIGHER

106

Race“HAWAIIAN”“MIXED” (TWO OR MORE)“ASIAN”“BLACK”“LATINO”“WHITE”

RACIAL IDENTITY(PERCENT OF POPULATION)LOWER

HIGHER107

Income

MEDIAN HOUSEHOLD INCOME
COMPARED TO STATE AVERAGE

BELOW

ABOVE

POVERTY(PERCENT OF POPULATION)LOWER

HIGHER

K

$1

$2

5K
-$3

$3
5K

5K
-$5

$5
0K

0K
-$7

$7
5K

5K
-$1

14.7%

12.8%

18.3%

11.5%

8.8%

10.4%

$1
5
0K
-$1 K-$2
5K
5K

$1
00

K

00

K$1

50

K

4.1%

10

5.0%

<$

5.4%

9.1%

PERCENTAGE OF HAWAI‘I HOUSEHOLDS BY INCOME BRACKETAVERAGE 4-PERSON HOUSEHOLD SURVIVAL BUDGET IN HAWAI‘I COUNTY IS $78,420.

$1

$2
00
KK+
20
0K

50

108

Time

+7 HOURS SLEEPCOMPARED TO
STATE AVERAGE
ABOVE

BELOW

EXERCISE
COMPARED TO
STATE AVERAGE
ABOVE

BELOW

COMMUTE(DRIVING ALONE)
LESS

MORE

COMMUTE(OVER 40 MINUTES)+ 40 MIN.

109

High Schools

HIGH SCHOOLDROPOUTS
FREE/REDUCED LUNCH

se

1%
<1%
1%
1%
5%
<1%
2%

13%
25%
22%
16%
21%
11%
14%

10%
2%
2%
5%
2%
7%
20%

<1%
<1%
<1%
1%
<1%
<1%
1%

3%
2%
4%
1%
2%
1%
4%

1%
<1%
2%
1%
1%
2%
1%

3%
2%
3%
7%
3%
10%
2%

11%
9%
15%
23%
17%
19%
10%

hi
W

7%
12%
4%
10%
1%
7%
3%

pa
is
H

te

ni

c

ue

1%
<1%
1%
2%
0%
1%
1%

ac
k
Bl

tu
g
Po
r

n
Ko
re
a

ne
Ja
pa

in

o

e

lip

46%
44%
43%
27%
44%
40%
38%

in

Fi

es

se

ia
es
Ch

ro
n

M
ic

oa
n

n
ia

aw
ai

ce
s
en
11%
22%
18%
15%
19%
18%
7%

bs

Sa
m

53%
86%
76%
50%
55%
61%
46%

n

du
ts
F
Lu ree
nc /R
h e

ro
po
u
10%
25%
11%
24%
15%
16%
12%

H

94%
88%
90%
91%
89%
90%
96%

A

Hilo HighKa‘ū HighKea‘au High
Kealakehe High
Kohala HIgh
Konawaena HighWaiākea High

D

A

tt
en

da

nc
e

ce
d

ABSENCES110

Hawaiʻi Island Strengths and Priorities
Statewide Health Priorities
GOAL 1 - FOUNDATIONSProvide the basic foundations sothat people can have more control
over their own health

GOAL 2 - COMMUNITY
Preserve, nurture, expand, andemploy the healing properties ofcommunity

GOAL 3 - HEALTHCARE
Improve the relationship between
people and the healthcare system

1.1 Address ﬁnancial insecurity
1.2 Work together for equality andjustice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

2.1 Restore environment andsense of place
2.2 Nurture community identity
and cohesiveness
2.3 Invest in teenagers and healthy
starts
2.4 Shift kūpuna care away from“sick care”

3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive
support for those with highneeds

Hawaiʻi Island Strengths●

Access to natural resources and strong
connection to place●

Diverse array of close-knit communities
with numerous seasoned community
leaders and emerging leaders in Hawaiian
and COFA communities●●

Populations of Note
Estimate
HOUSELESS900PEOPLE IN POVERTY

33,700NO HEALTH INSURANCE

11,700WOMEN GIVING BIRTH IN LAST YR

2,500

Record of social innovations andcollaboration among agencies

DISABLED CHILDREN

1,100

CHILDREN IN POVERTY

10,100Speciﬁc success and traction with
farm-to-school eﬀorts

NO HS 25 older

10,300

UNEMPLOYED (IN LABOR FORCE)

6,200

DISABLED ADULTS (18-64)

11,100VETERANS

15,10065+ LIVING ALONE

7,300

DISABLED 65+

13,60085+

4,900

HAWAIIAN

66,500ON HAWAIIAN HOMESTEAD

6,700

OTHER PACIFIC ISLANDER

5,300

RECENT FOREIGN IMMIGRANT

3,700

LIMITED-ENGLISH

11,500All 5-year estimates from U.S. Census, American Community Survey, 2017 except Hawaiian
Homestead population from 2018 Hawaiʻi State Data Book, and houseless count from
Partners in Care, 2018 Point-In-Time Homeless Count.

111

Hawaiʻi Island Priorities(Highest need areas in RED)
CRITERIA
Evidence ofhigh need

Community
readiness

Available
partners

Existing eﬀorts

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing eﬀorts

Political will
/resources✓✓

Continue to provide meaningful opportunities fordiﬀerent communities to be at the table for thevisioning and planning of their own rapidly changing
island

✓

✓

✓

✓

✓

KEIKI

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing eﬀorts

Political will
/resources

Improve relationship to healthcare focusing on
community and cultural competence and overall
availability of care

✓

✓

✓

✓

SUPPORT FOR HIGH NEEDS

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

FOUNDATIONSFINANCIAL INSECURITY

Increase family self-suﬃciency through higher earningand asset building
EQUALITY AND JUSTICE

Build stronger connections with immigrants andcommunities from the COFA states
EQUALITY AND JUSTICE

Support community-based capacity building andeconomic self-suﬃciency in Hawaiian communities
FOOD SYSTEMS

Develop and strengthen food systems throughincreased production and distribution
COMMUNITYCOMMUNITY COHESION

Address gentriﬁcation and class inequality

Political will
/resources

COMMUNITY COHESION

Create a broader array of positive activities for youth,
especially pre-teens and teens
HEALTHCARE
TRUST

Implement more joint strategies to provide houselessservices and solutions
SUPPORT FOR HIGH NEEDS

Improve transportation system—more ways to avoid
travel, improved public transportation
SUPPORT FOR HIGH NEEDS

Develop more services to support people with mental
health needs

✓

112

MAUI
HĀNA

KO‘OLAUHĀMĀKUALOAHĀMĀKUAPOKOKĀ‘ANAPALIWAILUKU

PaiaKĪPAHULU

Makawao
Kula

Kahului

KAUPŌ

Kihei

KAHIKINUIKULALAHAINAHONUA‘ULA

96713

96708
96779

96793

96768

96732
96790
96753

96761

113

Maui, it has been boasted by travelers, is the best island in the U.S. Come relax in its resorts and ventureout into the lush forests and world-class beaches, they say, while still having the conveniences of a big
city. Tourism aﬀects every island in the state, but it has latched onto Maui in a very unique way.
Beneath that glossy veneer are the residents of Maui that participated in this CHNA. These seniors,
community volunteers, health providers, cultural practitioners, workers, and family members don’t
want to lose their island to the tourism story. They would rather boast about their pockets of tight knit
communities: of neighbors looking out for each other, senior clubs and paddling clubs that connect
generations and cultures, work friends that they lean on for support, and thriving practices of farming,ranching, ﬁshing, and subsistence living.

LIFE EXPECTANCYCOMPARED TO STATE AVERAGE
ABOVE

BELOW

At a meeting in Lahaina, the oldest tourist town of Maui, employees of the area’s visitor service
industry talked about their extremely busy lives. When the facilitator asked the group, “Who here has
only one job?” No one raised their hand. This was followed by another question, “Who here owns ahome?” Again, no hands raised. The two questions and the responses were illustrative of the life of
Hawaiʻi’s service sector working class. In Maui, the eight most common occupations—retailsalespersons, waiters/waitresses, housekeepers, cashiers, cooks, landscaping/groundskeeping,25
janitors/cleaners, and oﬃce clerks—have average annual wages between $26,000 and $38,000. Given
26
that a survival budget in Maui is in the $76,000 range for a family of four, simple math explains why
having multiple jobs is just a fact of life for many Maui families.
In addition to the income constraints, Maui has severe housing constraints. According to HawaiʻiAppleseed, 52% of Maui homes are sold to nonresident buyers and 60% of Maui condos and27
apartments are sold to investors and second home buyers. In Lahaina, where the community meeting
28
took place, Appleseed estimated that one out of every three homes is being used as a vacation rental.
“Most of us will never aﬀord a house in Lahaina; that’s why you get multiple family members in one
household,” one person shared. Another explained, “Construction is booming and we don’t have
25
26
27
28

County of Maui. Ofﬁce of Economic Development, 170.
Aloha United Way, 31.
Geminiani, 3.
Geminiani, 9.

114enough construction workers on island so they bring people from oﬀ island, who bring their families
and then they want to stay. They can aﬀord the housing that we can’t.”
The service sector working class makes too much to receive public assistance, but makes too little to domuch of anything except work. They spoke of older children raising younger children, and how a life of
constant work has just become normal. The meeting in Lahaina, which took place in the late morning ofAugust 21, 2018, ended earlier than planned. The workers had to go back to their worksites to makethem safe and secure in preparation for Hurricane Lane, hoping to have enough time afterward to
make long runs into town for supplies to take care of their own families.
Central Maui, including Kahului and Wailuku, is home to most of the healthcare resources, shopping,and modern conveniences of Maui. Living amongst all the new development are people who go hungry.
At Faith Family Fellowship in Kahului, a group of community volunteers were brought together by theMaui Food Bank to talk about their views on community health. Whether descended from many
generations on Maui or recently arrived looking for a community to belong to, these volunteers put
their faith into action by distributing food and performing other acts of service for people in need. One
volunteer put it this way, “if we get beyond our own personal likes and dislikes and come together todiscuss what is best for our community, for the general good, that’s healthy.”
The kūpuna of Maui share that spirit with some of the most active and engaged senior clubs that can befound anywhere in the state. In group discussions, they shared about their enduring sense of purpose,strong friendships, active lifestyles, family support, and community service. In the same meeting, they
piled on the criticisms of a medical care system which they often ﬁnd lacking in understanding,unavailable, and not something that they generally trust.
For Upcountry Maui, Lahaina, Hāna, and other communities, traveling to the healthcare resources inCentral Maui is a long commute that is sometimes riddled with traﬃc. With just one major hospital on
Maui in Kahului, there’s little choice for people. It is not unusual for people to ﬂy to Oʻahu for surgeries,
to see a specialist, or get more intensive care.
In Hāna, one of the most isolated places in Hawaiʻi, residents have a high degree of self-reliance.
Community leaders have developed activities for youth to have positive outlets away from drinking anddrugs, and while there are fantastic programs like Hāna Arts and Ma Ka Hana ʻIke, the struggle tosupport youth is always a diﬃcult one. Building a strong community is a priority. When there is acommunity event, turnout is high, although one health provider noted that after the events, people
come in with gout from all the party food consumed.
Huge wealth disparities and gentriﬁcation is also a reality in Maui. Rich celebrities have bought
property in Hāna and Kīpahulu. Some construct walls for privacy, but it eﬀectively cuts oﬀ access tocertain important healthy places. In the resort town of Kīhei, residents talked about a similar dynamicof wealthy individuals mixed with working class families, many of whom are employed by the hotels.
There are stories of immigrant workers living in group homes because they can’t aﬀord housing on
their own. The beautiful beaches are becoming inundated with tourists. The busy highway makes
walking unsafe, and there are more signs of drug use littering the ground.
Back in Lahaina, the group was asked, if they could change something to make their community
healthier, what would that be. One person said, “I would put a cap on tourists.” The whole groupnodded in agreement, and then she added, “but we all work hospitality, so our lives would be lower
quality.” That seemingly no-win dilemma is a central plot line in the story of Maui: people trying to
reaﬃrm their identity and sense of place in a rapidly changing landscape.
*NOTE: This sub-report was derived only from conversations and analysis done as part of this CHNA. The island summary and list of priorities are based on community talk stories,
key informant interviews, data reviews, and other observations, and they are intended to highlight the important themes that emerged in the process. It is far from, and not meant
to be, a complete or deﬁnitive statement of every relevant health factor on the island. As part of sound community practice, users of this report are advised to regularly check inwith community partners and engage new voices, as situations change and opinions evolve.

115

Population

POPULATION DENSITY
LOWER

200000HIGHER

POPULATION GROWTH SINCE 1970
THERE ARE 4 TIMES MORE PEOPLE
ON MAUI TODAY THAN 1970.

150000POP: 144,444

POP: 153,911

POP: 117,644
100000

POPULATION

POP: 91,361
POP: 62,823

50000
POP: 38,691

0
YEAR: 1970

1980

1990

2000

2010

2017

2 OUT OF 5 PEOPLE
ON MAUIARE VISITORS:

116

Keiki & KūpunaPOPULATION DENSITY(CHILDREN UNDER 18)
LOWER

HIGHER

POPULATION DENSITY(ELDERLY OVER 65)
LOWER

HIGHER

117

Race“HAWAIIAN”“MIXED” (TWO OR MORE)“ASIAN”“BLACK”“LATINO”“WHITE”

RACIAL IDENTITY(PERCENT OF POPULATION)LOWER

HIGHER118

Income

MEDIAN HOUSEHOLD INCOME
COMPARED TO STATE AVERAGE

BELOW

ABOVE

POVERTY(PERCENT OF POPULATION)LOWER

HIGHER

<$

10

K

$1

$
$3
$
0K 15K 25K
5K-$1 -$2 -$3
-$5
5K
5K
0K
5K

$5

0K
-$7

$7
5K

5K
-$1

$1
00

K

00

K$1

$1
50

K

50

K20

8.1%

8.5%

18.1%

14.7%

18.1%

10.7%

7.6%

6.6%

2.8%

4.8%

PERCENTAGE OF MAUII HOUSEHOLDS BY INCOME BRACKETAVERAGE 4-PERSON HOUSEHOLD SURVIVAL BUDGET IN MAUI COUNTY IS $76,872.

$2
0K

00

K+

119

Time

+7 HOURS SLEEPCOMPARED TO
STATE AVERAGE
ABOVE

BELOW

EXERCISE
COMPARED TO
STATE AVERAGE
ABOVE

BELOW

COMMUTE(DRIVING ALONE)
LESS

MORE

COMMUTE(OVER 40 MINUTES)+ 40 MIN.

120

High Schools

HIGH SCHOOLDROPOUTS
FREE/REDUCED LUNCH

2%
<1%
5%
1%
1%

1%
1%
2%
<1%
1%

c
hi

te

ni

e
es

ro
n

aw
ai

en

ro
p

W

1%
<1%
1%
<1%
1%

pa

10%
1%
6%
3%
5%

is

25%
1%
12%
34%
50%

H

Ja
pa

2%
<1%
2%
1%
1%

no
pi

Fi
li

ne
se
Ko
re
an
Po
rt
ug
ue
se
Bl
ac
k

n
ia
in

4%
<1%
1%
2%
4%

es
Ch

1%
2%
0%
1%
1%

oa
n

M
ic

34%
76%
34%
22%
17%

ia
n

Sa
m

12%
13%
14%
14%
13%

35%
79%
47%
36%
38%

ce
s
H

93%
93%
92%
92%
93%

D

A
tt
en
Baldwin High
Hāna High
Kekaulike HighLahainaluna High
Maui High

du
A
bs

16%
-16%
21%
17%

da

ou
ts
Fr
Lu ee
nc /R
h e

nc
e

ce
d

ABSENCES

4%
1%
5%
15%
5%

11%
16%
30%
16%
10%

121

Maui Strengths and Priorities
Statewide Health Priorities
GOAL 1 - FOUNDATIONSProvide the basic foundations sothat people can have more control
over their own health

GOAL 2 - COMMUNITY
Preserve, nurture, expand, andemploy the healing properties ofcommunity

GOAL 3 - HEALTHCARE
Improve the relationship between
people and the healthcare system

1.1 Address ﬁnancial insecurity
1.2 Work together for equality andjustice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

2.1 Restore environment andsense of place
2.2 Nurture community identity
and cohesiveness
2.3 Invest in teenagers and healthy
starts
2.4 Shift kūpuna care away from“sick care”

3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive
support for those with highneeds

Maui Strengths
●

●
●
●

Relatively strong economic capacity andpotential to activate resources forcommunity health

Populations of Note
Estimate
HOUSELESS

900

Strong kūpuna network, family ties, andconnection to tradition

PEOPLE IN POVERTY

14,700NO HEALTH INSURANCE

9,200

Population with a diversity of cultural
strengths without the “big city” dynamic

WOMEN GIVING BIRTH IN LAST YR

1,800

DISABLED CHILDREN

1,100

Community-based leadership in many
towns and Hawaiian cultural stronghold in
Hāna

CHILDREN IN POVERTY

3,700

NO HS 25 older

8,300

UNEMPLOYED (IN LABOR FORCE)

4,100

DISABLED ADULTS (18-64)

6,900

VETERANS

8,400

65+ LIVING ALONE

4,500

DISABLED 65+

7,700

85+

2,900

HAWAIIAN

38,900ON HAWAIIAN HOMESTEAD

4,500

OTHER PACIFIC ISLANDER

3,500

RECENT FOREIGN IMMIGRANT

4,100

LIMITED-ENGLISH

15,200All 5-year estimates from U.S. Census, American Community Survey, 2017 except Hawaiian
Homestead population from 2018 Hawaiʻi State Data Book, and houseless count from
Partners in Care, 2018 Point-In-Time Homeless Count.

122Maui Priorities(Highest need areas in RED)
CRITERIA
FOUNDATIONSFINANCIAL INSECURITY

Seriously address housing aﬀordability and availability
for local residents
FINANCIAL INSECURITY

Develop higher paying jobs outside of tourism
EQUALITY AND JUSTICE

Support leadership development among immigrants
and COFA communities
FAMILIES

Address stress of overwork; make it a priority to help
families and communities ﬁnd more time for health
FAMILIES

Address Maui’s relatively higher incidence of violenceagainst women

Evidence ofhigh need

Community
readiness

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓
✓

✓

✓

Available
partners

Existing eﬀorts

Political will
/resources

COMMUNITY

Evidence ofhigh need

Community
readiness

Available
partners

Existing eﬀorts

ENVIRONMENT

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing eﬀorts

Political will
/resources

✓

✓

✓

✓

✓

✓

Mitigate more of the impacts that the visitor industry
is having on environment
ENVIRONMENT

Secure local access to healthy places around the island
COMMUNITY COHESION

Mitigate more of the impacts that the visitor industry
is having on community cohesion
KEIKI

Create more positive activities for youth, particularly
for those with working parentsKŪPUNA

Develop innovative housing and activity options
HEALTHCARE
TRUST

Improve the relationship between people andhealthcare resources focusing on trust and culturalcompetence
SUPPORT FOR HIGH NEEDS

Address transportation regarding access to healthresources for more remote neighborhoods

Political will
/resources✓

123

MOLOKAʻI
KO‘OLAU

Kalaupapa

KONA

Kaunakakai

96742

96748

96757

96729

96770

124

Many outsiders are quick to drown Molokaʻi in generalizations and stereotypes: that it is economicallydepressed because of a rejection of development; the community is in constant battle with one
another; and there is nothing to do and not enough action to change that. It’s really not the story.
Molokaʻi is like a patient that gets the wrong diagnosis and therefore the wrong treatment.
The reality of Molokaʻi is what makes it, in many intangible ways, a uniquely healthy place. Spendenough time with the people of Molokaʻi and three common themes stand out: independence, deeproots, and strong connections.

LIFE EXPECTANCYCOMPARED TO STATE AVERAGE
ABOVE

BELOW

Molokaʻi is a tough place because it chooses to be. The island rejects the conveniences of otherislands—no fast food, no big box stores, no major developments. As a result, Molokaʻi is healthy in waysthat aren’t measured, including people’s deep connection to the land, their culture, to one another, andto their way of life.
Many residents know how to live oﬀ the land by ﬁshing, hunting, and planting, and are still able to passdown these practices to their children. Important places around the island are still accessible toresidents and not overrun by visitors. Cultural practices, including the Hawaiian language, live on inboth formally organized and informally authentic ways.
Economically, Molokaʻi can be a diﬃcult place to live. Young people and families have few public spaces
to regularly gather like how they did before when there was a bowling alley and theater. Molokaʻi teens
talked about how easy it would be to succumb to vaping or drugs because it is so pervasive aroundthem. Health services available to residents on more developed islands require Molokaʻi residents to ﬂy
to Maui or Oʻahu. And an aging population is becoming increasingly diﬃcult to support with care.
Residents face high unemployment and underemployment. There are both really busy people andreally idle people.
Like all communities across Hawaiʻi, idleness can lead some into the darkness of drugs, violence, sexual
abuse, or depression. Because of the island’s strong connections, pain and struggle reverberate in thecommunity more than in most places. People who lose hope or who fall to disease are people who were125

known as children; former children who were once healthy and full of potential. Even people who aren’t
really close on Molokaʻi are still people known to each other in school or around town. And in a tightcommunity where anyone’s fate could be anyone else’s, it is understandable why some say they feel
fated to bad endings.
“The closeness of our ʻohana is a double-edged sword,” one person shared. “When there are problems
in the family, we tend to protect one another rather than do what’s right. Some people might describe
people as ‘resilient’ when they are just normalizing bad behaviors or coping.” As families do, sometimes
people protect each other and keep problems like childhood sex abuse, domestic abuse, and substanceabuse within the home, away from the attention, intervention, and help they need. In surveys done byteens who interviewed their peers, parents, and teachers, several talked about still living with theimpact of past traumas like rough childhoods or cultural discrimination. They hinted at poor mental
health, and not always having a consistent, healthy outlet to express their troubles.
On a tight-knit, small island, people cannot hide from one another as they do in more populated places.
Conﬂict and disagreement do occur. Organizations in Molokaʻi working in community health haveclashed in the past, because of overlapping responsibilities, diﬀerences of strategy, conﬂicting
personalities, and limited resources. But collaboration is growing among the hospital, health center,
Native Hawaiian health system, public health system, and other healthcare providers. Like in any tightknit family, it will take some time for the organizations to align their purposes and move beyond past
conﬂicts. However, this collaboration is crucial because solutions for Molokaʻi have better success when
they are homegrown and have the necessary amount of cultural and community competency.
Community organizations of Molokaʻi are also building momentum with great intention, including
those who were met with over the course of this report: the Molokaʻi Health Foundation, Ka Honua
Momona, Sustʻāinable Molokaʻi, Kualapuʻu School, and Liliʻuokalani Trust. Molokaʻi needs resources
and support, but at the same time, the island needs the space to identify and solve its own problems.
During the course of this CHNA, Islander Institute was also engaged in a partnership with residents of
Kalaupapa, their family and friends. Kalaupapa—with its oft-told story of isolation, banishment, andshame for patients who suﬀered from Hansen’s disease—in fact feels like a story of health and healing
for all of Hawaiʻi to contemplate. Theirs is a story of bringing life, spirituality, community, and aloha outof the darkest of circumstances. These days, the remaining patients live in their homes or in a carefacility of their choosing. A few of the remaining residents, descendents, and supporters have beenworking to share their stories with pride as a way to move past historic trauma. They are claiming theirown story, and not letting others deﬁne their place for them.
Molokaʻi has a kind of contentment, and contentment is an unmeasured indicator of health.
Being content sometimes gets twisted into being lazy. Molokaʻi people are hard at work, many
employed in making life better for others—especially children, kūpuna, and those with the greatest
needs. Being content can get misinterpreted as being ignorant. Molokaʻi people are well aware of thechallenges they face and the things they would like to see made better. Some think being content
means not caring. Molokaʻi people care very much about making things better to the point where theycreate their own solutions, try things, and are even willing to ﬁght for their beliefs. People who don’t
like life on Molokaʻi leave, but for those who stay, their contentment is rooted in aloha for the land anda lifestyle worth ﬁghting for. That contented sense of home is something that all people might be solucky to have in their lives.
*NOTE: This sub-report was derived only from conversations and analysis done as part of this CHNA. The island summary and list of priorities are based on community talk stories,
key informant interviews, data reviews, and other observations, and they are intended to highlight the important themes that emerged in the process. It is far from, and not meant
to be, a complete or deﬁnitive statement of every relevant health factor on the island. As part of sound community practice, users of this report are advised to regularly check inwith community partners and engage new voices, as situations change and opinions evolve.

126Population

POPULATION DENSITY
LOWER

8000

POPULATION GROWTH SINCE 1970
THERE ARE 30% MORE PEOPLE
ON MOLOKA‘I TODAY THAN 1970.

POP: 7,404

HIGHER

POP: 7,345
POP: 6,980

7000
POP: 6,717

POPULATION

6000

POP: 6,049

POP: 5,261
5000
YEAR: 1970

1980

1990

2000

2010

2017

1 OUT OF 10 PEOPLE
ON MOLOKA‘I
ARE VISITORS:127

Keiki & KūpunaPOPULATION DENSITY(CHILDREN UNDER 18)
LOWER

HIGHER

POPULATION DENSITY(ELDERLY OVER 65)
LOWER

HIGHER

128

Race“HAWAIIAN”“MIXED” (TWO OR MORE)“ASIAN”“BLACK”“LATINO”“WHITE”

RACIAL IDENTITY(PERCENT OF POPULATION)LOWER

HIGHER

129

Income

MEDIAN HOUSEHOLD INCOME
COMPARED TO STATE AVERAGE

BELOW

ABOVE

POVERTY(PERCENT OF POPULATION)LOWER

HIGHER

<$

10

K

$1

0K
-$1

$1
5K

5K
-$2

$2
5K

5K
-$3

$3
5K

5K
-$5

$5
0K

0K
-$7

$7
5K

5K
-$1

$1
00

K

00

K$1

50

3.1%
1.4%

14.2%

9.7%

15.5%

11.2%

11.8%

13.4%

7.0%

12.7%

PERCENTAGE OF MOLOKA‘I HOUSEHOLDS BY INCOME BRACKETAVERAGE 4-PERSON HOUSEHOLD SURVIVAL BUDGET IN MAUI COUNTY IS $76,872.

K

$1 $2
50 00
K- K +
20
0K

130

Time

+7 HOURS SLEEPCOMPARED TO
STATE AVERAGE
ABOVE

BELOW

EXERCISE
COMPARED TO
STATE AVERAGE
ABOVE

BELOW

COMMUTE(DRIVING ALONE)
LESS

MORE

COMMUTE(OVER 40 MINUTES)+ 40 MIN.

131

Moloka‘i High

an

M
ic
Ch
i
pi

Sa

Fi
li
Ja
p
Ko
re
a
Po
rt
u
Bl
a
H
is
W

79%
1%
<1%
<1%
15%
1%
<1%
<1%
<1%
<1%
3%

te

hi

e

es

c

ni

pa

ck

gu

n

ia
n

e

es

no

se

es

ro
n

ne

n

n

m
oa

ia

ce
s

H
aw
ai

11%

69%

en

15%

du

A
bs

da
nc
e

ou
ts
Fr
Lu ee
nc /R
h e

94%

D
ro
p

tt
en

A

ce
d

High School

HIGH SCHOOLDROPOUTS

FREE/REDUCED LUNCH
ABSENCES132

Molokaʻi Strengths and Priorities
Statewide Health Priorities
GOAL 1 - FOUNDATIONSProvide the basic foundations sothat people can have more control
over their own health

GOAL 2 - COMMUNITY
Preserve, nurture, expand, andemploy the healing properties ofcommunity

GOAL 3 - HEALTHCARE
Improve the relationship between
people and the healthcare system

1.1 Address ﬁnancial insecurity
1.2 Work together for equality andjustice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

2.1 Restore environment andsense of place
2.2 Nurture community identity
and cohesiveness
2.3 Invest in teenagers and healthy
starts
2.4 Shift kūpuna care away from“sick care”

3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive
support for those with highneeds

Molokaʻi Strengths●

Deep connection to place and good accessto healthy places●

Strong sense of community identity andconnectedness●

Widespread subsistence skills●

General consensus about the problems thatneed to be addressed

Populations of Note
Estimate
HOUSELESS

N/A

PEOPLE IN POVERTY

1,210

NO HEALTH INSURANCE

270

WOMEN GIVING BIRTH IN LAST YR

70

DISABLED CHILDREN

50

CHILDREN IN POVERTY420

NO HS 25 older

330

UNEMPLOYED (IN LABOR FORCE)

120

DISABLED ADULTS (18-64)

470

VETERANS

480

65+ LIVING ALONE370

DISABLED 65+

610

85+

220

HAWAIIAN

4,220

ON HAWAIIAN HOMESTEAD

2,150

OTHER PACIFIC ISLANDER

60

RECENT FOREIGN IMMIGRANT180

LIMITED-ENGLISH

410

All 5-year estimates from U.S. Census, American Community Survey, 2017 except Hawaiian
Homestead population from 2018 Hawaii State Data Book, and houseless count from
Partners in Care, 2018 Point-In-Time Homeless Count.

133

Molokaʻi Priorities(Highest need areas in RED)
CRITERIA
Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsIncrease economic self-suﬃciency throughentrepreneurship, asset building, and foodself-suﬃciency

✓

✓

✓

✓

FAMILIES

✓

✓

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources✓✓

Develop more positive activities andopportunities for youth, including those in more
remote areas and those with high needs

✓

✓

✓

✓

✓

KŪPUNA✓✓✓✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources

✓

✓

✓

✓

✓

Develop and/or attract more services andsolutions to support people with mental health
needs

✓

✓

✓

✓

SUPPORT FOR HIGH NEEDS

✓

✓

✓

✓

FOUNDATIONSFINANCIAL INSECURITY

Address domestic abuse and sexual abuse inculturally appropriate and eﬀective ways
EMERGENCIESEngage community in disaster preparedness
planning
COMMUNITYCOMMUNITY COHESION

Develop healthy activities and opportunities forcommunity contribution among idle adults
KEIKI

Develop an array of care and supports for thegrowing population of kūpunaHEALTHCARE
TRUSTContinue fostering eﬀective collaboration among
health agencies and community partners
SUPPORT FOR HIGH NEEDSWork with community by employing proactive
outreach and engagement

Political will
/resources✓134LĀNAʻI
HONUAULA

Lāna‘i City

96763

135

On Lānaʻi, residents describe this small island as safe, peaceful, connected, close-knit, and quiet. It is aplace where people take care of each other and where motorists drive well below the speed limit intown and wave to one another. They share the outside resources of food and supplies that come infrom the barge once a week, which are distributed through a handful of markets and restaurants.
It is a place where babies are rarely born on island and where seniors commonly go oﬀ island toward
the end of life. As a part of the tradeoﬀ of living in a small community, they learn to live without
everything they need. With two doctors on island, Lānaʻi residents go oﬀ island for specialized services,such as pediatrician visits and mammograms. This leaves Lānaʻi residents dependent on the onecommercial airline carrier that services Lānaʻi and a ferry service to Maui for their oﬀ-islandtransportation to doctor visits. Once on another island, they rely on taxis or family and friends toshuttle them to doctor oﬃces. One doctor’s appointment can take a full day of travel. Insurance covers
airfare and taxis, but typically not hotel stays or delayed ﬂights.

LIFE EXPECTANCYCOMPARED TO STATE AVERAGE
ABOVE

BELOW

Every weekday, a group of seniors gather at the Lānaʻi Senior Center for activities and lunch as a way tocreate and maintain social connections. Some catch the Maui Economic Opportunity (MEO) shuttle tothe center while others drive. They bring food and gossip to share. For many, this is the highlight of
their day to talk story with friends in a comfortable, welcoming environment. Several times a month,they catch the ferry together to Maui, where they are met by the MEO bus there, to go shopping at
Costco, Walmart, and other places.
On a rainy Tuesday before Tropical Storm Olivia was to hit Lānaʻi in September of 2018, a group of 14
seniors ate together while also talking story about what makes them healthy in Lānaʻi. They take careof one another, whether it is checking up on a friend at home, giving each other rides, or cooking foodto share. With the tropical storm coming, many said they were prepared, and even if it got worse than
anticipated, they felt assured that they had the protection of their fellow community members.
While these seniors were healthy enough to stay on Lānaʻi, there are many others who had to leave
because of poorer health. The seniors who live in the senior housing in town need to be independentand healthy enough to get by on their own. Kūpuna lack a long term care facility, a nursing home, and136

other more intensive health services. One kupuna said he would want to die on his beloved island, but
because of a lack of care needed for his wife, he would likely move oﬀ island. Some did point to having
good care on island, such as routine dental services and doctor visits.
In a small place, even small changes and individuals can have a big impact. Some point to the successful
lobbying of a few community champions to open a dialysis center and hospice. In the summer of 2018,an abrupt closing of the Native Hawaiian Health System oﬃce, Ke Ola Hou o Lānaʻi Na Puʻuwai, createdconcern in the community about the end of home visits by nurses and a community fund beneﬁting
cancer patients.
Another recent change was the creation of Sensei Farms Lānaʻi, a company created by the island’s
majority landowner, the billionaire and Oracle co-founder Larry Ellison, to grow fresh produce on islandusing hydroponics, starting ﬁrst with lettuce to export. Because much of the island’s produce arrives on
the barge weekly, some are already weeks old. Residents ﬁnd produce expensive to buy in stores,making it unaﬀordable and diﬃcult to eat healthy. Some residents were excited at the prospect of theisland growing its own food with hopes that some will go toward feeding the Lānaʻi community.
Lānaʻi lacks fast food restaurants and traﬃc, but they still experience the stress of living in an isolated
place that sometimes feels quite crowded. The main employer is the Four Seasons Resorts on Lānaʻi,owned and managed by Ellison’s company called Pūlama Lānaʻi, where high-end tourism is thedominant economic industry. Though houselessness is not really a problem on island, there is still ashortage of aﬀordable housing. It is common for multiple generations to live together in one house,
which can lead to other social problems like domestic violence and substance abuse.
Lānaʻi people have pride in and strong connection with land and culture. Many point to the love ofactivities on the land, including hunting, diving, ﬁshing, camping, and going to the beach. More thanjust “recreation,” these activities produce needed food supplies and also form a large part of theidentity of many Lānaʻi residents.
The story of Lānaʻi has largely centered around the decisions made its major landowners. The current
era of luxury tourism was preceded by a rocky transition from agriculture to resorts, which included a
community struggle over a proposed wind farm. Prior to that, Lānaʻi was known worldwide for its
identiﬁcation as the “Pineapple Island,” and lesser known for a successful 200-day plantation worker
strike in 1951 that some residents continue to recollect with pride and as evidence of the resilience of
Lānaʻi people. And before pineapple, and before the preceding ranching era, the story of Lānaʻi spansmany generations of rich stories of a land and its people. These stories of old are being restored andretold in current eﬀorts to build cultural identity and community connection, including a mural at theschool and restoration of one of the island’s ﬁshponds.
*NOTE: This sub-report was derived only from conversations and analysis done as part of this CHNA. The island summary and list of priorities are based on community talk stories,
key informant interviews, data reviews, and other observations, and they are intended to highlight the important themes that emerged in the process. It is far from, and not meant
to be, a complete or deﬁnitive statement of every relevant health factor on the island. As part of sound community practice, users of this report are advised to regularly check inwith community partners and engage new voices, as situations change and opinions evolve.

137Population

POPULATION DENSITY
LOWER

3500

POPULATION GROWTH SINCE 1970
THERE ARE 45% MORE PEOPLE
ON LĀNA‘I TODAY THAN 1970.

POP: 3,193

POP: 3,135

HIGHER

POP: 3,203

3000

POPULATION

2500
POP: 2,426

POP: 2,204
POP: 2,119
2000
YEAR: 1970

1980

1990

2000

2010

2017

1 OUT OF 5 PEOPLE
ON LĀNA‘I
ARE VISITORS:138

Keiki & KūpunaPOPULATION DENSITY(CHILDREN UNDER 18)
LOWER

HIGHER

POPULATION DENSITY(ELDERLY OVER 65)
LOWER

HIGHER

139

Race“HAWAIIAN”“MIXED” (TWO OR MORE)“ASIAN”“BLACK”“LATINO”“WHITE”

RACIAL IDENTITY(PERCENT OF POPULATION)LOWER

HIGHER140

Income

MEDIAN HOUSEHOLD INCOME
COMPARED TO STATE AVERAGE

BELOW

ABOVE

POVERTY(PERCENT OF POPULATION)LOWER

HIGHER<$$$
10 10K 15K
K-$1 -$2
5K 5K

$2

5K
-$3

$3
5K

5K
-$5

$5
0K

0K
-$7

$7
5K

5K
-$1

$1
00

K

00

K$1

50

K

3.6%

3.1%

15.5%

11.2%

13.6%

20.6%

11.2%

13.4%

5.9%

1.9%

PERCENTAGE OF LĀNA‘I HOUSEHOLDS BY INCOME BRACKETAVERAGE 4-PERSON HOUSEHOLD SURVIVAL BUDGET IN MAUI COUNTY IS $76,872.

$1 $2
50 00
K- K +
20
0K

141

Time

+7 HOURS SLEEPCOMPARED TO
STATE AVERAGE
ABOVE

BELOW

EXERCISE
COMPARED TO
STATE AVERAGE
ABOVE

BELOW

COMMUTE(DRIVING ALONE)
LESS

MORE

COMMUTE(OVER 40 MINUTES)+ 40 MIN.

142

Lāna‘i High

an

M
ic
Ch
i
pi

Sa

Fi
li
Ja
p
Ko
re
a
Po
rt
u
Bl
a
H
is
W

10%
18%
1%
7%
1%
54%
2%
<1%
1%
2%
3%
9%

45%

te

hi

e

es

c

ni

pa

ck

gu

n

ia
n

e

es

no

se

es

ro
n

ne

n

n

m
oa

ia

ce
s

H
aw
ai

--%

en

du

A
bs

da
nc
e

ou
ts
Fr
Lu ee
nc /R
h e

94%

D
ro
p

tt
en

A

ce
d

High School

DROPOUTS

FREE/REDUCED LUNCH
ABSENCES

143

Lānaʻi Strengths and Priorities
Statewide Health Priorities
GOAL 1 - FOUNDATIONSProvide the basic foundations sothat people can have more control
over their own health

GOAL 2 - COMMUNITY
Preserve, nurture, expand, andemploy the healing properties ofcommunity

GOAL 3 - HEALTHCARE
Improve the relationship between
people and the healthcare system

1.1 Address ﬁnancial insecurity
1.2 Work together for equality andjustice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

2.1 Restore environment andsense of place
2.2 Nurture community identity
and cohesiveness
2.3 Invest in teenagers and healthy
starts
2.4 Shift kūpuna care away from“sick care”

3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive
support for those with highneeds

Lānaʻi Strengths●

New generation of emerging community
leaders establishing themselves●

Rich cultural diversity and community
history●

Strong community cohesion and aloha

Populations of Note
Estimate
HOUSELESS

N/A

PEOPLE IN POVERTY240

NO HEALTH INSURANCE200

WOMEN GIVING BIRTH IN LAST YR

0

DISABLED CHILDREN

10CHILDREN IN POVERTY

90

NO HS 25 older

300

UNEMPLOYED (IN LABOR FORCE)

90

DISABLED ADULTS (18-64)

140

VETERANS

160

65+ LIVING ALONE120

DISABLED 65+

200

85+

100

HAWAIIAN

680

ON HAWAIIAN HOMESTEAD

150

OTHER PACIFIC ISLANDER

140

RECENT FOREIGN IMMIGRANT

150

LIMITED-ENGLISH

620

All 5-year estimates from U.S. Census, American Community Survey, 2017 except Hawaiian
Homestead population from 2018 Hawaii State Data Book, and houseless count from
Partners in Care, 2018 Point-In-Time Homeless Count.

144

Lānaʻi Priorities(Highest need areas in RED)
CRITERIA
Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀorts

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources

✓

✓

✓

✓

Continue cultural strengthening work in schools
and with community members to establish a ﬁrm
island identity

✓

✓

✓

✓

COMMUNITY COHESION

✓

✓

✓

FOUNDATIONSFINANCIAL INSECURITY

Address crowded housing situations and the coreneeds of residents
FINANCIAL INSECURITY

Increase economic self-suﬃciency throughworkforce training and entrepreneurship training
FOOD SYSTEMS

Increase food production looking at what people
can produce from the land and sea
COMMUNITYCOMMUNITY COHESION

Create leadership opportunities and supports foryoung people to develop homegrown initiatives
COMMUNITY COHESIONEngage entire community in civic matterswherever possibleKŪPUNA

Expand and create more supports for kūpuna
who require more intensive care
HEALTHCARESUPPORT FOR HIGH NEEDSWork with community by employing proactive
outreach and engagement

Political will
/resources

✓

✓

✓

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources

✓

✓

✓

✓

✓

145

OʻAHU
KO‘OLAULOA

KahukuHau‘ulaLā‘ie

KO‘OLAUPOKO

KailuaKāne‘oheWaimānalo

Wahiawā

WAIALUAWaipahu

Hawai‘i Kai
KahalaHonolulu
KalihiKONA

WAI‘ANAE

96731

‘EWA

Nānākuli

96762

96712

96717

96863

96730
96744

96786
96789
96857
96759

96791

96782

96701

96797

96734

96795

96825

96821

96822
9681996817
96816
9681396826
96814 96815

96818
96706

96792
96707

146

Oʻahu is a place of tourism and gentriﬁcation. It is a place where many cultures are able to practicetheir traditions and share them. It is a place of visible disparities between rich and poor, urban andrural, sheltered and unsheltered. It is a place of rural living where you know your neighbors and care foreach other. It is a place of workplace stress, traﬃc and long commutes, sedentary lifestyles, poor sleep,and people locked in on their phones. It is a place of convenience, job opportunities, and healthcare
accessibility for most. It is a place of commercial activity and material abundance. It is a place ofconnection to loʻi, ﬁshponds, beaches, hiking, and ﬁshing. Oʻahu is a place for all of these things andmore.
Nearly one million people live on Oʻahu and nearly ﬁve million tourists visit the island during the year. It
is a crowded place ﬁlled with both vastly diﬀerent and common experiences. In all of the talk stories
for this report, from Kahuku to Kakaʻako, food was a common connector in people’s experience of
health. Cooking healthy meals feels like a luxury as people seek to ﬁnd the time, energy, and money tocook. In rural areas, it is typical to grab a plate lunch while at work and go to a drive-thru for dinner on
the way home. In some parts of Oʻahu, there are simply more options, more grocery stores, big box
stores, and farmers markets while some areas have few, if any. The availability of healthier options
doesn’t mean people have the time, money, or desire to partake. As summed up by a parent inWahiawā, “There is a Foodland on one end, but people who live in the ‘hood don't go there. Kids end up
eating musubis from the convenience store, from the manapua man, and from Jack in the Box and Taco
Bell.”

LIFE EXPECTANCYCOMPARED TO STATE AVERAGE
ABOVE

BELOW

A steady stream of development continues around rail, luxury condominiums, shopping centers, andsuburban neighborhoods. Many feel policies regarding public areas are made for the safety andwellbeing of visitors ﬁrst, thus exacerbating a crisis for houseless people in large part caused by a lackof suﬃcient aﬀordable housing and insuﬃcient services for those with mental illnesses. Care forhouseless individuals, particularly those in urban Honolulu, falls primarily to government andnonproﬁts rather than appealing to a broader notion of all caring for all. In a place that is so crowded,
it’s easy to get lost, remain anonymous, and stay disconnected.

147But that idea of taking care isn’t completely lost on Oʻahu. In Hauʻula, a local pastor takes in those inneed, providing them with shelter in yurts in his backyard. “The best community plan for the hospital isto keep people out of the hospitals,” he said with a smile in all sincerity. In Wahiawā, the community
recognized the importance of the hospital, organized to show their support and lobbied forgovernment aid. “The whole community knows the hospital almost went under, and it’s the largest
private employer in the community,” one worker in Wahiawā said. “People really banded together anddid fundraisers and car washes to raise money for the hospital.”
While there are many things that separate Oʻahu residents from one another—income level,
geography, lifestyle, and more—they still constitute one community susceptible to the same
vulnerabilities that aﬀect everyone. In 2018, the year of a false nuclear missile alarm and several
threatening hurricanes, Oʻahu’s sense of preparedness, resilience, and safety were tested. To prepare
for the hurricanes in the summer, media reports showed cleared shelves as people hurried to buy
water, canned goods, plywood, and supplies while businesses restocked them as quickly as they could
depending on the next delivery. For many working in the tourism industry, they cared for the safety of
tourists and hotels, which for some meant being away from their own families. Around the clock news
coverage showed numerous reports of ruined vacations for tourists in Waikīkī, while emergency
workers gave constant updates and families hunkered down. It has been an interesting time for Oʻahu,
challenging the degree to which it has a foundation of community health in place for its residents.
It is a common complaint on other islands that too many decisions that aﬀect them are made from an“Oʻahu-centric” perspective. Talking to people in communities from the North Shore, Leeward, Central,and Windward Oʻahu, it is clear that a more precise description of the phenomenon would be “urban
Honolulu-centric,” deriving from the place where most leaders of business, nonproﬁts, and government
work, meet, and make decisions. Honolulu, perhaps more than anywhere else in Hawaiʻi, is a place
where health is largely seen as something for each individual to maintain with the help of thehealthcare system. Setting aside for a moment whether that is a good way to think about health, it is
not diﬃcult to hold that view in Honolulu because its residents have more healthcare resources, morechoices of doctors, more kinds of available food, and more economic opportunities than others in therest of the state. Outside of urban Honolulu, decisions made in the furtherance of that kind of healthmindset are often met with frustration and resistance.
But as it turns out, it may be that the personal responsibility model of health is not what most people
believe, want, or experience even within urban Honolulu. Certainly for those who are houseless, living
in poverty, facing discrimination, or otherwise marginalized, personal access to healthcare is notenough to attain health. Many other Honolulu people who feel that health is a family matter, who crave
connection with others, and who want to be connected to the land, are also making a case for analternative to a medical model of health and care.
*NOTE: This sub-report was derived only from conversations and analysis done as part of this CHNA. The island summary and list of priorities are based on community talk stories,
key informant interviews, data reviews, and other observations, and they are intended to highlight the important themes that emerged in the process. It is far from, and not meant
to be, a complete or deﬁnitive statement of every relevant health factor on the island. As part of sound community practice, users of this report are advised to regularly check inwith community partners and engage new voices, as situations change and opinions evolve.

148

Population

POPULATION DENSITY
LOWER

1000000

POPULATION GROWTH SINCE 1970
THERE ARE 57% MORE PEOPLE
ON O’AHU TODAY THAN 1970.

HIGHER

POP: 990,060
POP: 953,207

900000POP: 876,151
POP: 836,231
800000

POPULATION

POP: 762,534
700000POP: 630,497
600000
YEAR: 1970

1980

1990

2000

2010

2017

1 OUT OF 10 PEOPLE
ON O‘AHU
ARE VISITORS:

149

Keiki & KūpunaPOPULATION DENSITY(CHILDREN UNDER 18)
LOWER

HIGHER

POPULATION DENSITY(ELDERLY OVER 65)
LOWER

HIGHER

150

Race“HAWAIIAN”“MIXED” (TWO OR MORE)“ASIAN”“BLACK”“LATINO”“WHITE”

RACIAL IDENTITY(PERCENT OF POPULATION)LOWER

HIGHER151

Income

MEDIAN HOUSEHOLD INCOME
COMPARED TO STATE AVERAGE

BELOW

ABOVE

POVERTY(PERCENT OF POPULATION)LOWER

HIGHER

$1

$7

$1

0K
-$7

5K

5K
-$1

00

K

00

K$1

$1
50

K

9.6%

$5

9.5%

10.3%

6.2%

5.6%

$2
$
$3
5
0K 15K
5K-$1 -$2 K-$3
-$5
5K
5K
5K
0K

19.8%

K

14.4%

10

17.1%

<$

2.7%

4.8%

PERCENTAGE OF O‘AHU HOUSEHOLDS BY INCOME BRACKETAVERAGE 4-PERSON HOUSEHOLD SURVIVAL BUDGET IN C&C OF HONOLULU IS $85,200.

50

K20

$2
0K

00

K+

152

Time

+7 HOURS SLEEPCOMPARED TO
STATE AVERAGE
ABOVE

BELOW

EXERCISE
COMPARED TO
STATE AVERAGE
ABOVE

BELOW

COMMUTE(DRIVING ALONE)
LESS

MORE

COMMUTE(OVER 40 MINUTES)+ 40 MIN.

153

High Schools

HIGH SCHOOLDROPOUTS
FREE/REDUCED LUNCH

e

n

Ja

Ko
re
a

Po
r

Bl

is
H

W

7%
1%
1%
12%
24%
<1%
1%
24%
<1%
<1%
38%
1%
4%
11%
1%
2%
3%
2%
2%
3%
3%
6%

4%
1%
3%
1%
2%
1%
3%
6%
10%
2%
-1%
1%
20%
4%
9%
<1%
5%
1%
19%
1%
1%

30%
43%
10%
59%
30%
5%
12%
9%
6%
5%
-24%
24%
22%
20%
24%
6%
29%
22%
10%
10%
68%

12%
5%
14%
1%
<1%
1%
7%
11%
25%
5%
-6%
4%
9%
22%
16%
<1%
21%
1%
20%
1%
3%

1%
<1%
<1%
<1%
<1%
<1%
<1%
1%
4%
1%
-1%
<1%
3%
2%
5%
<1%
1%
<1%
6%
<1%
<1%

1%
1%
2%
<1%
<1%
1%
2%
1%
1%
2%
39%
1%
1%
<1%
<1%
1%
<1%
1%
<1%
<1%
2%
<1%

3%
5%
2%
1%
2%
1%
1%
3%
2%
5%
33%
5%
11%
2%
4%
7%
2%
2%
15%
1%
2%
1%

4%
3%
1%
1%
<1%
2%
2%
3%
2%
4%
35%
4%
7%
3%
4%
4%
2%
3%
7%
2%
3%
1%

8%
12%
1%
1%
2%
21%
14%
8%
30%
50%
31%
13%
20%
5%
17%
14%
2%
7%
36%
8%
4%
2%

c
te
hi

pa

ac

k

ni

gu
tu

n

se
ne

in

o

e

lip

es
in

ro
n

n
oa
m

ia

aw
ai

en
bs

ro
p

es

pa

Fi

ia
Ch

7%
4%
2%
10%
7%
14%
4%
4%
1%
1%
-7%
4%
3%
2%
2%
11%
4%
4%
1%
7%
7%

es
ic

M

19%
20%
50%
10%
30%
42
51%
18%
12%
20%
35%
31%
20%
9%
18%
10%
70%
21%
5%
19%
64%
9%

n
Sa

12%
13%
21%
17%
15%
16%
15%
27%
12%
15%
30%
11%
11%
15%
7%
7%
24%
10%
7%
11%
26%
12%

50%
39%
41%
57%
59%
43%
51%
57%
14%
22%
-32%
55%
55%
16%
24%
76%
28%
25%
44%
69%
52%

ce
s
H

93%
93%
88%
91%
91%
91%
92%
85%
93%
92%
30%
94%
94%
91%
96%
96%
87%
95%
96%
94%
85%
94%

D

tt
en
A
‘Aiea HighCampbell High
Castle High
Farrington HighSch for the Deaf & Blind
Kahuku High
Kailua High
Kaimukī High
Kaiser High
Kalāheo HighKalani High
Kapolei High
Leilehua HighMcKinley High
Mililani HighMoanalua HighNānākuli High
Pearl City High
Radford High
Roosevelt HighWai‘anae HighWaipahu High

du
A

8%
10%
18%
--9%
17%
25%
8%
17%
0
14%
18%
24%
6%
7%
16%
16%
6%
11%
19%
18%

da

ou
ts
Fr
Lu ee
nc /R
h e

nc
e

ce
d

ABSENCES154

Oʻahu Strengths and Priorities
Statewide Health Priorities
GOAL 1 - FOUNDATIONSProvide the basic foundations sothat people can have more control
over their own health

GOAL 2 - COMMUNITY
Preserve, nurture, expand, andemploy the healing properties ofcommunity

GOAL 3 - HEALTHCARE
Improve the relationship between
people and the healthcare system

1.1 Address ﬁnancial insecurity
1.2 Work together for equality andjustice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

2.1 Restore environment andsense of place
2.2 Nurture community identity
and cohesiveness
2.3 Invest in teenagers and healthy
starts
2.4 Shift kūpuna care away from“sick care”

3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive
support for those with highneedsOʻahu Strengths●

Economic resources, opportunities, accessto power●Innovative population with broad reachbeyond the shores●

Strong community cohesion in spots,
particularly in rural areas●

Healthcare options and availability●

Overall diversity●

Growth of cultural, educational, andenvironmental activities for youth

Populations of Note
Estimate
HOUSELESS

4,500

PEOPLE IN POVERTY

86,900NO HEALTH INSURANCE

37,600WOMEN GIVING BIRTH IN LAST YR

14,600DISABLED CHILDREN

6,000

CHILDREN IN POVERTY

23,500NO HS 25 older

56,800

UNEMPLOYED (IN LABOR FORCE)

21,800DISABLED ADULTS (18-64)

43,600VETERANS

78,40065+ LIVING ALONE

29,300DISABLED 65+

53,90085+

28,000HAWAIIAN

242,500

ON HAWAIIAN HOMESTEAD

19,500OTHER PACIFIC ISLANDER

26,500RECENT FOREIGN IMMIGRANT

28,600

LIMITED-ENGLISH

131,100

All 5-year estimates from U.S. Census, American Community Survey, 2017 except Hawaiian
Homestead population from 2018 Hawaiʻi State Data Book, and houseless count from
Partners in Care, 2018 Point-In-Time Homeless Count.

155

Oʻahu Priorities(Highest need areas in RED)
CRITERIA
Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀorts

✓

✓

✓

✓

✓

✓

✓

✓

✓

Acknowledge and address the population’s
stress, lack of sleep, lack of physical activity, andoveruse of screens

✓

✓

✓

FOOD SYSTEMS

✓

✓

✓

✓

✓

COMMUNITY

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources

ENVIRONMENT

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources

✓

✓

✓

✓

✓

FOUNDATIONSEQUALITY AND JUSTICE

Lead the charge to establish justice and support
for immigrants and COFA communities
EQUALITY AND JUSTICE

Achieve economic and educational equity,
particularly for Hawaiian communities
FAMILIES

Develop strong community-based local foodsystems with farmers, food hubs, and others

Involve the community in preparation for the
impacts of climate change
ENVIRONMENT

Restore more natural sites and recreation areas
for community use
COMMUNITY COHESION

Develop traﬃc solutions to reduce commute
times
COMMUNITY COHESION

Resist gentriﬁcation and inequality of conditions
exacerbated by development
COMMUNITY COHESION

Address the impacts of more visitors inresidential areas
HEALTHCARESUPPORT FOR HIGH NEEDSEngage the public in developing andimplementing solutions for houseless population

Political will
/resources

156

KAUAʻI
KO‘OLAU

Kapa‘aHALELE‘A
Hanalei

PUNA
Līhu‘eKōke‘eNĀPALI

Kōloa

WaimeaKekaha

KONA

96703
96703

96751

96754
96722

96746

96714
96766

96741

96716

96796

96756
96765

96769
96747
96752

96705

96752

157

Twenty ﬁve years later, the experience of Hurricane Iniki is woven into the fabric of the community ofKauaʻi. After heavy rains devastated the North Shore in April 2018, the tight-knit, resilient community
came together once again in a scary time to take care of each other. And they were tested yet again in
the summer of 2018, when streams overﬂowed from a tropical storm. They dug themselves out of the
mud. They ﬁgured out a system to get around closed roads. And they took responsibility for more thanjust themselves.
The ﬂoodings and road closures also disrupted tourism, the dominant economic industry, thus giving
residents a rare present-day glimpse into life on the North Shore without as many visitors. The
signiﬁcant increase in visitors to Kauaʻi is having widespread impacts on everyday life. Rental cars are
jamming up traﬃc, particularly in Kapaʻa; more vacation rentals are disrupting community life;
residents are struggling to keep up with rising housing prices and the cost of living; and pervasive useof social media is exposing favorite local spots to overuse.

LIFE EXPECTANCYCOMPARED TO STATE AVERAGE
ABOVE

BELOW

While tourism provides much needed employment, many say they still need multiple jobs to get by. The
need to work, the time spent in traﬃc, and other demands of life lead to many feeling like there isn’t
enough time for activities that make them feel healthy and well. Healthy, home cooked meals competewith the convenience and price of fast food. In addition, television and phones are taking over quality
time with family and friends.
At a talk story at the Boys and Girls Club of Kauaʻi, local teenagers shared their ﬁrsthand accounts of
their families’ economic stress. They spoke about the tradeoﬀs of tourism from an environmental
perspective, seeing an increase in waste and less respect for the land. They also spoke about thediﬃculties of being teenagers today: the stress of family economics, stress of school, navigating theirsocial and online life, and the inﬂuence of vaping and drugs. In a small community, news of teenage
suicides and attempted suicides travels fast and hurts the community deeply.
Yet, even with these challenges, the teens expressed a desire to help out, whether through volunteer
activities with their peers or with younger kids. “Kauaʻi is a small place where relationships are
everything. We have three high schools—Kauaʻi, Kapaʻa, Waimea—and we all understand that there’s a158

time for competition and a time for cooperation. I saw this video from back in the day after Hurricane
Iniki. That same aloha continues to this day,” one said. That particular teen worked with others to starta peer support group to help youth who are feeling hopeless and may be contemplating suicide.
Some point to the strength of the community going even further back to the island’s history of neverbeing conquered by King Kamehameha, a story that they carry with pride. Building and maintaining theancestral connection to Kauaʻi is important to many for their cultural identity, and it contributes tohealth and wellbeing.
For example, a group of women interested in learning the traditional practices of Hawaiian healing,including lā‘au lapa‘au and lomilomi, gathers regularly to learn from one another. One Saturday in July
2018, they started their day with a morning hike into a native forest in the western part of Kauaʻi tolearn about diﬀerent Hawaiian plants that can be used to treat diabetes, high blood pressure,inﬂammation, and other ailments. The plants were of both cultural and medicinal value. A majority ofthis group chooses to receive care from both Western medical doctors as well as Hawaiian
practitioners. They value the cultural approach of Hawaiian practitioners, who treat the whole person,
trust their patients’ opinions, and care about patients like family.
Kauaʻi seems to have a propensity to ﬁnd balance, forged over diﬃcult experiences that mostcommunities have not had to endure; experiences that demand cooperation, generosity and patience.
Kauaʻi today feels stressed out, but it also feels very wise. The County of Kauaʻi, Kauaʻi Community
College, Wilcox Medical Center, Hoʻōla Lāhui, the Boys and Girls Club of Kauaʻi, Liliʻuokalani Trust,
Kamehameha Schools, Kauaʻi Planning and Action Alliance, Waipā Foundation, Mālama Kauaʻi, andmany others have a good grasp of the challenges and potential of Kauaʻi. Those from Kauaʻi who
participated in this CHNA know what is most important in life and nothing seems to distract from that
focus.
----Although Islander Institute did not travel to Niʻihau for this report, Kauaʻi residents and providers
talked about their connection with residents of Niʻihau, a small, privately owned island 18 miles west ofKauaʻi. Niʻihau residents routinely commute to Kauaʻi for work, medical care, and/or school, and manycall both islands home. On Niʻihau, there are no telephone services, no paved roads, no power lines, andno plumbing or running water. This makes it harder to refrigerate foods. Almost all residents of Niʻihau
qualify for QUEST, but because there is no mail delivery, residents don’t receive the re-enrollment
letters that the state agency sends to them. People come oﬀ the island for health reasons and ﬁnd that
their insurance has lapsed. Transportation, language access, and getting needed medical attention are
particularly diﬃcult for this island.
*NOTE: This sub-report was derived only from conversations and analysis done as part of this CHNA. The island summary and list ofpriorities are based on community talk stories, key informant interviews, data reviews, and other observations, and they are intended
to highlight the important themes that emerged in the process. It is far from, and not meant to be, a complete or deﬁnitive statementof every relevant health factor on the island. As part of sound community practice, users of this report are advised to regularly checkin with community partners and engage new voices, as situations change and opinions evolve.

159

Population

POPULATION DENSITY
LOWER

80000

POPULATION GROWTH SINCE 1970
THERE ARE 2.4 TIMES MORE PEOPLE
ON KAUA‘I TODAY THAN 1970.

HIGHER

POP: 71,093

70000
POP: 66,921
60000
POP: 58,303
50000

POP: 50,947

POPULATION

40000

30000

POP: 38,856

POP: 29,524

20000
YEAR: 1970

1980

1990

2000

2010

2017

1 OUT OF 3 PEOPLE
ON KAUA‘I
ARE VISITORS:

160

Keiki & KūpunaPOPULATION DENSITY(CHILDREN UNDER 18)
LOWER

HIGHER

POPULATION DENSITY(ELDERLY OVER 65)
LOWER

HIGHER

161

Race“HAWAIIAN”“MIXED” (TWO OR MORE)“ASIAN”“BLACK”“LATINO”“WHITE”

RACIAL IDENTITY(PERCENT OF POPULATION)LOWER

HIGHER

162

Income

MEDIAN HOUSEHOLD INCOME
COMPARED TO STATE AVERAGE

BELOW

ABOVE

POVERTY(PERCENT OF POPULATION)LOWER

HIGHER

<$

10

K

$1

$
$2
$3
0K 15K
5K
5K-$1 -$2
-$3
-$5
5K
5K
5K
0K

$5

0K
-$7

$7
5K

5K
-$1

$1
00

K

00

K$1

$1
50

K

50

K20

6.3%

7.1%

20.4%

14.6%

15.6%

11.7%

8.1%

6.5%

4.7%

5.1%

PERCENTAGE OF KAUAI‘I HOUSEHOLDS BY INCOME BRACKETAVERAGE 4-PERSON HOUSEHOLD SURVIVAL BUDGET IN KAUAI COUNTY IS $79,416.

$2
0K

00

K+

163

Time

+7 HOURS SLEEPCOMPARED TO
STATE AVERAGE
ABOVE

BELOW

EXERCISE
COMPARED TO
STATE AVERAGE
ABOVE

BELOW

COMMUTE(DRIVING ALONE)
LESS

MORE

COMMUTE(OVER 40 MINUTES)+ 40 MIN.

164

High Schools

HIGH SCHOOLDROPOUTS
FREE/REDUCED LUNCH

<1%
<1%
<1%
--

2%
3%
3%
--

1%
1%
1%
--

c
hi

te

ni
W

5%
10%
6%
--

pa

18%
36%
34%
--

is

1%
1%
1%
--

H

Ja
pa

ne
se
Ko
re
an
Po
rt
ug
ue
se
Bl
ac
k

lip

2%
4%
1%
--

in

Fi

in

o

ia
n
es
e

es

Ch

aw
ai
ia
n
Sa
m
oa
n

en

ro
p

bs

H

1%
1%
<1%
--

ro
n

15% 30%11% 24%
13% 43%
24% 100%

37%
35%
51%
--

M
ic

92%
94%
93%
86%

D

A
tt
en
d
Kapa‘a High
Kaua‘i High
Waimea HighNi‘ihau High

ce
s
A

9%
10%
12%
--

an
ce

ou
ts
Fr
Lu ee
nc /R
h ed

uc
ed

ABSENCES

5%
2%
1%
--

30%
17%
8%
--

165

Kauaʻi Strengths and Priorities
Statewide Health Priorities
GOAL 1 - FOUNDATIONSProvide the basic foundations sothat people can have more control
over their own health

GOAL 2 - COMMUNITY
Preserve, nurture, expand, andemploy the healing properties ofcommunity

GOAL 3 - HEALTHCARE
Improve the relationship between
people and the healthcare system

1.1 Address ﬁnancial insecurity
1.2 Work together for equality andjustice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

2.1 Restore environment andsense of place
2.2 Nurture community identity
and cohesiveness
2.3 Invest in teenagers and healthy
starts
2.4 Shift kūpuna care away from“sick care”

3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive
support for those with highneeds

Kauaʻi Strengths●

Proven community cohesion, resilience and
aloha

●

Civic engagement and capacity forcross-sector collaboration●

Relatively healthy and active population●

Entrepreneurial and resourceful culture

Populations of Note
Estimate
HOUSELESS300

PEOPLE IN POVERTY

6,400

NO HEALTH INSURANCE

4,000

WOMEN GIVING BIRTH IN LAST YR

800

DISABLED CHILDREN

400

CHILDREN IN POVERTY

1,300

NO HS 25 older

4,000

UNEMPLOYED (IN LABOR FORCE)

1,600

DISABLED ADULTS (18-64)

2,600

VETERANS

4,100

65+ LIVING ALONE

2,300

DISABLED 65+

4,200

85+

1,700

HAWAIIAN

16,900ON HAWAIIAN HOMESTEAD

2,100

OTHER PACIFIC ISLANDER

600

RECENT FOREIGN IMMIGRANT

1,900

LIMITED-ENGLISH

6,000

All 5-year estimates from U.S. Census, American Community Survey, 2017 except Hawaiian
Homestead population from 2018 Hawaiʻi State Data Book, and houseless count from
Partners in Care, 2018 Point-In-Time Homeless Count.

166

Kauaʻi Priorities(Highest need areas in RED)
CRITERIA
Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀorts✓✓✓✓Address the stress of overwork, developing more
job opportunities outside of the service sector,
and generating more time for families andcommunities✓✓

FOOD SYSTEMS

✓

✓

✓

✓

COMMUNITY

Evidence ofhigh need

Community
readiness

Available
partners

Existing
eﬀortsENVIRONMENT

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Community
readiness

Available
partners

Existing
eﬀortsPolitical will
/resources✓✓

FOUNDATIONSEQUALITY AND JUSTICE

Continued development of Hawaiian
communities and cultural practice

Political will
/resources

FAMILIES

Develop a strong community food system for
locally grown, healthy foodBalance the impacts of tourism; ensure more
local access to healthy places
ENVIRONMENT

Protect and preserve natural resources of theislandKEIKI

Develop more positive activities for youth,
especially teens, that help ease stresses of lifeand develop leadership
KEIKI

Increase early childhood education opportunities
HEALTHCARESUPPORT FOR HIGH NEEDS

Support for the houseless population

Political will
/resources✓
Evidence ofhigh need✓

167

ADDRESSINGHEALTH NEEDSAs she mourned the death of her husband from cancer, a Kalihi
woman at the age of 70 spent her days alone watching TV to pass
the time. She couldn’t walk very far, it was hard for her to movearound, and she couldn’t lift her arms. Sharing her story with her
friend, she was told to go to the senior center at Kōkua Kalihi Valley(KKV). So she went one day, and saw lots of other seniors smiling at
her, and not long after, she found herself laughing and talking story
with her new friends. “I told myself that laughter is better medicine
than any pill,” she said. As a part of the kūpuna program at KKV, they
sing, dance for an hour, and eat together. It’s fun and communal, andit’s exercise. She noticed her body got stronger—she could walk,dance, and lift her arms. She feels great and happy. At KKV, shefound a community of doctors and health workers who care about
her. She also has a community of friends where they share recipes
and learn how to make the Filipino dishes they love, but healthierand in the right portion. She loves her neighborhood of Kalihi, where
she is able to walk from her house to the shopping center, KKV,
grocery stores, and bus stops. She loves watering her plants andeating vegetables from her garden. “I’m 77 years old and I’m thehealthiest I’ve ever been,” she said.

168

A SHARED KULEANA FORCOMMUNITY HEALTH
In Hawaiʻi, health is a shared experience and endeavor. No single person, no single entity, and no single
industry can be solely responsible for community health.
At some point in history, a model of healthcare was established that went this way: It is up to thedoctor to heal the patient, and it is up to the patient to comply with the doctor’s orders. But even as
our understanding of health grew to include public health, prevention, and social determinants, ourconcept of responsibility for health doesn’t seem to have kept pace. We are still primarily looking tohealthcare—now in the form of the healthcare industry—to drive the improvement of health, now
including community health. In turn, the industry puts increasing onus on individuals to adopt “healthy
lifestyles”—something that many in the community would say is essentially impossible for lack of abasic foundation for health. Expectations are unrealistic on both sides of the equation.
Rather than pushing responsibility back and forth between individuals and the healthcare system, it ismore realistic and more consistent with Hawaiʻi values to engage one another and share kuleana
throughout the entire healthcare ecosystem.

The healthcare ecosystem...
●

Includes the individual, the healthcare system, and all the other non-medical contributors tohealth. Health encompasses essentially everything, therefore every person, family,organization, and agency has the opportunity to advance community health.

●Acknowledges, values, and strives to generate the non-sickness aspects of health: things likehealthy relationships, purpose and meaning, community pride, and time at the beach.

●

Has the collective authority and potential capability to address all the causes of poor health,including everything upstream of medical care: things like ending discrimination, creating
better jobs, making communities safer, improving transportation infrastructure, preparing forclimate change, improving schools, curbing sexual violence, and providing considerably more
aﬀordable housing

It is only by sharing kuleana—doctor, patient, and everyone else in the ecosystem—that Hawaiʻi canadequately address both the measured and unmeasured health challenges facing our people.
In this section, a speciﬁc process is laid out for hospital facilities to choose priorities and develop
strategies based on what was learned in this CHNA. But really any interested individual, organization,or agency can develop priorities and strategies in the same way. The process begins by reviewing stateand island priorities, running ideas through a screen of important factors, and then developing plans toengage community and other partners in strengthening existing initiatives and developing new ones.

169

CHOOSING PRIORITIES &DEVELOPING STRATEGIESHAH facilities and others in the health industry have brought up the need for and beneﬁts of collectiveplanning. This CHNA is designed to be a shared frame of reference so that hospitals can plan initiatives
together if they so choose. For even greater impact, the CHNA can be a catalyst for cross-sector
planning along with community organizations, ﬁnancial institutions, foundations, large employers,
unions, government agencies, educational institutions, and others.
There are many kinds of priority initiatives that HAH member facilities and others in the healthcare
ecosystem can adopt, including direct service programs, outreach programs, internal policy changes,
public policy advocacy, internal capacity building, network building, and education campaigns. For the
purpose of selecting priorities and initiatives, follow these steps:

STEP 1 - Choosing community/island health priorities
to address
STATEWIDE PRIORITIES

Hawaiʻi

Maui

Molokaʻi

LānaʻiOʻahu

Kauaʻi

●
●

●
●
●

●

●

●
●

●
●

●

●

●

●

●
●

●

●

●

GOAL 1 - FOUNDATIONSProvide the basic foundations so that people canhave more control over their own health
1.1 Address ﬁnancial insecurity
1.2 Work together for equality and justice
1.3 Strengthen families
1.4 Prepare for emergencies
1.5 Build good food systems

GOAL 2 - COMMUNITY
Preserve, nurture, expand, and employ the healing
properties of community

●

●
●

●
●
●
●

●
●
●

●
●

●
●

●
●

2.1 Restore environment and sense of place
2.2 Nurture community identity and cohesiveness
2.3 Invest in teenagers and healthy starts
2.4 Shift kūpuna care away from “sick care”

GOAL 3 - HEALTHCARE
Improve the relationship between people and thehealthcare system
3.1 Strengthen trust in healthcare
3.2 Provide accessible, proactive support for those withhigh needs

●
●

●

●

●

Important island priorities marked with “●”Highest need areas on island in RED
Note: all statewide priorities are signiﬁcant on all islands

170

STEP 2 - Setting organizational purpose
Determine how addressing the priorities aligns with and advances your values, mission, and strategy.

STEP 3 - Identifying existing initiatives
APPENDIX A contains a list of current community health strategies throughout Hawaii. This list can
provide ideas and organizations to connect with and learn from.

STEP 4 - Evaluating partnership needs and potential
Make an inventory of the tangible and intangible resources you bring to the eﬀort and what might beneeded from partners. Make a list of potential partners who could help make the initiative successful.

STEP 5 - Building internal capacity
Determine what resources, skills and other internal capacities are needed in order to do your part forthis initiative and support partners. This includes the capacity to eﬀectively engage with community
members, organizations, and other entities in ways that engender good communication, trust, andcollaboration.

STEP 6 - Engaging community and building
partnerships
Reach out to potential partners including the skillful engagement of members of and leaders fromaﬀected communities. Share existing plans and ideas, develop collaborative plans, and build systems ofopen communication. Discuss potential unintended consequences and risks to the community that canbe discussed and mitigated. Develop shared indicators of success so that data collection and evaluation
can happen in conjunction with community partners.

171

Pali Momi Medical CenterIn the early 1980s, Dr. Joseph “Joe” Nishimoto returned to Hawai‘i from the mainland to practice
medicine in ʻAiea and Pearl City. As the community grew, he envisioned a local, state-of-the-art
hospital so Leeward families would not have to drive into town for medical care. The road to achievingthat vision spanned eight years and took the efforts of many.
Pali Momi opened on July 31, 1989. Since its opening, the hospital has delivered many medical firsts forCentral and West O‘ahu, including:• The first interventional cardiac catheterization unit to detect and treat heart disease.
• First retina center in Hawai‘i.
• Minimally invasive surgical technology featuring the da Vinci robot-aided system.
• A comprehensive women’s center.
• Hawai‘i’s only team triage approach to emergency medicine.
• A complete bariatric surgery program.
• The most advanced diagnostic imaging technology available.
Today, Pali Momi continues to provide award-winning care to thousands of patients each year. Pali Momi
is a Level III Trauma Center, accredited by the American College of Surgeons. It has been recognized by
the American Heart Association and American Stroke Association for its stroke care program. Pali Momi’s
Bariatric Surgery Program offers complete patient care, lifestyle transition and support, and has received
Metabolic and Bariatric Surgery Accreditation and is recognized as a Quality Improvement Program
Accredited Center, a joint program of the American College of Surgeons and the American Society for
Metabolic and Bariatric Surgery. With more than 1,200 employees and 400 physicians, Pali Momi is fully
accredited by The Joint Commission, an independent nonprofit organization that certifies health careorganizations and programs in the United States.

Hawai‘i Pacific Health
Hawai‘i Pacific Health (HPH) is a not-for-profit health care network of hospitals, clinics, physicians andcare providers dedicated to the mission of improving the health and well-being of the people of Hawai‘iand the Pacific Region. Anchored by its four hospitals—Kapi‘olani Medical Center for Women & Children,
Pali Momi Medical Center, Straub Clinic Medical Center and Wilcox Medical Center—HPH includes morethan 50 convenient locations and service sites statewide. As the state’s largest health care provider,
Hawai‘i Pacific Health’s network of doctors and specialists provide a distinctive model of coordinatedcare. Its not-for-profit mission means all earnings are reinvested into improving medical equipment andfacilities, as well as invested in research, education, training, and charity care for under-served people
within the island community.

Community Served by Pali Momi Medical Center
Pali Momi serves the health needs of residents in Central and West O‘ahu, as well as patients from all
across O‘ahu. Therefore, the island of O‘ahu, which comprises the County of Honolulu, will serve as theunit of analysis for this CHNA. An assessment of community health issues specific to O‘ahu can be foundon pages 146 - 156 of this report.

Demographics of O‘ahu
In 2017, O‘ahu had a population of 990,060. 1 O‘ahu’s population of children under 18 is similar to the restof the state of Hawai‘i. Children under 18 made up 21.4% of the island’s population (compared to 21.6%
in Hawai‘i) and adults over 65 made up 16.4 % of the population (compared to 16.7% in the state).

1 U.S. Census Bureau, American Community Survey, 2013-2017 Estimates

The largest single race group in O‘ahu is Asian at 42.9%, with the majority of the Asian population
identifying as Filipino or Japanese. The Black/African American, Native Hawaiian and Other PacificIslander, multiracial, and Hispanic populations are relatively larger in Hawai‘i overall, and a closer
examination of the multiracial population shows that the majority (42.9%) of O‘ahu residents identified as
any part Asian.1
A comparable percentage of Hawai‘i State and O‘ahu residents have at least a high school degree or abachelor’s degree. 22.4% of O‘ahu residents ages 25 and older had at least a bachelor’s degree,compared to 21.2% in the state.
The 2008-2012 median household income on O‘ahu ($80,078) was relatively high compared to the state($74,923). Per capita income was $33,776 on O‘ahu in 2013-2017, higher than the rest of the State($32,511), and the U.S. ($31,177).1 Larger household sizes account for this juxtaposition. While theaverage household has 2.63 members in the USA, the average O‘ahu household has over 3.02
members. 9.1% of O‘ahu’s population lived below poverty level in 2013-2017, comparable to Hawai‘ioverall (10.3%) and lower than the U.S. average (14.6%). Certain race/ethnic groups on O‘ahu are also
more affected by poverty. Overall, the American Indian and Alaska Native, “Other” and Native Hawaiian,or Other Pacific Islander populations had the highest poverty rates in 2013-2013.1
It is important to note, however, that federal definitions of poverty are not geographically adjusted, so thedata may not adequately reflect the proportion of residents who struggle to provide for themselves due tothe high cost of living across the state of Hawai‘i.
The Asset Limited, Income Constrained, Employed (ALICE) Report may provide a more accurate pictureof economic hardship and survival in accordance with Hawai‘i’s relatively high cost of living, dominance of
low wage jobs, lack of affordable housing, and gaps in public assistance. 2 This measure, developed by
the United Way, provides estimates for those who live above the Federal Poverty Level but still struggle
financially. The ALICE population is working, but they are typically just one major crisis (loss of job, healthemergency, etc.) away from being at an increased risk for long term problems such as loss of housing or
chronic health concerns. The report has determined that while 9% of O‘ahu households meet Federal
Poverty Level guidelines for financial hardship, an additional 35% (108,209 households) met ALICE
criteria.
According to the ALICE Report, many households with children fall under the ALICE threshold, andfamilies headed by a single parent are even more likely to meet this criteria. Of the 13,191 single female
headed households on O‘ahu, 43% meet ALICE criteria, as do 55% of the 5,948 single male headedhouseholds. This is compared to just 29% of the 63,385 married households with children who meet
ALICE criteria. Ethnicity is also a factor in the ALICE breakout, and the Native Hawaiian, Black, andHispanic populations meet the ALICE threshold at the highest rates. While there are ALICE households inevery age bracket on O‘ahu, 61% of the 10,317 households consisting of individuals under the age of 25
meet ALICE criteria.
Food insecurity is a major component of poverty, and 194,610 people in Hawai‘i struggle with foodsecurity. Of that figure, an estimated 83,000 do not qualify for government assistance and roughly 1 in 5
children struggle with hunger in Hawai’i. 3Homelessness is a significant issue for women and children in Hawai‘i. Of the 7,220 homeless individuals
identified in 2017, 1,667 were children under the age of 18 and 3,177 identified as female (women andchildren), accounting for 67% of the total homeless population in the state. 4

2

Hawai‘i United Way ALICE Report, 2017

3 Hunger in Hawai’i Report, 2016
4 State of Hawai‘i Homeless Point-in-Time Count, 2017

SocioNeeds Index®
Healthy Communities Institute developed the SocioNeeds Index® to easily compare multiplesocioeconomic factors across geographies. This index incorporates estimates for six different social andeconomic determinants of health that are associated with health outcomes. The data, which coverincome, poverty, unemployment, occupation, educational attainment, and linguistic barriers, are thenstandardized and averaged to create one composite index value for every zip code in the United Stateswith a population of at least 300.
Zip codes with higher values are estimated to have the highest socioeconomic need and are correlatedwith poor health outcomes, including preventable hospitalizations and premature death. Within Hawai‘i,
zip codes are ranked based on their index value to identify the relative level of need within the state.
Index values were not calculated for those areas missing on the map below due to low population count.
The zip codes in Honolulu County with the highest levels of socioeconomic need are found in the
Waianae, Wahiawa, and Kalihi areas of the island.

Zip
Code

Index

County

96792

76.9

Honolulu

96817

64.4

Honolulu

96786

47.9

Honolulu

96819

45.6

Honolulu

96826

44.4

Honolulu

96814

32.9

Honolulu

96791

29.4

Honolulu

96717

28.6

Honolulu

96795

26.3

Honolulu

96818

25.7

Honolulu

96797

24.7

Honolulu

96860

24.5

Honolulu

96815

21.7

Honolulu

Selected Priority Health Needs
In 2016, the Hawai‘i Pacific Health system undertook a planning process to provide focus for HPH’s
community health initiatives and develop a strategy to more meaningfully address the social (non-clinical)
determinants of health. A work group made up of leadership from across the HPH system conducted
listening sessions with a wide range of community organizations to learn about critical social issues
impacting the health of our community, with special attention to vulnerable populations.
As a result of this process, HPH adopted the following priority areas of focus for its community healthpartnerships: Strengthening families and developing resilient children by promoting 1) Economic
Empowerment through food security, housing stability, and self-sufficiency; and 2) Education throughholistic child development and family educational attainment.

The work group evaluated the significant health needs identified in this CHNA (page 4) based on thefollowing criteria:• Alignment with above HPH community health focus areas• Opportunity to leverage planned and existing HPH community partnerships and initiatives• Alignment with HPH’s resources and expertise• Potential to make a measurable impact in collaboration with partners
Together with the other Hawai‘i Pacific Health facilities, Pali Momi selected the following four community
health priorities:
GOAL 1 - FOUNDATIONS: Provide the basic foundations so that people can have more control overtheir own health
1) Strengthen families. Create the conditions and opportunities for families to be healing forces for
its own members, including addressing financial stress that will enable more healthy time
together.
2) Build good food systems. Establish access to nutritious food so that it is available to all.
GOAL 2 - COMMUNITY: Preserve, nurture, expand, and employ the healing properties of community
3) Invest in teenagers and healthy starts. Invest in health and education at the earliest stages oflife. Support school-based structures, community-based activities, and youth empowerment for
pre-teens and teens.
GOAL 3 - HEALTHCARE: Improve the relationship between people and the healthcare system
4) Provide accessible, proactive support for those with high needs. Identify, develop, andstrengthen outreach, early intervention, free healthcare services, mental health, and oral healthfor those who are struggling with houselessness, mental illness, and addiction.
A plan for addressing these priorities will be further described in Pali Momi’s 2020-2022 Implementation
Strategy.

Evaluation of Prior 2017-2019 Implementation Strategy
Over the past three years, Pali Momi Medical Center conducted the following programs to address thetwo priority community health needs identified in the medical center’s 2016 Community Health Needs
Assessment: Access to Health Services and Diabetes.
Priority 1: Access to Health Services
Strategy 1.1: Support development of West O‘ahu’s health care workforce.
•

Health Professions Education: Pali Momi provided clinical training and continuing education for
physicians, medical students, nursing students and allied health professionals to increase thecapacity of the local health care workforce and improve the availability of and access to quality
specialty medical care in West O‘ahu. Over the past three years, Pali Momi provided residencies
and training for 367 residents, 616 medical students, 277 nursing students, and 578 allied healthprofessionals in such fields as ultrasound, surgical technology, pharmacy, radiology, medicallaboratory services, and respiratory technology. Pali Momi also contributed $750,000 to support
the Family Medicine Primary Care Consortium which worked to develop quality family medicine
residencies in Hawai‘i.

•

Continuing Medical Education for Community Physicians: Pali Momi offered 28 continuing
medical education presentations annually, open to all physicians in the community, on pertinent
medical topics to help keep them apprised of the latest developments in health care. Eachsession was attended by 50 to 60 physicians.

•Physician Recruitment: The Hawai‘i Physician Workforce Assessment Project estimates a 20
percent shortage of physicians statewide. This shortage is especially acute in rural areas such as
Central and West O‘ahu, where Pali Momi is located. To improve access to quality specialty carefor its surrounding community, Pali Momi actively recruited physicians for specialties for whichO‘ahu has shortages. Over the past three years, Pali Momi successfully recruited 20 physicianswith needed specialties including neurology, obesity medicine, cardiology, urology, orthopedics,
general surgery, family practice, palliative care, bariatrics, and oncology to practice in West andCentral O‘ahu.

•

Scholarships for UH Medical Students: The Hawai‘i Pacific Health Medical Student
Scholarship Fund addresses the physician shortage in Hawai‘i by supporting Hawai‘i residents
who commit to practicing medicine in Hawai‘i to attend the University of Hawai‘i John A Burns
School of Medicine. The scholarship, beginning Fall 2019, will provide four-year full-tuition
scholarships to five in-coming Hawai‘i resident medical students each year. Pali Momi has
donated $194,736 to the scholarship fund.

Strategy 1.2: Increase access to health services for medically-underserved communities andvulnerable populations.
•

Wahiawa Center for Community Health: Over the past three years, Pali Momi contributed$10,000 to support development of the Wahiawa Center for Community Health (Wahiawa Health)in Wahiawa, one of the most economically disadvantaged areas of O‘ahu, and a designatedMedically Underserved Population area. To date, Pali Momi has donated a total of $30,000
toward the health center’s development. Federal health centers are important community-based
safety net providers that offer comprehensive primary care, behavioral health, and oral healthservices on a sliding fee scale to rural, underserved communities, and low-income, under-insured
individuals. Wahiawa Health provides care for 6,400 patients.

•

Community Care for Homeless Patients: Homeless individuals face significant barriers toaccessing routine medical care leading to high rates of multiple chronic health conditions, illness
and injury, and disproportionate use of emergency services. Pali Momi gave financial support anddonated medical supplies to the Hawai‘i HOME Project, a program of the UH John A. Burns
School of Medicine that provides free clinics for homeless individuals, staffed by medical students
and physician volunteers at homeless shelters and from a mobile health van. Since its inception
in 2006, HOME has served more than 5,200 homeless patients.

Strategy 1.3: Provide and subsidize health services that would not otherwise be available tothe community.
•

Cancer Research Center of Hawai‘i: Cancer is the second leading cause of death in Hawai‘i.
Pali Momi, together with the other hospitals of Hawai‘i Pacific Health, Queen’s Medical Center,
and Kuakini Medical Center, partnered with the University of Hawai‘i’s Cancer Research Centerof Hawai‘i to enhance the quality and breadth of cancer care in Hawai‘i, supporting enhanced
access for more than two-thirds of the cancer patients in the state to clinical trials, state-of-the-art
treatment, and innovative therapies near to home for local patients. Many of these trials aredesigned specifically for populations in Hawai‘i with cancer mortality disparities. Over the past six
years, more than 13,000 cancer patients were enrolled in over 600 interventional therapeutic
trials.

Priority 2: Diabetes
Strategy 2.1: Improve diabetes self-management.
•

Diabetes Self-Management Education: Pali Momi provided funding to the YMCA and Straub
Medical Center to support free American Diabetes Association-approved diabetes selfmanagement education programs at community locations around O‘ahu. The initiative focusedon recruiting and enrolling high-need, low-income, under-insured individuals with diabetes. 79
under-insured individuals were enrolled at locations in Wahiawa, Kalihi, Kaneohe, and Nuuanu,
with 80% completing the program.
Strategy 2.2: Prevent diabetes by reducing obesity and promoting healthy lifestyles.
•

Child and Adolescent Weight Management: Healthy Weight and Your Child is an intensive,
family-based program to combat childhood obesity, a leading cause of diabetes, based on bestpractices identified by the CDC. The YMCA of Honolulu and Pali Momi, together with the other
Hawai‘i Pacific Health facilities, partnered to provide the program in communities around O‘ahu.
Eleven cohorts were conducted over the past three years, enrolling 366 participants (168 enrolled
youth, and 198 family members). Upon completion of the program, 74% of enrolled youth
maintained or lowered their BMI, and 100% of families reported initiating lifestyle changes.

•

Diabetes Screening: Pali Momi partnered with Pearlridge Center (the community’s largest
shopping mall) to provide free bi-monthly blood pressure and diabetes screenings to the generalpublic. Individuals at risk for disease were given educational materials and recommendations toimprove their health. Over the past three years, 2,039 individuals were screened.

•

Kids Fest: This annual health fair for children and families offers hands-on activities, such as a
Teddy Bear Clinic, Keiki Zumba, Balloon Olympics, Wheel of Nutrition and Fire Safety House, toteach participants about child health, nutrition and injury prevention. This popular event, held at
the Bishop Museum, was attended by more than 5,000 children and adults in each of the past
three years. Kids Fest is a collaboration of Hawai‘i Pacific Health’s four medical centers.

•

School-Based Fitness Programs: Pali Momi supported DOE Fitness Days attended by
students from 64 public elementary schools in Central, West, and Windward O‘ahu. The
objectives of the events were to promote health and wellness among students, align fitness andperformance goals to national standards, and increase student participation in fitness activities.
Pali Momi provided education on healthy eating and how to live a healthy, active lifestyle. A totalof 8,672 students participated over the past three years.

Pali Momi Medical Center did not receive any written feedback from the community regarding its 2016
Community Health Needs Assessment and 2017-2019 Implementation Strategy.

CONCLUSION
My family used to go camping at the beach every year from when I
was young. We would camp on the beach basically from June toAugust every year. My family was poor but we were rich because we
had love. When we went camping, we had to utilize the natural
resources. We knew how to live out of coolers. My family started todie oﬀ and we got older but we tried to keep the camping tradition
going. Because of that experience living on the beach, I feel like we
can handle dealing with hurricanes and their aftermath. When theother hurricanes came in the past, we were all together and we tookcare of each other. We never had the connection to phones,
internet—being able to constantly keep up with the news and what
everyone else is doing—that stuﬀ can make you crazy. Sometimes
being too educated can trip you out.
- Waiʻanae resident

178

Each person’s story of health reminds us of the important things in life.
Each person’s story of health matters. It matters to the individual, it matters to loved ones, and it
matters to the entire community.
Each person’s story of health tells us that living a healthy life is more than just being free of disease. It
is more than just maximizing the number of years one gets to live. And so, getting healthy is more thanjust the treatment of disease or the adoption of healthy behaviors.
Each person’s story of health weaves into other people’s stories of health, forming a tapestry of sharedexperiences of people just trying to survive or trying to deal with fear or despair or shame or stress or
discrimination or all of those things; of people in need of love and connection; of people breathing air
and drinking water and eating food from these islands; of people trying to ﬁgure out the complexitiesof their health and seeking the help that they need. This shared experience tells us that we are morealike than statistics or stereotypes might make us think.
Each person’s story of health reminds us of the obvious fact that health—although a private
relationship between individuals and their healers—is not just determined by those two. No one
patient, no matter how compliant, and no one doctor, no matter how high quality, can achieve health in
the community. The ingredients of good health come from every corner of society.
Therefore, each person’s story of health enlists more people into the health conversation—farmers,
caregivers, emergency responders, judges, store managers, chefs, bankers, environmentalists, bus
drivers, architects, cultural practitioners, teenagers, grandparents. It draws more and more people inuntil everyone is together in a single health ecosystem that determines the health of people andwhether it accrues to all or just for those with enough advantages. It calls upon each of us to listen to
one another and share kuleana for the health of our people and place.

ACKNOWLEDGMENTS
This assessment of community health in Hawaiʻi is the product of many hands and hearts. Islander
Institute wishes to acknowledge and thank the following community members who shared their time,
perspectives, care, stories, and support throughout the year:
The Healthcare Association of Hawaiʻi and its Associate Vice President of Post-Acute Care &Operations, Andrew Garrett, for their diligent management of this process and for their sincerecommitment to lifting up community voices.
The nineteen HAH member facilities, including their lead contacts, leadership teams, and staﬀ
members who collectively invested in this CHNA and participated in the process.
Bob Agres, Punahele Alcon, Joy Barua, Janet Berreman, Andrew Garrett, Carol Ignacio, Karey Kapoi,
Lorraine Lunow-Luke, Jon Matsuoka, May Okihiro, Judy Mohr Peterson, Mike Robinson, Tracie Ann
Tjapkes, JoAnn Tsark, Sharlene Tsuda, and Chris Van Bergeijk who, as members of the CHNA steeringcommittee, oﬀered valuable guidance, supported community engagement eﬀorts, and engaged in
critical dialogue that had profound impacts on this ﬁnal document.

179

The Hawaiʻi Public Health Institute, including Fadi Youkhana and Maggie Morris, who helped with datacollection and analysis, and Executive Director Jessica Yamauchi and her staﬀ for their support.
Special mahalo to Marisa Castuera Hayase, Kilikina Mahi, and Lily Bloom Domingo, the Hawaiʻi-based
consultants who conducted interviews for the 2013 and 2015 CHNAs and who generously shared theirnotes and wisdom; to Dr. Lee Buenconsejo-Lum and her colleagues at the John A. Burns School of
Medicine for going above and beyond by arranging numerous conversations with interns, residents andfaculty in many of the school’s programs; and to Lorraine Lunow-Luke of Hawai’i Paciﬁc Health forsharing her extensive knowledge of the CHNA requirements and helping ensure this document meetsthe needs of Hawaiʻi’s hospitals.
Mahalo to the many key informants who took the time to share their valuable wisdom and expertise byphone or in person throughout the islands, and without whom this assessment could not be complete.
Finally, Islander Institute extends a sincere mahalo nui to everyone who participated in the community
convenings. To the organizations and individuals who put their trust in us, reached out to theircommunities, and created safe, welcoming, comfortable, nourishing spaces for meaningful talk story,
this CHNA would literally not be possible without your kōkua. And to every community member who
shared their truth so that we can all live in a healthier Hawaiʻi, we are humbled by your generosity andhumanity.

180

APPENDICES181

APPENDIX A – SHARED KULEANA STRATEGIESThe health of Hawaiʻi’s people is the responsibility of all. It is a shared kuleana. The following initiatives
are some of the promising eﬀorts moving in the three strategic directions. Hospitals and others in thehealth ecosystem can look to these examples and work with communities to develop their priorities
and partnerships.
1. FOUNDATIONAL HEALTH
GOAL: Provide the basic foundations so that people can have more agency over their own health
Accountable Health Communities Model, The Centers for Medicare & Medicaid Services(CMS). The AHC Model identiﬁes and addresses the health-related basic needs of Medicare andMedicaid beneﬁciaries—such as food insecurity and inadequate or unstable housing—throughscreening, referral, and community navigation services. It tests whether addressing theseneeds will impact health care costs and reduce their use of health care. The AHC model is being
piloted in a partnership between UnitedHealth, Queen’s Medical Center, Kalihi-Pālama HealthCenter, and Waiʻanae Coast Comprehensive Health Center.
(https://innovation.cms.gov/initiatives/ahcm)‘Āina Pono: Farm to School Program, Hawaiʻi State Department of Education (HIDOE). This
program is increasing local food in student meals as well as connecting keiki with the ‘āina
through their food, using produce farm local farms. HIDOE has established partnerships that
include the Oﬃce of the Lieutenant Governor, the Hawaiʻi Department of Agriculture (HDOA),
the Hawaiʻi State Department of Health (DOH), The Kohala Center, Kōkua Hawaiʻi Foundation,
Ulupono Initiative, the Hawai‘i Farm to School Hui, Dorrance Family Foundation, HawaiʻiAppleseed, Johnson ʻOhana Charitable Foundation, Kaiser Permanente, the Hawaiʻi Farm
Bureau Federation (HFBF) and HMSA.
ALEA Bridge. Based in Wahiawā, ALEA Bridge works with at-risk individuals, families, youths,
and veterans including people who are houseless through a personal, respectful, collaborativeand grassroots approach. They help with ﬁnding employment and housing; managing ﬁnances;and placing people into substance abuse and behavioral health program. They often partnerwith Wahiawā General Hospital. (http://www.aleabridge.org)
ALICE. Aloha United Way recently released a report, ALICE: A STUDY OF FINANCIAL HARDSHIPIN HAWAI‘I. ALICE (Asset Limited, Income Constrained, Employed) individuals and families arethose who have at least one job yet cannot aﬀord housing, child care, food, transportation andhealth care. Nearly one in two households in Hawaiʻi are ALICE and below. Since release its
report, AUW has focused on supporting the ALICE community on strengthening their ﬁnancial
health. AUW embraces the reality that sustainable social change must involve cross-sector
coordination, long-term commitment, and investment in deeper relationships with strategic
partners. (https://www.auw.org/alice)
Double Up Food Bucks. This program helps low-income people who are on SNAP or foodstamp beneﬁts buy more healthy fruits and vegetables at participating markets and grocery
stores. As its name suggests, the program doubles the value of beneﬁts that enables people toeat local produce and support local farmers. Many organizations are oﬀering this program
throughout Hawaiʻi, including The Food Basket (Hawaiʻi Island’s Food Bank), Sust‘āinable
Molokaʻi, Mālama Kauaʻi, Mālama Learning Center’s Mākeke Kapolei market, Waiʻanae Coast

182

Comprehensive Health Center’s Mākeke Waiʻanae, Kōkua Kalihi Valley, and others.
(http://www.doubleupfoodbucks.org)
Farm to School Hui. Under the Hawaiʻi Public Health Institute, this hui aims to strengthen thefarm-to-school movement in Hawaiʻi. It does this by support networks on ﬁve islands by sharing
resources, capacity building, professional development, and advocacy. It works with community
organizations, and representatives of the Hawai‘i departments of agriculture, education,
health, and the University of Hawai‘i. (https://www.hiphi.org/farmtoschool)
Hawaiʻi Budget & Policy Center (HBPC). A program of Hawaiʻi Appleseed, HBPC works onstate and local economic policies to increase opportunity for all residents by analyzing andunderstanding the implications of tax and budget decisions and educating public andpolicy-makers. The HBPC’s advisory board includes representatives from Kaiser Hospital,
Federally Qualiﬁed Health Centers, the University of Hawaiʻi System, and community-basedorganizations. (https://hibudget.org and https://hiappleseed.org)
Hawaiʻi County Fire Department Paramedicine Program. The Hawaiʻi Fire Department has
been focusing on advocating for vulnerable populations that have become disconnected fromhealth care for any of a variety of reasons. These groups could include the elderly, the medicallyfragile, the houseless, high utilizers of the EMS system, and those at high risk of falling. This
program tries to identify these individuals, assess their situation and work as their advocates toﬁnd solutions that will improve their overall health and wellness.
(http://www.hawaiicounty.gov/ﬁre)Hawaiʻi Housing Coalition. The Federal Reserve Bank of San Francisco has been convening agroup of Hawaiʻi stakeholders to develop a vision and strategy for establishing a multi-sector,
community-driven coalition that promotes aﬀordable housing for low-income residents of
Hawaiʻi. (https://www.frbsf.org)
Hawaiian Community Assets. HCA helps low- and moderate-income communities, particularly
Native Hawaiians, become more self-suﬃcient in their housing and ﬁnances. They provide
workshops in housing and ﬁnancial education, counseling for individuals, and access to asset
building services—all of which are grounding in Native Hawaiian culture. HCA has been playing
a critical role in assisting with relief and recovery eﬀorts in the aftermath of the 2018 natural
disasters on Hawaiʻi Island and Kaua‘i—providing housing counseling, ﬁnancial coaching,
emergency ﬁnancial planning, and access to grants and loans for assistance.
(http://www.hawaiiancommunity.net)
Kahauiki Village. This housing community will provide long term, permanent, aﬀordable
housing for approximately 153 currently houseless families with children on Oʻahu. Kahauiki
Village is a community of approximately 144 one- and two-bedroom homes being built on 11.3
acres of land located between Nimitz Highway, Keehi Lagoon Park, and Sand Island. Whencompleted, Kahauiki Village is expected to house over 600 adults and children. This project, led
by the State of Hawaiʻi, City and County of Honolulu, and aio Foundation, has another goal toprovide employment opportunities within walking distance for houseless parents.
(http://www.kahauiki.org)
Keiki Produce Prescription. The Mākeke Waiʻanae Farmacy Keiki Produce Prescription Pilot
Project provides children and their families with produce prescriptions, redeemable for locallygrown produce at Mākeke Waiʻanae (farmers market). Each “prescription” is good for three $24
reﬁlls to be distributed to patients monthly when they visit the Waiʻanae Farmers Market. The
objective of the project is to increase access to healthy, locally grown food, improve diet quality
and reduce the burden of childhood obesity and risk for future chronic disease.

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Kōkua Life, Suicide Prevention App for Hawai‘i. Kōkua Life is a suicide prevention app thatprovides users with Hawaiʻi resources and tools related to suicide prevention. It is designed foruse by both healthcare or other professionals and the general public to ﬁnd help for oneself orothers. It includes a resource directory for mental health and social service providers on eachisland. Kōkua Life was created by Mental Health America of Hawaiʻi with funding from the Stateof Hawaiʻi Department of Health. (https://kokualife.org)
Medical-Legal Partnership for Children in Hawai‘i. MPLC provides legal services to
low-income clients in a community health setting. These populations may not know they have alegal issue or know how to get help, and health centers are spaces more familiar than legal
service oﬃces. MPLC is a partnership between the William S. Richardson School of Law(University of Hawaiʻi at Mānoa), Kōkua Kalihi Valley Comprehensive Family Services, andWaikiki Health Center. (http://www.mlpchawaii.org)
PILI ‘Ohana Partnership (POP). POP addresses obesity in Hawaiʻi and the larger Paciﬁc. It
integrates community wisdom with scientiﬁc methods to conduct research in Native Hawaiian
and Paciﬁc Peoples (including Filipinos, Chuukese, and other Paciﬁc Islanders). The partnership
includes Hawai‘i Maoli of the Association of Hawaiian Civic Clubs; Kula no nā Po‘e Hawai‘i of the
Papakōlea, Kewalo, and Kalāwahine Hawaiian Homestead communities; Ke Ola Mamo; Kōkua
Kalihi Valley; the Paciﬁc Chronic Disease Coalition; the Department of Native Hawaiian Healthat the University of Hawai‘i at Mānoa; and the Oﬃce of Hawaiian Aﬀairs.
(http://www2.jabsom.hawaii.edu/pili/about.html)
Project Hiehie Mobile Hygiene Services. This mobile unit, named after “the Hawaiian way toexpress an inalienable sense of dignity,” provides access to bathing and hygiene services tohouseless individuals—to reduce infections and disease, improve feeling of self-worth, andallow houseless individuals to connect with social and community services without having to“walk through an oﬃce door.” (http://hiehie.org)
Roots Mobile Market, Kōkua Kalihi Valley. The Mobile Market is a mobile produce service,bringing local farmers’ products right to local businesses, agencies, or community sites. The
Mobile Market began as a way to distribute produce to KKV employees who couldn’t make it to
the market during their work day. (https://www.rootskalihi.com)
The Sundays Project of the Parents and Children Together Family Center at Kūhiō Park
Terrace. This program aims to reduce the high rates of absenteeism in public schools amongchildren from The Federated States of Micronesia, the Marshall Island, Palau, and others who
are new to Hawaiʻi. It provides learning opportunities grounded in culture for families.
(https://pacthawaii.org)
Transition to Success (TTS). Transition to Success, which began in Detroit in 2006, coordinatescare across healthcare, human services, government, faith-based organizations and education
to work on social determinants aﬀecting low-income families. This includes racism, low-paying
jobs, and lack of food, healthcare, transportation, aﬀordable housing, reliable, stable child careand education. TTS is being piloted in Hawaiʻi by Child & Family Service through its Family
Centers on Maui, Molokaʻi, and Kauaʻi, with hopes to expand statewide.
(http://transitiontosuccess.org) (https://www.childandfamilyservice.org)
Waipahu Safe Haven Immigrant Resource Center. In 2015, Safe Haven began as a computer
access center for youth and adults in Waipahu, and a site to help train and develop women’ssewing skills so that they would be able to use their skills for their families and as a source ofincome. The center’s mission expanded to include a focus on improving the success of thecommunity and helping individuals and families out of poverty. Currently, the center provides

184services to a variety of migrant and immigrant populations, including Samoan and Filipino, andthe majority are Marshallese and Chuukese families. (https://www.waipahusafehaven.com)
2. HEALTHY COMMUNITY
GOAL: Preserve, nurture, expand, and employ the healing properties of community
Blue Zones Project. Dan Buettner’s book, The Blue Zones: Lessons for Living Longer from thePeople Who’ve Lived the Longest, evolved into a worldwide network of “community-wide
well-being improvement initiatives” intended to people people live longer, healthier, andhappier lives. The Hawaiʻi Medical Service Association (HMSA) brought the Blue Zones Projectto Hawaiʻi, with program staﬀ implementing various activities in communities throughout thestate. For example, in September 2018, Blue Zones held a Big Island Food Policy Summit in Hilothat convened close to 100 stakeholders from agriculture, the food industry, health, education,
local government, and various parts of the community to build a common agenda for HawaiʻiIsland’s food self-reliance and work toward creating a healthy food system for Hawaiʻi Island.
(https://hawaii.bluezonesproject.com)
The Bodacious Women of Pāhoa, Nānāwale, Hawaiʻi. What began as a small group of friends
getting together to socialize grew to volunteers helping with a monthly food pantry. In thesummer of 2014, when Hurricane Iselle hit Hawaiʻi Island, isolating many communities fromassistance, the group began to aggregate and distribute hundreds of bags of groceries tohouseholds that needed food. Following that experience, Bodacious stationed shipping
containers stocked with food in several Puna communities to prepare for future disasters.
(https://www.punalavaﬂow2018.com/bodacious)
Chief Community Health Oﬃcer. At a systemwide level, Kaiser Permanente established aposition of Chief Community Health Oﬃcer, reporting directly to the Chief Executive Oﬃcer,
reﬂecting an eﬀort to move beyond the minimum compliance of “community beneﬁt” andelevating the centrality of place in building health and well-being.
(https://share.kaiserpermanente.org/article/kaiser-permanente-names-bechara-choucair-md-m
s-as-ﬁrst-chief-community-health-oﬃcer)
Community First, Hilo, Hawaiʻi. Community First is a non-proﬁt organization established in2014 in East Hawaiʻi to change the the deﬁnition of healthcare to caring for health and not justtreating disease. Community First formed a Regional Health Improvement Collaborative (RHIC),
which aims to fundamentally reform healthcare payment.
(https://www.communityﬁrsthawaii.org)
Community Meal, St. James’ Church, Waimea, Hawaiʻi Island. The Community Meal is aweekly Thursday evening dinner hosted by St. James’ Church in Kamuela, which began as a meal
for the “homeless, working poor, lonely and downright hungry in our community.” It has grown
to a popular and diverse community event for everyone. Local farmers and ranchers contribute
food to the meal; volunteers cook, bake and serve; and leftovers are delivered to senior homes,
houseless shelters, and to the homes of families who need food. Many cite the weekly event asa source of community pride, bringing people together to build relationships and help eachother. (http://stjameshawaii.org/community-meal)
Community “Poi Day,” Waipā Foundation. This community gathering happens every Thursday
at 5 am when community volunteers gather to process cooked kalo into poi and lunch is served
when the job is done. Poi Day was started about 30 years ago by the Hawaiian families along
Kauaʻi’s north shore to keep poi available and aﬀordable. Today, Waipā distributes poi tokūpuna and ʻohana throughout the island. (http://waipafoundation.org/community_poi)

185

Epigenetics Study in Wai‘anae. The University of Hawai‘i at Mānoa and MA‘O Organic Farms is
researching community health impact of ‘āina or land-based programs in Waiʻanae. The study
hopes to identify how a community program such as MAʻO’s community-based program
focused on restoring our connection to ‘āina can actually impact the health of individuals,
especially in the reduction of obesity and other cardio-metabolic disorders. The study issponsored by the HMSA Foundation and Kamehameha Schools. (http://mauliolanetwork.com)
Hāna Ola Project. Hāna Ola aims to reduce the burden of obesity and other cardiovasculardisease risk factors among Native Hawaiians. The project utilizes community practices of lo‘i
restoration, organic agriculture, kūpuna assisted living, and ku‘i (the cultural practice ofpounding kalo or taro into pa‘i ‘ai and poi). It is a partnership between Ma Ka Hana Ka ‘Ike andQueen’s Medical Center. (https://hanabuild.org)
Healthy Mothers Healthy Babies Coalition of Hawai‘i. This local nonproﬁt, with oﬃces in
Chinatown, Honolulu, is part of a national network of organizations and individuals committed
to improving Hawai‘i’s maternal, child and family health. Their program includes creating
support groups and community spaces for mothers and children to connect.
(https://www.hmhb-hawaii.org)
Keiki to Career Kaua‘i. Launched in 2012, Keiki to Career Kaua‘i is a network of partners ineducation, health, human service and youth programs, families, and businesses working
together to ensure Kaua‘i’s young people are “ready to learn and ready for life.” The goal of
Keiki to Career is for every young person to be ready for each key transition point in theirlife—entry to kindergarten, middle school, high school, and college or work.
(http://keikitocareer.org)
KEY Project Kūpuna Program. The Kūpuna Program promotes socialization, culture, exercise
and access to healthy foods. On Wednesdays and Fridays, up to 100 senior citizens ﬁll into the
KEY Project campus to have fellowship and a freshly prepared meal. The program involves
many other activities, like ukulele and art classes, ﬁeld trips, and guest speakers.
(https://keyproject.org/index.php/senior-citizens-kupuna)
Kōkua Kalihi Valley Elder Services. KKV’s Elder Care Programs provide Kalihi seniors from all
cultural backgrounds with holistic care. At KKV’s Elder Center and at the nearby public housing
community of Kūhiō Park, elderly clients gain daily opportunities for social engagement,
physical activity health education, and primary health care.
(http://kkv.net/index.php/elder-care)
Lānaʻi mural project. A partnership between Lāna‘i Culture & Heritage Center, Lāna‘i High &Elementary School, and local artist collective 808 Urban created a large-scale mural at Lāna‘iHigh & Elementary School depicting scenes from Lāna‘i's history—creation, settlement, native
lore, historic era, plantation, and ongoing practices. The creation of the mural included artists
and students visiting some of Lāna‘i’s storied places and conducting interviews with elder
residents to develop the themes for the mural. The mural has become a source of community
pride. (https://www.lanaichc.org/mural-project.html)
Kailua Homeless Aid. On the fourth Tuesday of each month, the Windward branch of the
YMCA of Honolulu and neighboring Daybreak Church provide support for houseless people in
Kailua. Supported by Alexander & Baldwin and the Harold K.L. Castle Foundation, partner
agencies include AlohaCare, Waimānalo Health Center, Veteran Services, Residential Youth
Services Empowerment, Catholic Charities, Legal Aid, Institute for Human Services, Child andFamily Services, Hiehie Mobile Hygiene, and Community Outreach Court.
(https://www.daybreakhawaii.church and https://www.ymcahonolulu.org/locations/windward)186

Maui Economic Opportunity (MEO). A nonproﬁt Community Action Agency committed helping
low income individuals and families become stable and achieve economic security, MEO
provides many important programs. This report focuses on its transportation services. On Mauiand Molokaʻi, van drivers transport their participants to doctor’s oﬃces. The services, fundedlargely via County of Maui grant appropriation, include transport for services such as Ala Hou,
Easter Seals & Adult Day Care, Employment for the Disabled, Dialysis, Low-income andEconomically Challenged, Kaunoa Leisure Program, Ka Lima O Maui Program, Rural Shuttle,
Senior Nutrition Program, Youth and Community, HeadStart Program, Hospice of Maui,
Independent charter, Maui Memorial Medical Center, and Medicaid. (http://www.meoinc.org)
Molokaʻi Child Abuse Prevention Pathways (MCAPP). Launched launched in 2013 by theConsuelo Foundation as an exploratory pilot program, MCAPP addresses childhood sexual
violence on Molokaʻi through primary prevention education. The program partners withschools to educate children in a culturally responsive way on how to address and prevent thisdevastating problem. (https://www.molokaicapp.org)
PATH (Peoples Advocacy for Trails Hawaiʻi). This advocacy organization aims to to safely
connect people and places on Hawaiʻi Island with pathways and bikeways.
(https://pathhawaii.org/about-path)
School-Based Health Centers. Waiʻanae Coast Comprehensive Health Center manages three
School-Based Health Centers located at Waiʻanae High, Waiʻanae Intermediate, and Nānākuli
High & Intermediate Schools so that students are able to receive primary care and behavioral
health services at school. The Health Centers oﬀer a full range of health services, from sickvisits to sports physicals, keeping students healthy and focused on theirstudies.(http://www.wcchc.com/SBHC)
Sustainable Transportation Coalition of Hawaiʻi. This network of organizations andindividuals aims to reduce the use of cars. The work of the coalition has direct health
implications, whether related to active modes of transportation such as bicycling and walking,or reducing the stress and time of commutes with car sharing, carpooling, and public
transportation. (http://www.stchawaii.org)
Walking School Bus. The Walking School Bus is a program in which children walk to school as agroup, led by parents or another adult. Students are picked up in front of their home or at adesignated stop. Children and their parents can choose when they participate. The goal of the“walking school bus” is to increase childrenʻs rates of active commuting to school and physicalactivity. Communities throughout Hawaiʻi, including Kaua‘i and Hawaiʻi Island, haveexperimented with the Walking School Bus program. (http://www.walkingschoolbus.org)
3. HUMAN CONNECTION TO HEALTHCARE
GOAL: Improve the relationship between people and the healthcare system
The Baldrige Award. This program, established by Congress in 1987 and administered by the
National Institute of Standards and Technology within the U.S. Department of Commerce,
recognizes U.S. organizations and businesses that demonstrate “an unceasing drive for radical
innovation, thoughtful leadership, and administrative improvement.” Adventist Health Castle
won the Malcolm Baldrige National Quality Award in 2017, becoming the ﬁrst recipient of theBaldrige Award in Hawaiʻi. Castle was recognized for its “demonstrated continuous
improvement practices for delivering health care services, exhibited eﬃcient and eﬀective
operations, and revealed systematic methods for engaging and responding to patients andother stakeholders.” (https://www.nist.gov/baldrige)

187

Basic Adult Dental Care for Medicaid Members in Hawaiʻi. AlohaCare and ‘Ohana Health Plan
will oﬀer basic adult dental care coverage beginning January 1, 2019. Since 2009, dental carecoverage for adults enrolled in the state’s Medicaid program has been limited to emergency
care. (https://www.wellcare.com/Hawaiʻi and https://www.alohacare.org)
Cardiac Rehab Lab. At the Cardiac Rehab Lab at Wilcox Medical Center, patients receive
customized treatment plans that focus on their own conditions and limitations. The Cardiac
Rehab Lab utilizes exercise treadmills, bikes, cross-trainers and free weights. The program waslaunched in 2012 in response to a lack of rehab options for residents of Kaua‘i following cardiac
interventions. (https://www.hawaiipaciﬁchealth.org/wilcox/services/heart-health)Care for houseless discharged from hospital facilities. OHANA (Oʻahu Health Access andNetwork Association) project provides case management and short-term residential care thatallows houseless individuals discharged from Queen’s Medical Center and Adventist HealthCastle the opportunity to rest in a safe environment while accessing medical care. Tūtū Bert'sHomes, an 8-bed private medical respite, oﬀer medically frail houseless individuals who are nolonger in need of in-patient hospitalization, but still too frail to recuperate on the streets. The
house facilitates short-term stabilization and supportive case management that accelerates
their transition out of houselessness, and into available housing options.
(http://www.kphc.org/patient/healthcare-homeless)Community Health Workers. A Community Health Worker (CHW) is a trusted member of thecommunity and a valuable member of a healthcare or social services team. They serve as abridge, helping to improve access to services and ensure services are culturally appropriate.
Maui College and Kapiolani Community College oﬀer Certiﬁcate programs for CHWs, andHawaiʻi Public Health Institute is helping to develop and facilitate a statewide network of
CHWs. (http://maui.hawaii.edu/communityhealth andhttps://www.kapiolani.hawaii.edu/academics/programs-of-study/community-health-worker)
Hui Pono, the Ornish Lifestyle Medicine at Hilo Medical Center. The Intensive Cardiac
Rehabilitation program helps participants adopt and sustain lifestyle changes in what they eat;
how active they are; how they respond to stress; and how much love and support they have intheir lives. The result is a decrease in their reliance on medication, avoidance of future
surgeries, and most importantly, a control of their health.
(https://www.hilomedicalcenter.org/the-ornish-lifestyle-medicine.html)
Kukui Ahi Patient Navigation Program. Molokai General Hospital’s Patient Navigation
Program, Kukui Ahi, helps patients, families and their caregivers navigate the healthcare
system. They assist with coordination of air and ground transportation and lodging for patientsrequiring services and treatment on the neighbor islands. Patient navigation services are
tailored to the individual patient’s needs and provides culturally sensitive care. They work
closely with community organizations such as Molokaʻi Cancer Fund, Cancer Care, Paciﬁc
Cancer Foundation, Senior Aging Services, and American Cancer Society.
(https://www.queens.org/molokai/patients-and-visitors/patient-tools-resources/patient-naviga
tion-mgh)
Milestones Hawaiʻi. Milestones was founded in 2018 by a team of physicians and therapists
who saw an opportunity and unmet need for a uniﬁed eﬀort to improve care for children withneurodevelopmental and behavioral conditions in Hawaiʻi. Milestones provides medical
assessments and treatments for children with disabilities; interisland and rural care with clinics,
medical centers, and community providers; child-centered and family-focused therapy forchildren on the autism spectrum; and comprehensive care for children ages 0-5 with behavioral
conditions. (https://www.milestoneshawaii.org)

188

The Native Hawaiian Traditional Healing Center, Waiʻanae Coast Comprehensive HealthCenter. The center promotes traditional Native Hawaiian healing and cultural education,practices, and traditions. The primary practices include lomilomi, lāʻau lapaʻau, lāʻau kāhea(spiritual healing), and hoʻoponopono (conﬂict resolution). (http://www.wcchc.com/Healing)
PRAPARE. The Protocol for Responding to and Assessing Patients’ Assets, Risks, andExperiences (PRAPARE) is a national eﬀort to help health centers and other providers collectthe data needed to better understand and act on their patients’ social determinants of health.
Health centers and other providers can deﬁne and document the increased complexity of theirpatients, transform care with integrated services and community partnerships, advocate forchange in their communities, and demonstrate the value they bring to patients, communities,
and payers. PRAPARE is being used by facilities in Hawaiʻi, including West Hawaiʻi Community
Health Center and Waiʻanae Coast Comprehensive Health Center.
(http://www.nachc.org/research-and-data/prapare)
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). This treatment for children andadolescents impacted by trauma and their parents or caregivers successfully removes a broadarray of emotional and behavioral diﬃculties associated with trauma. There are 30 providers
being trained in TF-CBT on Kaua‘i, including organizations such as the YWCA of Kaua‘i.
(https://tfcbt.org)
Walk with a Doc. Started in 2005 by a cardiologist in Columbus, Ohio who began inviting his
patients to go for a walk with him in a local park, Walk with a Doc has grown as a grassroots
eﬀort. In association with North Hawaiʻi Community Hospital, it is a simple model that involves
a doctor giving a brief presentation on a health topic and then leading participants on a walk attheir own pace. (https://walkwithadoc.org)

189

APPENDIX B – EXISTING HEALTHCARE FACILITIESThis CHNA calls for a healthcare ecosystem approach to community health that includes all community
entities, too numerous to list in this document. Among those are healthcare facilities that serve thepublic. HAH member hospitals are speciﬁcally required by the IRS to describe “existing health carefacilities and resources within the community that are available to respond to the health needs in thecommunity.” Health care facilities in Hawaii registered with the federal Health Resources and Services
Administration (https://ﬁndahealthcenter.hrsa.gov), U.S. Department of Veterans Aﬀairs(https://www.va.gov/ﬁnd-locations), and Hawaiʻi State Oﬃce of Health Care Assurance(http://health.hawaii.gov/ohca) are listed, by island, below.

HAWAIʻI ISLAND
Health Centers
Bay Clinic, Inc.

https://www.bayclinic.org/

Hāmākua Health Center

http://www.hamakua-health.org/

Hui Mālama Ola Nā ‘Ōiwihttps://hmono.org/

West Hawai‘i Community Health Center

https://www.westhawaiichc.org/

Rural Health Clinics
Kīpuka o ke Ola

https://www.kipukaokeola.com/

Kaʻū Hospital Rural Health Clinic

https://www.kauhospital.org/rural-health-clinic.html

Medical/Surgical/Critical Care/Obstetric
Hilo Medical Center

https://www.hilomedicalcenter.org/

Kona Community Hospital

https://kch.hhsc.org/

North Hawaii Community Hospital

https://www.queens.org/north-hawaii/north-hawaii-community-hospital

Acute Care, Skilled Nursing Facility (SNF), and Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF)
Hale Ho‘ola Hāmākua

https://www.halehoolahamakua.org/

Ka‘ū Hospital

https://www.kauhospital.org/

Kohala Hospital

https://kohala.hhsc.org/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
Hale ʻĀnuenue Restorative Care Center

http://haleanuenuecarecenter.com/

Hilo Medical Center

https://www.hilomedicalcenter.org/

Life Care Center of Hilo

http://lifecarecenterofhilo.com/

Life Care Center of Kona

http://lifecarecenterofkona.com/

VA Facilities
VA Hilo Community Based Outpatient
Clinichttps://www.hawaii.va.gov/locations/Hilo_Hawaii.asp

190

VA Kona Community Based Outpatient
Clinichttps://www.hawaii.va.gov/locations/Kailua_Kona_Hawaii.asp

Psychiatric
Hilo Medical Center

https://www.hilomedicalcenter.org/

Kona Community Hospital

https://kch.hhsc.org/

Ambulatory Surgery Centers
Big Island Endoscopy Center, LLC

http://www.bigislandgastro.com/

Hilo Community Surgery Center

http://www.hiloeye.com/hilo-community-surgery-center.html

Kona Ambulatory Surgery Center, LLC.

http://www.konasurgerycenter.com/

The Endoscopy Center

http://www.hawaiigastro.com/treatment/endoscopy-center

End Stage Renal Disease Programs
Liberty Dialysis – Hawaii LLC – Hilo Dialysis
Facility
https://www.freseniuskidneycare.com/dialysis-centers/hawaii/hilo/
Liberty Dialysis – Hawaii LLC – Kona
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/kailua-kona/

Liberty Dialysis – North Hawaiʻi LLC

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/kamuela/

Home Health Care
Bayada Home Health Care — Hilo

https://www.bayada.com/oﬃces/hi/hilo/68-kekuanaoa-st/home-healthCareresource Hawaiʻi — Hilo

http://www.careresourcehawaii.org/

Careresource Hawaiʻi — Kona

http://www.careresourcehawaii.org/

Hilo Medical Center Home Care

https://www.hilomedicalcenter.org/long-term-care.html

Kohala Home Health Care

https://www.queens.org/north-hawaii/services/kohala-home-health-care/kohala-home-health-care-nhch

Kokua Nurses, Inc. Home Health Services,Inc.

http://kokuanurses.com/

Hospice
Hawaiʻi Care Choices formerly Hospice ofHilohttps://www.hawaiicarechoices.org/

Hospice of Kona

https://hospiceofkona.org/

North Hawaiʻi Hospice, Inc.

https://northhawaiihospice.org/

Special Treatment Facility
C.A.R.E. Cottage - Hilo
Care Hawaiʻi Licensed Crisis Residential
Services

https://www.carehawaii.info/programs/crisis-services/

Hawaiʻi Island Recovery

https://hawaiianrecovery.com/

The Exclusive Addiction Treatment Center

https://theexclusivehawaii.com/

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MAUI
Health Centers
Hāna Health

http://hanahealth.org/

Hui No Ke Ola Pono

http://hnkop.org/

Mālama I Ke Ola Health Center

http://ccmaui.org/

Rural Health Clinics
Kīhei Clinic

https://healthy.kaiserpermanente.org/hawaii/facilities/kaiser-permanentekihei-clinic-100440

Lahaina Clinic

https://healthy.kaiserpermanente.org/hawaii/facilities/Kaiser-PermanenteLahaina-Clinic-100437

Medical/Surgical/Critical Care/Obstetric
Maui Memorial Medical Center

https://www.mauihealthsystem.org/

Acute Care, Skilled Nursing Facility (SNF), and Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF)
Kula Hospital

https://www.mauihealthsystem.org/kula-hospital/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
Hale Makua -- Kahului

https://www.halemakua.org/

Hale Makua -- Wailuku

https://www.halemakua.org/

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
The Arc Of Maui (Hale Kanaloa)

http://www.arcofmaui.org/

The Arc Of Maui (Hale Kīhei)http://www.arcofmaui.org/

The Arc Of Maui (Mana Ola Na Keanuenue) http://www.arcofmaui.org/
VA Facilities
VA Maui Community Based Outpatient
Clinichttps://www.hawaii.va.gov/locations/Maui.asp

Psychiatric
Maui Memorial Medical Center

https://www.mauihealthsystem.org/

Ambulatory Surgery Centers
Aloha Eye Clinic Surgical Center, LLC

https://alohaeyeclinic.com/

Aloha Surgery Center

https://alohasurgicalcenter.com/

Kaiser Wailuku Clinic Asc

https://healthy.kaiserpermanente.org/hawaii/facilities/Kaiser-PermanenteWailuku-Medical-Oﬃce-100431

192

End Stage Renal Disease Programs
Liberty Dialysis – Hawaiʻi LLC – Kahana
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/lahaina/4405-honoapiilani-hwy-96761/7385

Liberty Dialysis – Maui Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/wailuku/105mauilani-pkwy-96793/7375

Rainbow Dialysis Lahaina

https://www.mauihealthsystem.org/

Rainbow Dialysis Wailuku

https://www.mauihealthsystem.org/

Home Health Care
Bayada Home Health Care — Wailuku

https://www.bayada.com/oﬃces/hi/wailuku/2200-main-street--suite-660/h
ome-healthCareresource Hawaii — Kahului

http://www.careresourcehawaii.org/

Hale Makua Home Health Care Agency —Wailukuhttps://www.halemakua.org/home-healthHome Health by Hale Makua

https://www.halemakua.org/home-health

Kaiser Permanente Home HealthAgency—Maui

https://kpinhawaii.org/

Hospice
Hospice Maui, Inc.

https://www.hospicemaui.org/

Special Treatment Facility
Ai Pono Mauihttps://www.aipono.com/

Aloha House, Inc

http://www.aloha-house.org/

Nova Luna, Inc.

https://www.novalunacenter.com/

MOLOKAʻI
Health Centers
Moloka‘i Community Health Center

http://molokaichc.org/

Na Pu‘uwai

https://www.napuuwai.org/

Rural Health Clinics
Molokai General Hospital Rural Health
Clinichttps://www.queens.org/molokai/molokai-general-hospital

Obstetric, Acute Care, Skilled Nursing Facility (SNF)
Molokai General Hospital

https://www.queens.org/molokai/molokai-general-hospital

VA Facilities
VA Molokai Outreach Clinic

https://www.hawaii.va.gov/locations/molokai.asp

Hansen’s Disease193

Kalaupapa Care Home

https://www.nps.gov/kala/index.htm

End Stage Renal Disease Programs
Liberty Dialysis – Hawaiʻi LLC – Molokai
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/kaunakakai/
28-kamoi-street-96748/7382

Home Health Care
Careresource Hawaiʻi — Molokai

http://www.careresourcehawaii.org/

Hospice
Hospice Hawaiʻi -- Molokai

https://www.hospicehawaii.org/

LĀNAʻI
Health Centers
Lāna‘i Community Health Center

https://lanaihealth.org/

Ke Ola Hou o Lānaʻi Na Pu‘uwai

https://www.napuuwai.org/

Medical/Surgical, Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF)
Lānaʻi Community Hospital

https://www.mauihealthsystem.org/lanai-hospital/

VA Facilities
VA Lānaʻi Outreach Clinic

https://www.hawaii.va.gov/locations/lanai.asp

End Stage Renal Disease Programs
Fresenius Medical Care – Lānaʻihttps://www.freseniuskidneycare.com/dialysis-centers/hawaii/lanai-city/62
8-7th-st-96763/2809

Hospice
Hospice Hawaiʻi — Lānaʻihttps://www.hospicehawaii.org/our-services/care-settings/lanai-hope-hous
e/

OʻAHU
Health Centers
Kalihi-Pālama Health Center

http://www.kphc.org/

Ke Ola Mamo

http://www.keolamamo.org/

Ko‘olauloa Health Center

https://koolauloachc.org/

Kōkua Kalihi Valley

http://kkv.net/

Wahiawā Center for Community Healthhttps://www.wahiawahealth.org/

194

Wai‘anae Coast Comprehensive HealthCenterhttp://www.wcchc.com/

Waikīkī Health

http://waikikihc.org/

Waimānalo Health Center

https://waimanalohealth.org/

Rural Health Clinics
Castle Health Clinic of Lāʻie

https://www.adventisthealth.org/locations/health-clinic-of-laie/

Kahuku Clinic

http://www.kmc-hi.org/

Medical/Surgical/Critical Care/Obstetric
Adventist Health Castle

https://www.adventisthealth.org/castle/

The Queen’s Medical Center

https://www.queens.org/the-queens-medical-center/queens-medical-centerKaiser Permanente – Moanalua Medical
Center

https://healthy.kaiserpermanente.org/hawaii/facilities/kaiser-permanentemoanalua-medical-center-100434

Kapʻiolani Medical Center for Women &Childrenhttps://www.hawaiipaciﬁchealth.org/kapiolani/

Medical/Surgical/Critical Care
Kuakini Medical Center

https://www.kuakini.org/

Pali Momi Medical Center

https://www.hawaiipaciﬁchealth.org/pali-momi/

Straub Medical Center

https://www.hawaiipaciﬁchealth.org/straub/

Wahiawā General Hospital

https://wahiawageneral.org/

Pediatric, Neonatal ICU
Kaiser Permanente – Moanalua Medical
Center

https://healthy.kaiserpermanente.org/hawaii/facilities/kaiser-permanentemoanalua-medical-center-100434

Kapʻiolani Medical Center for Women &Childrenhttps://www.hawaiipaciﬁchealth.org/kapiolani/Child Ortho
Shriners Hospital for Children -- Honolulu

https://www.shrinershospitalsforchildren.org/honolulu

Acute Care, Skilled Nursing Facility (SNF), and Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF)
Kahuku Medical Center

http://www.kmc-hi.org/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
Wahiawa General Hospital

https://wahiawageneral.org/

15 Craigside

https://arcadia.org/companies/15-craigside/

Aloha Nursing & Rehab Centre

http://www.alohanursing.com/

Ann Pearl Nursing Facility

http://www.ohanapaciﬁc.com/locations/oahu/kaneohe/ann-pearl/

Arcadia Retirement Residence

https://arcadia.org/companies/arcadia/

195

Avalon Care Center -- Honolulu

https://www.avalonhealthcare.com/honolulu/

Care Center of Honolulu

https://www.ccoh.us/

Hale Ho Aloha

http://halehoaloha.com/

Hale Malamalama

http://www.halemalamalamanursing.com/

Hale Nani Rehabilitation & Nursing Center

https://www.avalonhealthcare.com/halenani/

Hale Ola Kino

https://www.haleolakino.com/

Harry & Jeannette Weinberg Care Centerat Pohai Nani

https://www.good-sam.com/locations/pohai-naniHi‘olani Care Center at Kahala Nui

http://www.kahalanui.com/

Ka Punawai Ola

http://kapunawaiola.com/

Kalākaua Gardens

http://kalakauagardens.com/

Kuakini Geriatric Care, Inc

https://www.kuakini.org/wps/portal/public/Programs-Services/Geriatric-Ca
re-Services

Kūlana Mālama

http://kulanamalama.com/

Leahi Hospital

https://leahi.hhsc.org/

Maluhia Hospital

https://maluhia.hhsc.org/

Mānoa Cottage Kaimukī

https://manoacottage.com/

Maunalani Nursing and Rehabilitation
Center

https://maunalaninursing.org/

Oʻahu Care Facility

http://oahucarefacility.com/

Palolo Chinese Home

https://palolohome.org/

Pearl City Nursing Home

http://pearlcitynursinghome.com/

Pu‘uwai ‘O Mākaha

http://www.ohanapaciﬁc.com/locations/oahu/waianae/puuwai-o-makaha/Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
Opportunities And Resources, Inc.

http://www.ori-hawaii.com/

The Arc In Hawaiʻi (6a)http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (6b)http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (ʻEwa B)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (ʻEwa C)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (Kaimukī A)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (Kaimukī B)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (Wahiawā A)

http://www.thearcinhawaii.org/

VA Facilities
Spark M. Matsunaga VA Medical Center

https://www.hawaii.va.gov/locations/directions.asp

Tripler Army Medical Center

https://www.tamc.amedd.army.mil/

VA Leeward Community Based Outpatient
Clinichttps://www.hawaii.va.gov/locations/Leeward.asp
National Center for PTSD

https://www.ptsd.va.gov/

Rehabilitation Facility

196

Rehabilitation Hospital of the Paciﬁc

https://www.rehabhospital.org/

PsychiatricAdventist Health Castle

https://www.adventisthealth.org/castle/

The Queen’s Medical Center

https://www.queens.org

The Queen’s Medical Center – West Oʻahu

https://www.queens.org/west-oahu/queens-medical-center-west-oahu

Hawaiʻi State Hospital

http://health.hawaii.gov/amhd/hawaii-state-hospital-about-us/

Kāhi Mōhala Behavioral Healthhttps://www.sutterhealth.org/kahi

Ambulatory Surgery Centers
Asia Paciﬁc Surgery, LLC

https://www.drshimching.com/

Cataract And Vision Center Of Hawaiʻi

https://www.cataractandvisioncenter.com/

Endoscopy Institute Of Hawaiʻi

https://endoscopyhawaii.com/

Eye Surgery Center Of Hawaiʻi

http://www.eyesurgeryhi.com/

Hawaiʻi Endoscopy Centers, L.L.C.

http://www.hawaiiec.com/

Hawaiian Eye Surgicenter

http://www.hawaiianeye.com/

Honolulu Spine Center

https://www.honoluluspine.com/

Kaiser Permanente Mapunapuna Clinic –Asc

https://healthy.kaiserpermanente.org/hawaii/facilities/Kaiser-PermanenteMapunapuna-Medical-Oﬃce-100428

Minimally Invasive Surgery Of Hawaiʻi

http://www.mishawaii.com/

Paciﬁc Endoscopy Center, LLC

http://paciﬁcendoscopy.com/

Surgicare Of Hawaiʻi

https://surgicareofhawaii.com/

The Surgical Suites, LLC

http://www.thesurgicalsuites.org/

Windward Surgery Center

http://windwardsurgerycenter.com/

Hansen’s Disease
Hale Mohalu Hospital

https://leahi.hhsc.org/

End Stage Renal Disease Programs
DSI – Aloha Dialysis

http://www.usrenalcare.com/locations/aloha

DSI – Honolulu Dialysis

http://www.usrenalcare.com/locations/honolulu

DSI – Kapahulu Dialysis

http://www.usrenalcare.com/locations/kapahulu

DSI – Kapolei Dialysis

http://www.usrenalcare.com/locations/kapolei

DSI – Koʻolau Dialysis

http://www.usrenalcare.com/locations/ko%20olau

DSI – Pearlridge Dialysis

http://www.usrenalcare.com/locations/pearlridge

DSI – Wahiawā Dialysis

http://www.usrenalcare.com/locations/wahiawa

DSI – Windward Dialysis

http://www.usrenalcare.com/locations/windward

Liberty Dialysis – Hawaiʻi – Kaimuki Dialysis https://www.freseniuskidneycare.com/dialysis-centers/hawaii/honolulu/36
Facility
25-harding-ave-96816/7381
Liberty Dialysis – Hawaiʻi LLC – Ala Moana
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/honolulu/50
0-ala-moana-blvd-96813/100115

197

Liberty Dialysis – Hawaiʻi LLC – Hawaiʻi Kai
Dialysis

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/honolulu/71
92-kalanianaole-hwy-96825/7384

Liberty Dialysis – Hawaiʻi LLC – Kailua
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/kailua/25-ka
neohe-bay-dr-96734/7372

Liberty Dialysis – Hawaiʻi LLC – Leeward
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/honolulu/22
30-liliha-st-96817/7379

Liberty Dialysis – Hawaiʻi LLC – Mililani
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/mililani/95-1
105-ainamakua-drive-96789/9226

Liberty Dialysis – Hawaiʻi LLC – Salt Lake
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/honolulu/43
80-lawehana-st-96818/9227

Liberty Dialysis – Hawaiʻi LLC – Siemsen
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/honolulu/22
26-liliha-st-96817/7380

Liberty Dialysis – Hawaiʻi LLC – Waiʻanae
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/waianae/86080-farrington-hwy-96792/7389

Liberty Dialysis – Hawaiʻi LLC – Waipahu
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/waipahu/94450-mokuola-st-96797/7388

U.S. Renal Care Beretania Dialysis

http://www.usrenalcare.com/locations/beretania-2

U.S. Renal Care Waipahu Dialysis

http://www.usrenalcare.com/locations/waipahu%20home

U.S. Renal Care West Oʻahu Dialysis

http://www.usrenalcare.com/locations/west-oahu

Home Health Care
Adventist Health Castle Home Care

https://www.adventisthealth.org/home-care-services/locations/castle/

Arcadia Home Health And Home Care
Services

http://www.arcadiahomecare.com/

Attention Plus Care

https://www.attentionplus.com/

Bayada Home Health Care — Honolulu

https://www.bayada.com/oﬃces/hi/honolulu

Careresource Hawaiʻi — Honolulu

http://www.careresourcehawaii.org/

Kaiser Home Health Agency--Oʻahu

https://kpinhawaii.org/

Lou’s Quality Home Health Care Services,
LLC

http://louscare.com/

Mastercare Homecare & Healthcare

https://www.gomastercare.com/

Oʻahu Home Healthcare

http://www.oahuhomehealthcare.com/

Prime Care Services Hawaiʻi, Inc.

http://primecarehawaii.com/

Safe Harbor Homecare, Inc.

http://www.safeharborhomecare.net/

Seniorcare Foundation

http://seniorcarefoundation.org/

Wahiawā General Hospital Home HealthAgencyhttps://wahiawageneral.org/

Wilson Homecare

https://www.wilsoncare.com/

Hospice
Bristol Hospice, Hawaiʻi LLC

https://bristolhospice-hawaii.com/

Hospice Hawaiʻi

https://www.hospicehawaii.org/

Islands Hospicehttps://www.islandshospice.com/

St. Francis Hospice

http://www.stfrancishawaii.org/services/hospice198

Special Treatment Facility
Benchmark Behavioral Health System

https://www.bbhsnet.com/

Bobby Benson Center

http://bobbybenson.org/dev/

Habilitat, Inc

https://www.habilitat.com/

Hina Mauka

http://www.hinamauka.org/

Hoʻomau Ke Ola

http://www.hoomaukeola.org/

Hope Inc

http://www.hopehi.com/

Ka Pa Ola

https://www.childandfamilyservice.org/programs/kapaola/

Kline-Welsh Behavioral Health Foundation http://www.sandisland.com/
Pearl City Specialized Residential Services
Population

https://www.carehawaii.info/Po‘ailani, Inc -- Kailua

https://poailani.org/

Po‘ailani, Inc -- Kāneʻohe

https://poailani.org/

The Salvation Army Addiction Treatment
Services

https://hawaii.salvationarmy.org/hawaii/ats

The Salvation Army Family Treatment
Services

https://hawaii.salvationarmy.org/hawaii/fts

KAUAʻI
Health Centers
Ho‘ōla Lāhui Hawai‘i

http://www.hoolalahui.org/

Medical/Surgical/Critical Care/Obstetric
Wilcox Memorial Hospital

https://www.hawaiipaciﬁchealth.org/wilcox/

Medical/Surgical/Acute Care/Skilled Nursing Facility (SNF)
Samuel Mahelona Memorial Hospital

http://smmh.hhsc.org/

Medical/Surgical/Critical Care/Skilled Nursing Facility (SNF), and Intermediate Care Facilities for Individuals withIntellectual Disabilities (ICF)
West Kauaʻi Medical Center (KVMH)

http://kvmh.hhsc.org/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
Garden Isle Rehabilitation & Healthcare
Centerhttp://www.ohanapaciﬁc.com/locations/kauai/lihue/garden-isle-rehabilitati
on-healthcare-center/

Hale Kūpuna Heritage Home

http://www.ohanapaciﬁc.com/locations/kauai/koloa/hale-kupuna-heritagehome/

Kauaʻi Care Center

http://www.regency-paciﬁc.com/senior-living/hi/waimea/kauai-care-center/

VA Facilities

199

VA Kauaʻi Community Based Outpatient
Clinichttps://www.hawaii.va.gov/locations/

PsychiatricSamuel Mahelona Memorial Hospital

http://smmh.hhsc.org/

West Kauaʻi Medical Center (KVMH)

http://kvmh.hhsc.org/

End Stage Renal Disease Programs
Liberty Dialysis – Hawaii LLC – Kauaʻi
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/lihue/3224-e
lua-st-96766/7386

Liberty Dialysis – Hawaii LLC – West Kauaʻi
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centersHome Health Care
Haumea Home Health Agency, LLC‘Ohana Home Health, LLC

http://ohanahomehealthllc.com/

Stay At Home Healthcare Services

http://www.ohanapaciﬁc.com/locations/kauai/lihue/stay-at-home-healthca
re-services/

HospiceKauaʻi Hospice

http://kauaihospice.org/

200

APPENDIX C – STEERING COMMITTEE
Name

Aﬃliation

Bob AgresCounty of Hawaiʻi

Punahele Alcon

Molokai General Hospital

Joy Barua

Kaiser Permanente

Janet Berreman

Kauaʻi District Health Oﬃce

Andrew Garrett

Healthcare Association of Hawaiʻi

Carol Ignacio

Blue Zones Project

Karey Kapoi

HMSA

Lorraine Lunow-Luke

Hawaiʻi Paciﬁc Health

Jon Matsuoka

Pili Group Consulting

May Okihiro

John A. Burns School of Medicine

Judy Mohr Peterson

State of Hawaiʻi Department of Human Services

Mike Robinson

Hawaiʻi Paciﬁc HealthTracie Ann Tjapkes

Adventist Health Castle

JoAnn TsarkOﬃce of Public Health Studies, University of
Hawaiʻi

Sharlene Tsuda

Queen’s Medical Center

Chris Van Bergeijk

Hawaiʻi Community Foundation

201

APPENDIX D – COMMUNITY MEETINGS
Host

Location/Date

Description

Pastor Sage Chee

Hauʻula, Oʻahu
July 12, 2018

Provider working with youth and groups in Hauʻula

Hoʻōla Lāhui

Kōkeʻe, Kauaʻi
July 28, 2018

Women and families interested in Hawaiian healing

Bobby Benson Center

Kahuku, Oʻahu
July 31, 2018

Girls and boys in residential treatment for substanceabuse

West Hawaiʻi Community HealthCenterKealakehe, Hawaiʻi
August 7, 2018

Patients of WHCHC and residents of West Hawaiʻi

North Kohala Community Resource
CenterHāwī, Hawaiʻi
August 17, 2018

Residents of North Kohala

Ka Honua Momona

Kaunakakai, MolokaʻiAugust 18, 2018

Women from Molokaʻi and across the paeʻāina

Healthy Mothers, Healthy Babies

Honolulu, Oʻahu
August 20, 2018

Support group for expecting and new parents

Maui Food Bank

Kahului, Maui
August 21, 2018

Clients and partners of Maui Food Bank

Nā Hoaloha ʻEkolu

Lahaina, Maui
August 21, 2018

Employees of Nā Hoaloha ʻEkolu companies

Catholic Charities

Waiʻanae, Oʻahu
August 28, 2018

Residents of transitional housing

Bodacious Women of Pāhoa

Pāhoa, Hawaiʻi
August 30, 2018

Volunteers who help with food distribution andemergency preparedness

HOPE Services

Hilo, Hawaiʻi
August 30, 2018

Clients living in shelters and receiving treatment

ALEA Bridge

Wahiawā, Oʻahu
September 6, 2018

Wahiawā health workers, nonproﬁt employees andclients, and area politicians

Boys and Girls Club Kauaʻi

Līhue, Kauaʻi
September 7, 2018

Teen participants

Bay Clinic

Pāhala, Hawaiʻi
September 10, 2018

Ka‘ū residents and service providers who are in Bay
Clinic’s network

Lānaʻi Senior Center

Lānaʻi City, Lānaʻi
September 11, 2018

Seniors who gather every weekday for lunch andfriendshipSurﬁng the Nations

Wahiawā, Oʻahu
September 19, 2018

After school program for children and teens

Maui Economic Opportunity

Wailuku, Maui
September 21, 2018

Presidents of the various senior clubs throughout
Maui County

Tūtū’s House

Kamuela, Hawaiʻi
September 29, 2018

Residents of the Waimea/North Hawaiʻi region

Kōkua Kalihi Valley Gulick Elder Center

Kalihi, Oʻahu
October 19, 2018

Elder participants

Liliʻuokalani Trust

Kaunakakai, Molokaʻi
November 7, 2018

Teens in an afterschool program202

APPENDIX E – KEY INFORMANTS
HAWAIʻI ISLAND
Name

Aﬃliation

Elena Cabatu

Hilo Medical Center

Tina Clothier

PATH (Peoples Advocacy for Trails Hawaiʻi)

Angela Dean

La Comunidad Latina de HawaiʻiVicky Hanes

West Hawaiʻi Community Health Center

Cyd Hoﬀeld

Bay Clinic

Liana Honda

North Hawaiʻi Community Hospital

Carol Ignacio

Blue Zones Project

Cindy Kamikawa & admin teamNorth Hawaiʻi Community HospitalKaʻi Kiefer

West Hawaiʻi Community Health Center

Wally Lau

Former Hawaiʻi County Managing Director

Viviana Martinez

Konawaena High School

Michelle Medeiros

Tūtū’s House

Brandee Menino

HOPE Services

Heather Miner

West Hawaiʻi Community Health Center

Misty Pacheco

UH Hilo

Christine Richardson

North Kohala Community Resource Center

Lia Rozmiarek-Held

Teach for America

Mike Sayama

Community First

Jasmine Staup

West Hawaiʻi Public Health Nursing

Richard TaaﬀeWest Hawaiʻi Community Health Center

Roseanne Uno

Waipahu Community School for Adults

Franz Weber

Community Volunteer

MAUI
Name

Aﬃliation

Nicole Apoliona

Kula Hospital and Clinic

Perry Artates

Waiohuli Hawaiian Homesteaders Association

Curtis Bekkum

Family Medicine

Stephen Bennett

Boys & Girls Clubs of Maui

Kevin Block

Attorney

Debbie Cabebe

Maui Economic Opportunity

Victor Comaianni

Kaiser Permanente

Joey Gonsalves

Hui No Ke Ola Pono

Lehua Huddleston-Hafoka

Kīhei Youth Center

Karey Kapoi

HMSA

203

Judy Kodama

Maui Memorial

Pomai Konohia

Hui No Ke Ola Pono

Wesley Lo

Hale Makua

Joylynn Paman

Maui Fishpond Association

Lorrin Pang

Maui District Health Oﬃce

Rick Paul

Hāna High School

Stacey Prusky

Makana ʻO Ka La

Rochelle Sommerville

HMSA

Kirsten Szabo

Hale Makua

Jayme Tamaki

Maui Public Health Nursing

Heidi Taogoshi

Maui Public Health Nursing

MOLOKAʻI
Name

Aﬃliation

Billy Akutagawa

Rural Health

Punahele Alcon

Molokai General Hospital

Emmett Aluli

Community physician

Kamahana Farrar

Na Puʻuwai

Barbara Haliniak

Molokaʻi Health Foundation

Kekama Helm

Liliʻuokalani Trust

Glenn Izawa

Molokaʻi Health Foundation

Janice Kalanihuia

Molokai General Hospital

Noelani Lee

Ka Honua Momona

Louise Linker

Public Health Nurse

Margaret Makekau

Public Health Nurse

Judy Mikami

Rural HealthJamie RonzelloSustʻāīnable MolokaʻiHarmonee Williams

Sustʻāīnable MolokaʻiLĀNAʻI
Name

Aﬃliation

Melissa Champlin

Lānaʻi Hospice

Maggie Daub

Lānaʻi Community Hospital

Butch Gima

State of Hawaiʻi Department of Health

Kelly Gima

State of Hawaiʻi Department of Human Services

Val Janikowski

Nurse

Robin Kaye

Community organizer

Sally Kaye

Community organizer

Tina Kikuyama

Pharmacy

Jon Matsuoka

Pili Group Consulting

Linda Mau

Public Health Nurse

204

Albert Morita

Former Hawaiʻi Department of Land and Natural Resources

Diane Preza

Pulama LānaʻiAnnabel Raqueno

Nurse

Greg Sanders

Lānaʻi High and Elementary School

John Schaumburg

Lānaʻi Community Hospital

En Young

Sensei Farms

OʻAHU
Name

Aﬃliation

Phil Acosta

ALEA Bridge

Cindy Adams

Aloha United Way

Bob AgresCounty of Hawaiʻi

Joy Barua

Kaiser Permanente Hawaiʻi

Laura BonillaKapiʻolani Medical Center

Lee Buenconsejo-Lum

John A. Burns School of Medicine

Barbie-Lei Burgess

Waiʻanae Neighborhood Place

Sadrian Chee

‘Ohana Family of the Living God Church

Lowell Chun Hoon

Attorney

Makena Coﬀman

Institute for Sustainability and Resilience

Barbara Craft

Kapiʻolani Medical Center

Brian Cunningham & admin team

Wahiawā General Hospital

Jim Dannemiller

SMS Research

David Derauf

Kōkua Kalihi Valley

Ritabelle Fernandes

Geriatrics

Chip Fletcher

UH School of Ocean and Earth Science and Technology

Jerome Flores

Kahuku Medical Center

Kealoha Fox

Oﬃce of Hawaiian Aﬀairs

Dan FujiiWaiʻanae Coast Comprehensive Health Center

Beth Giesting

Hawaiʻi Appleseed Budget & Policy Center

Art Gladstone & Admin Team

Straub Medical Center

Aimee Grace

University of Hawaiʻi System

Cullen Hayashida

Senior issues

Hawaiʻi Medical Education Council

John A. Burns School of Medicine

Lynnette P. Higa

Central Oʻahu Public Health Nursing Section

Robert Hirokawa

Hawaiʻi Primary Care Association

Natividad HopewellKoʻolauloa Community Health CenterBill Hoshijo

Civil Rights Commission

JABSOM Family Medicine group

John A. Burns School of Medicine

JABSOM Ob/Gyn Residents/Fellows

JABSOM/Kapiʻolani Medical Center

JABSOM Pediatric Residents

JABSOM/Kapiʻolani Medical Center205Merlene Jose

Shriners Hospitals for Children

Kent Kaʻahanui

Ke Ola Mamo

Keawe Kaholokula

JABSOM Native Hawaiian Health

Katherine Keir

United Healthcare

Gail Kim

Public Health Nursing

Kanilehua Kim

Queen’s Medical Center

Lisa Kimura

Healthy Mothers Healthy Babies

Nagisa Kimura

East Honolulu Public Health Nursing Oﬃce

Gregg Kishaba

State of Hawaiʻi Department of Health

Keri Kobayashi

Windward Oʻahu Public Health Nursing Section

Jeannette Koijane

Kōkua Mau

Cheryl Kozai

Pali Momi Medical Center

Andi Kubota

Shriners Hospitals for Children

Douglas Kwock

Pali Momi Medical Center

Ryan Lee

Milestones Hawaiʻi

Steph Lee

University Health Partners/Planned Parenthood

Christy MacPherson

FACE (Faith Action for Community Equity) Hawaiʻi

Kyle Maschoﬀ

Rehab Hospital of the Paciﬁc

Kathleen Mau

Kaiser Moanalua

Blake McElhenyNorth Shore

Brigitte McKale

Pali Momi Medical Center

Alan McPhee

Kahuku Medical Center

Maile Meyer

Na Mea Hawaiʻi

Tai-an Miao

UH Department of Urban and Regional Planning

Judy Mohr Peterson

State of Hawaiʻi Department of Human Services

Lauren Nahme

Kamehameha Schools

Ken Nakamura

Kapiʻolani Medical Center

Quin Ogawa

Kāhi MōhalaMay Okihiro

JABSOM/Waiʻanae Coast Comprehensive Health Center

Lisa Oliveira-Tua

Kaiser Moanalua

Mary Oneha

Waimānalo Health Center

Deja Ostrowski

Medical Legal Partnership for Children

Karlee Palms

Kapiʻolani Medical Center

Adriana Ramelli

The Sex Abuse Treatment Center

Faith RexSMS Research

Mike Robinson

Hawaiʻi Paciﬁc Health

Gidget Ruscetta

Pali Momi Medical Center

Jodie SanadaWest Honolulu Public Health Nursing

Keith Sanderson

Shriners Hospitals for Children

Dina Shek

Medical Legal Partnership for Children

206

Debbie Shimizu

Executive Oﬃce on Aging

Martha Smith

Kapiʻolani Medical Center

Joan Takamori

Public Health Nursing

Karen Tan

Child & Family Services

Gavin Thornton

Hawaiʻi Appleseed

Tracie-Ann Tjapkes & admin teamAdventist Health Castle

Wennie Tomita

Kuakini Health System

JoAnn TsarkUH Oﬃce of Public Health Studies

Sharlene Tsuda

Queen’s Medical Center

Chris Van Bergeijk

Hawaiʻi Community Foundation

KAUAʻI
Name

Aﬃliation

Fran Becker

Na Lei Wili AHEC

Janet Berreman

Kauaʻi District Health Oﬃce

Nalani BrunCounty of Kauaʻi

Jen Chahanovich

Wilcox Medical Center

Mason Chock

Kauaʻi County Council

Kapono Chong Hanssen

Hoʻōla Lāhui

Sean Chun

Ho‘ōla Lāhui

Megan Fox

Mālama Kauaʻi

Chia Granda

Kapaʻa Pediatrics

Lori Miller

Kauaʻi Hospice

Chris Molina

Liliʻuokalani TrustBuﬀy Oﬁsa

Kamehameha Schools

Marion Paul

Kauaʻi Planning & Action Alliance

Stacy Sproat

Waipā Foundation

207

APPENDIX F – INTERVIEWS, 2013 & 2015 CHNAs
HAWAIʻI
Name

Aﬃliation

Donna AltshulWest Hawaiʻi Community Health Center

Deborah Baker

Kona-Kohala Chamber of Commerce

Katherine Ciano

North Hawaiʻi Hospice

Mary Correa

State of Hawaiʻi DOE Kaʻū, Keaʻau, Pāhoa Complex Area

Scott Daniels

State of Hawaiʻi Department of Health, Oﬃce of Rural Health

Dan Domizio

Puna Community Medical Center

Elizabeth Dykstra

County of Hawai’i

Louise Fincher

Hilo Medical Center

Josh GreenState Senate

Michelle Hiraishi

Hui Mālama Ola Nā ʿŌiwi Hawaiʻi

Susan Hunt

Hawaiʻi Island Beacon Community

Wally Lau

Hawaiʻi County Mayor's Oﬃce

Kaye Lundburg

Retired, Catholic Diocese, Oﬃce of Social Ministry

Jessanie MarquesKaʻū Community Rural Health Association

Pam McKenna

Hāmākua Health Center

Cathy Meyer-Uyehara

Hale Hoʻola Hāmākua

Karen Pellegrin

UH-Hilo, Daniel K. Inouye College of Pharmacy

John Saplan

State of Hawaiʻi DOE Kaʻū, Keaʻau, Pāhoa Complex Area

Robert Surber

Community Advocate

Nick Szubiak

West Hawaiʻi Community Health Center

Richard Taafe

West Hawaiʻi Community Health Center

Aaron Ueno

Hawaiʻi District Health Oﬃce

Sharon Vitousek

North Hawaiʻi Health Outcomes Project

MAUI
Name

Aﬃliation

Dana Alonzo-Howeth

Mālama I Ke Ola Health Center

Alan Arakawa

Mayor, County of Maui

Roz Baker

State Senate

Jud Cunningham

Aloha House

Donna Haytko

University of Hawaiʻi, Molokaʻi Education Center

Tony Krieg

Hale Makua

Wesley Lo

Hawaiʻi Health Systems Corporation

Lyn McNeﬀ

Maui Economic Opportunity

Lorrin Pang

Maui District Health Oﬃce

208

Lisa Ponichtera

Mālama Family Recovery Center

Diana Shaw

Maui Community Health Center

Alvin Shima

Complex Area Superintendent

Napua Spock

Hawaiʻi Primary Care Association

Deborah Stone-Walls

Maui County Oﬃce on Aging

Cheryl Vasconcellos

Hāna Health Center

MOLOKAʻI
Name

Aﬃliation

Emmett Aluli

Molokaʻi Family Health Center

Desiree Puhi

Molokaʻi Community Health Center

Lynette Schaefer

Maui Police Department, Moloka‘i Hospice

Tracy Stephenson

Molokaʻi Community Health CenterLĀNAʻI
Name

Aﬃliation

Kimberly Miyazawa-Frank

Pūlama Lānaʻi

Shirley Samonte

Straub Lānaʻi Family Health Center

Carole Starbird

Lānaʻi Community Hospital

OʻAHU
Name

Aﬃliation

Norm Baker

Aloha United Way

Sheila Beckham

Waikīkī HealthMike Broderick

YMCA of Honolulu

Jennifer Dang

State of Hawaiʻi Department of Education

David Derauf

Kōkua Kalihi Valley

Lynn Fallin

State of Hawaiʻi DOH, Behavioral Health Services

Kenny Fink

State of Hawaiʻi Department of Human Services

Loretta Fuddy

State of Hawaiʻi Department of Health

Dan FujiiWaiʻanae Comprehensive Community Health Center

Marc Gannon

Aloha United Way

Beth Giesting

Healthcare Transformation Coordinator, Governor’s Oﬃce

Marya Grambs

Mental Health America Hawaiʻi

Jan Harada

Helping Hands Hawaiʻi

Robert Hirokawa

Hawaiʻi Primary Care Association

Jim Ireland

City and County of Honolulu

Lola Irvin

State of Hawaiʻi Department of HealthBliss Kaneshiro

State Medical Director of Family Planning

Poka Laenui

Hale Naʻau Pono

Leslie Lam

American Diabetes Association

209

Bernie Ledesma

Nursing home administrator

Andy Lee

City and County of Honolulu

Leonard Licina

Kāhi Mōhala

Wes Lum

Executive Oﬃce on Aging

Deejay Mailer

Kamehameha Schools

Kathryn Matayoshi

Hawaiʻi Superintendent of Education

Connie Mitchell

Institute for Human Services

Ken Nakamura

John A. Burns School of Medicine

Deedee Nelson

Mountain Paciﬁc Quality HealthGary Okamoto

AlohaCareMay Okihiro

JABSOM/Waiʻanae Coast Comprehensive Health Center

Mary Oneha

Waimānalo Health CenterBill Osheroﬀ

Chief Medical Oﬃcer, HMSA

Neal Palafox

John A. Burns School of Medicine

Sarah Park

State of Hawaiʻi DOH, Disease Outbreak Control Division

Leolinda Parlin

Hilopaʻa Family to Family Health Information Center

Hilton Raethel

HMSA

Linda Rosen

Hawaiʻi Department of HealthMark Rigg

City and County of Honolulu, EMS Department

David Sakamoto

Hawaiʻi Department of Health

Emilie Smith

CareResource Hawaiʻi

Hardy Spoehr

Papa Ola Lōkahi

Corinne Suzuka

St. Francis Home Care Services

JoAnn Tsark‘Imi Hale, Native Hawaiian Cancer Network

Lori TsuhakoHomeless Programs Oﬃce

Stella Wong

Catholic Charities

Mark Yamakawa

Hawaiʻi Dental Services

Jackie Young

American Cancer Society

Ken ZeriHospice Hawaiʻi

KAUAʻI
Name

Aﬃliation

Kurt Akamine‘Ohana Paciﬁc Management Company

Dileep Bal

Kauaʻi District Health Oﬃce

Maile Ballesteros

St. Francis Home Healthcare

Laverne Bishop

Hale ‘Ōpio Kaua‘i, Inc.

Bev Brody

Get Fit Kauaʻi

Kathy Clark

Wilcox Memorial Hospital

Helen Cox

Kauaʻi Community College

Paul Esaki

Family Medicine

Harold Goldberg

Hawaiʻi Department of Health, Mental Health Division

210

Renae Hamilton

Kauaʻi YWCA

John Hunt

Department of Health

DQ Jackson

Mālama Pono

Scott McFarland

Hawaiʻi Health Systems Corporation

Gerald McKenna

McKenna Recovery Center

Lori Miller

Kauaʻi Hospice

Thomas Noyes

State of Hawaiʻi DOH, Kauaʻi District Health Oﬃce

David Peters

Hoʻōla Lāhui

Naomi Sugihara

Sugihara Planning and Consulting

Beth Tokioka

Kauaʻi Mayor's Oﬃce

Toni Torres

District Health Nurse

Geri Young

Kauaʻi Medical Clinic

211

APPENDIX G – RESOURCES UTILIZEDHEALTH REPORTS
Aloha United Way. “ALICE: A Study of Financial Hardship in Hawai‘i.” 2017.
https://www.auw.org/sites/default/ﬁles/pictures/AlohaUnitedWayALICE%20Report_HIFINAL.pdf
Association for Community Health Improvement. “Community Health Assessment Toolkit.” 2017.
http://www.healthycommunities.org/Resources/toolkit.shtml#.W_zfSSdRegQ
Bay Area Regional Health Inequities Initiative. “A Public Health Framework for Reducing Health Inequities.”
http://barhii.org/framework/
Beatty, Abigail, Dionne Foster. “The Determinants of Equity: Identifying Indicators to Establish a Baseline of Equity
in King County.” King County Oﬃce of Performance, Strategy and Budget, January 2015.
https://kingcounty.gov/~/media/elected/executive/equity-social-justice/2015/The_Determinants_of_Equity_Report
Beeson, Tishra et al. “Making the Case for Medical Legal Partnerships: A Review of the Evidence.” National Center
for Medical-Legal Partnership, School of Public Health and Health Services, George Washington University. 1 Feb.
2013.
https://medical-legalpartnership.org/wp-content/uploads/2014/03/Medical-Legal-Partnership-Literature-Review-F
ebruary-2013.pdf
Catholic Health Association of the United States. “Assessing & Addressing Community Health Needs: A Summary of
New Requirements & Recommended Practices.” January 2015.
https://www.chausa.org/communitybeneﬁt/assessing-and-addressing-community-health-needs
Centers for Disease Control and Prevention. “Social Determinants of Health: Know What Aﬀects Health.” 20 March2018. https://www.cdc.gov/socialdeterminants/
Children’s Hospital Association. “Screening for Social Determinants of Health; Children’s Hospitals Respond.” 30
March 2018.
https://www.childrenshospitals.org/Issues-and-Advocacy/Population-Health/Reports/Screening-for-Social-Determi
nants-of-Health
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