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NATIVE HAWAIIAN HEALTH TASK FORCE: 2017 PRELIMINARY REPORT AND RECOMMENDATIONS

Authors:

Abstract

This is a report from the Native Hawaiian Health Task Force to the 29th Legislature State of Hawai'i pursuant to Senate Resolution 60, SD1 (2014) requesting the University of Hawai'i, John A. Burns School of Medicine to establish a Native Hawaiian Health Task Force. The report outlines the task force membership, the social and cultural determinants of health frameworks and methodology employed, and 16 specific policy recommendations.
REPORT TO THE TWENTY-NINTH LEGISLATURE
STATE OF HAWAII
2017
PURSUANT TO SENATE RESOLUTION 60, SD1 (2014):
REQUESTING THE UNIVERSITY OF HAWAII JOHN A. BURNS SCHOOL OF MEDICINE TO ESTABLISH
A NATIVE HAWAIIAN HEALTH TASK FORCE
2017 PRELIMINARY REPORT AND RECOMMENDATIONS
PREPARED BY:
HAWAII PUBLIC HEALTH INSTITUTE
UNIVERSITY OF HAWAII DEPARTMENT OF NATIVE HAWAIIAN HEALTH
DECEMBER 2016
2
Table of Contents
Native Hawaiian Health Task Force Participants ……………………………………………………………..…………3
Acknowledgements …………………………………………………………………………………………………………………..5
Executive Summary …………………………………………………………………………………………………………………..6
Background.………………………………………………………………………………………………………………….…………11
Policy Recommendations…………….……………………...……………………………………..…………………..….....16
Continued Commitment…………………………………………………………………………………………………………..36
References ……………………………………………………………………………………………………………………………...37
Appendix A: Senate Resolution 60 S.D.1….………………………………………………………………………….……45
Appendix B: Senate Concurrent Resolution (Draft)…………………………………………………………………..48
3
Native Hawaiian Health Task Force Participants
Native Hawaiian Task Force Co-Chairs:
Joseph Keawe‘aimoku Kaholokula, PhD
Department of Native Hawaiian Health,
John A. Burns School of Medicine,
University of Hawai‘i at Mānoa
Kamana‘opono M. Crabbe, PhD
Office of Hawaiian Affairs
Lola Irvin and Lorrin Kim
Hawaii State Department of Health
(on behalf of the Director of Health)
Native Hawaiian Task Force members:
Noa Emmett Aluli, MD
Moloka‘i General Hospital and ‘Ahahui o
Kauka
Puni Kekauoha
Kula No Nā Po‘e Hawai‘i
Kamaki Kanahele
Sovereign Council
Nalani Benioni
Sovereign Council
Keola Chan and Miala Leong
‘Aha Kāne Native Hawaiian Men’s Health
Diane Paloma, PhD, MBA
Native Hawaiian Health Program, Queen’s
Health System
Dane Keohelani Silva
Traditional healer and community leader
Nālei Akina
Queen Lili‘uokalani Children’s Center
Sharlene Chun-Lum
Community Member
Claire Hughes, DrPH
Association of Hawaiian Civic Clubs
Joelene Lono
Ke Ola Mamo Native Hawaiian Health Care
System, O‘ahu
Michelle Hiraishi
Hui Mālama Ola Nā Oiwi Native Hawaiian
Health Care System, Hawai‘i Island
Kamahanahokulani Farrar
Nā Pu‘uwai Native Hawaiian Health Care
System, Moloka‘i
Sheri Ann Daniels, EdD
Papa Ola Lōkahi
Kūhiō Asam, MD
Lunalilo Home
Mary Oneha, APRN, PhD
Waimānalo Health Center
4
Sean Chun
Ho‘ola Lāhui Native Hawaiian Health Care
System, Kaua‘i
Joey Gonsalves
Hui No Ke Ola Pono Native Hawaiian Health
Care System, Maui
Shawn Kana‘iaupuni, PhD
Kamehameha Schools
Neil Hannahs
Ho‘okele Strategies and MA‘O Farms
Keopu Reelitz and Malia Taum-Deenik
Department of Human Services
(on behalf of the Director of DHS)
Mervina Cash-Kaeo
Alu Like. Inc
Maenette Benham, EdD
Dean, Hawaiinuiākea School of Hawaiian
Knowledge, UH Mānoa
Mahina Paishon-Duarte
Kanu o Ka ‘Āina New Century Charter School
Native Hawaiian Task Force Staff Members:
From the Office of Hawaiian Affairs:
Kealoha Fox, MA
Deja Ostrowski, JD
From the Department of Native Hawaiian
Health:
Andrea Hermosura, PhD
Tiffnie Kakalia
Mele Look, MBA
Robin Miyamoto, PsyD
Regina Cummings, MBA
Rebecca Delafield, MPH
The task force recognizes the assistance of the Hawai‘i Public Health Institute and their
personnel:
Jessica Yamauchi, MA
Roella Foronda, MPH
Trish La Chica, MPA
Ruth Leau, MPH
Jaylen Murakami
Maggie Kwock
5
Acknowledgements
During the 2014 Legislative Session, the Senate passed SR60, S.D.1: REQUESTING THE
UNIVERSITY OF HAWAII JOHN A. BURNS SCHOOL OF MEDICINE TO ESTABLISH A NATIVE
HAWAIIAN HEALTH TASK FORCE. In furtherance of this resolution, this task force was
established.
The task force would like to express its gratitude to the late Senator Gil Kahele, who introduced
and championed the resolution establishing this task force.
The task force would also like to recognize Loretta “Deliana” Fuddy, a founding member of the
task force as the Director of Health, who tragically lost her life before the resolution was
passed.
This task force was supported, in part, with funding from the Office of Hawaiian Affairs, Kaiser
Permanente, and other resources from the Department of Native Hawaiian Health of the John
A. Burns School of Medicine and the Hawai‘i State Department of Health.
6
Executive Summary
On September 23, 2013, the Senate of the Twenty-Seventh Legislature of the State of Hawai‘i,
Regular Session of 2014, passed Senate Resolution No. 60, S.D.1, creating a Native Hawaiian
Health Task Force, to specifically improve the health of Native Hawaiians with implications for
other Pacific Islanders and all people of Hawai‘i.
Per Senate Resolution No. 60 S.D.1, the task force will focus on the following work:
1) Create data sharing policies between state agencies to improve access to these data for
timely and disaggregated analyses to help inform policies and programs aimed at
improving Native Hawaiian health;
2) Propose cost-effective improvements to the environments where Native Hawaiians live,
learn, work, and play;
3) Propose state legislation to address social and cultural determinants of health in
Hawai‘i;
4) Raise awareness and propose programs to advance health equity;
5) Propose programs and legislative action that will address barriers to access to health
care;
6) Guide the use of existing collaborations, systems, and partnerships to leverage
resources and maximize outcomes;
7) Propose activities that will support community organizations promoting their own
health on their own terms; and
8) Propose initiatives that will increase preventive services available in Native Hawaiian
communities
The resolution called for this task force to be co-chaired by the Chair for the Department of
Native Hawaiian Health of the John A. Burns School of Medicine, the Director of Health, and the
Chief Executive Officer of the Office of Hawaiian Affairs (or their designees). It also called for an
additional 20 members from the Native Hawaiian community to serve on this task force. A copy
of SR No. 60 S.D.1 can be found in Appendix A.
Task Force Objective
The goal of the task force is to articulate priority areas that will help to advance health equity
for Native Hawaiians, and in turn, the health of Hawai‘i’s entire population. The framework and
recommendations discussed should be embraced by community members, agencies,
government, and individuals in addition to those who view themselves as native-serving
institutions. This work is community- and land-focused and emphasizes Native Hawaiian values
and aspirations.
7
Recognition of Past Efforts
The task force does not represent a culmination, duplication, or specific furtherance of a
particular project but seeks to compile and recognize past and current efforts being advanced
by many task force members to improve Native Hawaiian health:
E Ola Mau
1985 Native Hawaiian Health Needs Study Group highlighted health disparities
experienced by Native Hawaiians
Provided evidence needed to support Federal legislative efforts that led to the
enactment of the Native Hawaiian Health Care Act of 1988
Currently, the E Ola Mau reports are being updated to support the
reauthorization of the Act in 2018
Native Hawaiian Health Care Act
Meant to close the gap of chronic disease incidence and prevalence between
Native Hawaiians and other ethnic groups
Required U.S. Department of Health and Human Services to fund community-
based and culturally-meaningful health promotion initiatives and health care
workforce development
Established Papa Ola Lōkahi and Native Hawaiian Health Care Systems on each of
the five major islands
Assessment and Priorities Report by JABSOM
Released report, Assessment and Priorities for Health & Well-being in Native
Hawaiians and Other Pacific Peoples, which documented current health
disparities and their trends, experienced by Native Hawaiians and other Pacific
Islanders
Impetus for Senate Resolution No. 60 S.D. 1 calling for the Native Hawaiian
Health Task Force
Act 155 (2014)
Provided support for state agencies seeking to include social determinants of
health in policy planning
Papa Ola Lōkahi Master Planning
Plan outlines an agenda which recognizes and addresses social determinants of
health such as access to education, safe environments, employment, and
culturally relevant practices
8
Social & Cultural Determinants of Health for Native Hawaiians
Mohala i ka wai, ka maka o ka pua.
Flowers thrive where there is water, as thriving people are found where living conditions are
good.
-‘Ōlelo No‘eau
Ancient Hawaiians understood the role political, social, environmental, and cultural factors
played in a person’s health and wellbeing. This understanding has been passed down to Native
Hawaiians in present day and is figuratively illustrated in the above ‘Ōlelo No‘eau (Hawaiian
proverbial saying). Conventional sciences have only recently uncovered what this ancient
derived wisdom has understood for generations--that the foundation for optimal health, the
well-being, is tied to the quality of our interpersonal relations, of the environments in which we
live, work, learn, play, age and of society’s support for one’s cultural identity and preferred
modes of living. All of these factors are linked to political decisions and derived policies.
The Native Hawaiian Health Task Force uses a social and cultural determinants of health model
to inform and situate our findings. The definitions of social and cultural determinants of health
are provided below.
What are social determinants of health?
Social determinants of health are the societal, political, and economic forces that influence the
social structure and hierarchy and the distribution of power, resources, and opportunities in
society that differentially impact the health and wellbeing of people.1 These conditions include
the presence or absence of discrimination in employment, education, housing and health care;
whether one has a livable wage or lives in a safe neighborhood.
What are cultural determinants of health?
Cultural determinants of health are the socio-cultural conditions that influence group
differences in health status. For Indigenous Peoples, the preservation of cultural traditions (e.g.,
native language, values, and practices) and sacred places, access to ancestral lands, a strong
indigenous identity, and cultural participation are important determinants of health.2 However,
these indigenous values, practices, and aspirations are often challenged by mainstream values
and aspirations. A history of physical, emotional, and cultural marginalization due to
discriminatory acts and compulsory acculturation strategies (e.g., banning of native language)
have negatively impacted the health and wellbeing of Indigenous Peoples--a phenomenon
often referred to as historical or cultural trauma.3
9
Health Equity & Disparities
E mālama i ka iki kanaka, i ka nuʻa kanaka. O kākou no kēia ho‘akua.
Take care of the insignificant and great person alike. That is the duty of those who lead.
-‘Ōlelo No‘eau
What is health equity?
Health equity refers to the attainment of the highest level of health and wellbeing for all people
in a particular society and valuing everyone equally.4 In order to achieve health equity, efforts
must be made to address avoidable inequalities and injustices.
What are health disparities?
Health disparities are differences in the incidence, prevalence, burden, and adverse outcomes
of diseases and higher mortality rates.5 Disparities simply imply differences. Some of the
differences are preventable and some are not. For example, kūpuna (older adults) may have
health disparities, such as higher rates of cancer, compared to mākua (younger adults), but
these kinds of disparities are expected due to aging. In contrast, disparities based on factors like
education level, disability status, income, or housing conditions are factors which can be
addressed. A health disparity related to a social, economic, and/or environmental disadvantage
is called a health inequity. Health disparities are most problematic for those who identify with
characteristics linked to discrimination or exclusion, such as ethnicity or race or lower
socioeconomic status.3 The Native Hawaiian Health Task Force focuses on health inequities
that are preventable and avoidable.
10
Cultural-Based Strategy
‘O ke kahua ma mua, ma hope ke kukulu.
Set the foundation first and then build the hale.
-‘Ōlelo No‘eau
The Native Hawaiian Health Task Force uses Nā Pou Kihi as the cultural framework to organize
and situate the findings and recommendations of this task force.6 Consistent with the hale
(home) as a metaphor for establishing a healthy and vibrant Native Hawaiian population,
Pou Kihi reflects the four corner posts of a hale necessary to support the weight of the hale and
everyone who resides under its roof.
Thus, Nā Pou Kihi are the four important domains of Native Hawaiian health and wellbeing that
need to be addressed, and they are consistent with the social and cultural determinants of
health model used by this task force.
These four Nā Pou Kihi are:
1. Ke Ao ʻŌiwi our Native Hawaiian social and cultural space associated with our health
and wellbeing.
2. Ka Mālama Nohona the quality of the environments where Native Hawaiians live,
work, learn, play, and age that affect our health and wellbeing.
3. Ka Hana Pono our lifestyle choices and aspirations as Native Hawaiians in striving for
optimal health and wellbeing.
4. Ka Wai Ola achieving social justice through educational achievement and economic
success for Native Hawaiians.
11
Background
Nā Pou Kihi ‘Ekahi
Ke Ao ʻŌiwi focuses on our Native Hawaiian cultural space, which includes our cultural values,
practices, customs and rights as Indigenous Peoples that define us as the host and indigenous
population here in Hawai‘i. It also refers to our ability to exercise our indigenous prerogatives
and aspirations and express our cultural identity, without discrimination or prejudice, within
the larger society of Hawai‘i. Ke Ao ʻŌiwi is what makes Hawai‘i special and provides the values
that bind the people of Hawai‘i to each other.
Native Hawaiian cultural revival, spurred during the Hawaiian Renaissance of the 1970s, is on a
strong forward momentum toward further revitalization and integration into Hawai‘i’s
multiethnic society. A vast majority of Native Hawaiians (80%) believe it is important to practice
and access our culture on a daily basis and for our keiki (children) to learn the Hawaiian
language as means of developing cultural pride and a positive self-image.7 Scientific studies find
that when Native Hawaiian identity and aspirations are threatened, there is a risk for negative
health outcomes. For example, ethnic discrimination and cultural discord experienced by Native
Hawaiians are associated with increased risk for psychological distress,8 suicidal behaviors,9
substance use,10 hypertension,11 diabetes,12 and heart disease.13 A vast majority ( 97%) of
Native Hawaiians strongly identify with, and have an affinity towards, their Native Hawaiian
ancestry, despite their diverse ethnic ancestry.14 However, 50% of them report experiencing
discrimination from ‘most of the time’ to ‘often’ while the remaining 50% report experiencing
discrimination ‘sometimes’.13
Cultural revitalization and safety to support a strong positive Native Hawaiian identity and a
supportive environment can help to mend the cross-generational transmission of cultural
trauma and lessen the psychosocial and sociocultural stressors associated with chronic mental
and physical diseases.
Committee members
Noa Emmett Aluli, Co-Chair
Puni Kekauoha, Co-Chair
Tiffnie Kakalia, Facilitator
Kealoha Fox
Kamaki Kanahele
Nalani Benioni
Keola Chan/Miala Leong
Dane Silva
Diane Paloma
12
Nā Pou Kihi ‘Elua
Ka Mālama Nohona focuses on the environments where Native Hawaiians live, work, learn,
play, and age. Native Hawaiian values and practices are rooted in the relationships between
and amongst people (kānaka), our physical places (ʻāina), and spirituality (ho‘omana). They are
exemplified through our traditional values and practices that strive for aloha (compassion and
kindness), lōkahi (harmony), and mālama ʻāina (caring for our land and natural resources).
Native Hawaiians believe that personal health and wellbeing are intimately and reciprocally
linked to the health and wellbeing of ʻohana (family, friends, and community) and ʻāina. Ka
Mālama Nohona (caring for the people around us and the places we share) is essential to
promoting the health and wellbeing of all people in Hawai‘i.
Native Hawaiians are more likely than other ethnic groups of Hawai‘i to live in obesogenic
environments; that is, environments that promote obesity and make achieving and maintaining
a healthy weight challenging within the home or workplace.15 Diabetes is also becoming
prevalent among Native Hawaiians, leading to a greater risk for cardiovascular disease.16,17
Communities with less access to, or availability of, healthy eating and physical activity options
are associated with higher rates of obesity and diabetes for Native Hawaiians, and communities
with a larger Native Hawaiian population are more likely to have inadequate access to these
resources.18,19
Research findings have identified the beneficial effects of healthy communities on the social,
physical, and emotional health of individuals.20 For example, people who live in communities
with access to healthier food options and less fast food establishments; easy and affordable
access to recreational facilities; walking, biking, and hiking trails; safe and low density
neighborhoods; opportunities for social networking; and active community members and
strong local leadership are more likely to have residents who are not plagued by violence and
crime in their neighborhoods or by chronic diseases, such as obesity, diabetes, and stress-
related emotional problems. Ensuring healthy communities, neighborhoods, and families of
Native Hawaiians will decrease the risk for chronic mental and physical diseases.
Committee members
Nalei Akina, Chair
Andrea Hermosura, Facilitator
Mele Look, Facilitator
Sharlene Chun-Lum
Claire Hughes
Joelene Lono
Michelle Hiraishi
Kamahanahokulani Farrar
13
Nā Pou Kihi ‘Ekolu
Ka Hana Pono focuses on our lifestyle choices and aspirations as Native Hawaiians in striving
for optimal health and wellbeing in ways that are consistent with our shared cultural values and
practices. It includes the types of physical activities and foods we enjoy, the health care services
we access and receive, and the health promotion opportunities available to us, which are
inclusive of our cultural values and practices. Ka Hana Pono is directly linked to the domains of
Ke Ao ʻŌiwi and Ka Mālama Nohona. Native Hawaiians can only exercise the healthy lifestyle
choices that are available to them by the larger society and the communities in which they live,
work, learn, play, and age.
Native Hawaiians are more likely to develop chronic disease and die an average of 10 years
earlier than people of other ethnic groups in Hawai‘i.21,22 Native Hawaiians have among the
highest rates of obesity, hypertension, diabetes, cardiovascular and cerebrovascular diseases,
and certain cancers.23,24 Nationally, Native Hawaiians have among the highest mortality rates.25
Studies find that many Native Hawaiians feel alienated from the health care system and have a
mistrust toward and reluctance in seeking care, preferring more culturally-acceptable means to
managing their health.26,27,28
Studies also find that culturally-tailored, community-based health promotion programs offer
the promise of reducing the prevalence and burden of chronic diseases such as obesity,
diabetes, and heart disease among Native Hawaiians.29,30,31 The support of community-based
health promotion programs and the development of health care delivery models and strategies
that are inclusive of the cultural values and practices of Native Hawaiians can reduce their
disproportionate burden of chronic diseases and improve their life expectancy.
Committee Members
Sheri Ann Daniels, Chair
Robin Miyamoto, Facilitator
Kuhio Asam
Mary Oneha
Sean Chun
Joey Gonsalves
Deja Ostrowski
Lola Irvin
14
Nā Pou Kihi ‘Ehā
Ka Wai Ola focuses on achieving social justice through educational achievement and economic
success for Native Hawaiians. Native Hawaiians have a long history of valuing learning and the
pursuit of knowledge, which are celebrated in our mo‘olelo (history) and exemplified in the
phenomenal achievements of our kūpuna (ancestors). In the 1800s, Native Hawaiians were
among the most literate in the world and circulated over 20 Hawaiian language newspapers
that fed our ancestors’ love for knowledge and information. Our Ali‘i (Royalty) were among the
most educated, often speaking several languages, and were prolific poets, composers of music
and song, and writers among all Heads-of-States of their time. Economically, our ancestors
developed a sophisticated system of resource management that ensured equable access to the
riches of the ʻāina (land), wai (fresh water), and kai (ocean) for all. All members of society had a
clear and well-defined role that contributed to the welfare of the community. Ka Wai Ola
provides the foundation for securing the educational and economic benefits needed for people
to thrive and flourish.
Numerous studies, including those done of Hawai‘i, find that a person’s income is strongly
associated with his or her longevity, and income is also strongly tied to a person’s educational
qualifications. Native Hawaiians who have lower educational attainment and income are more
likely to engage in substance use and abuse and are at greater risk for behavioral health
problems and chronic diseases. A majority of Native Hawaiians are educated by our public
school system which is under-resourced and whose curriculum is often incongruent with the
learning preferences of many Native Hawaiian students. Studies find that children of Hawai‘i’s
public schools are at greater risk for substance use and abuse and emotional problems than
those who attend private schools. Compared to students of other ethnic groups, Native
Hawaiian students are more likely to attend low-quality schools with less experienced teachers,
to be overrepresented in special education, to repeat grade levels more frequently, and to have
among the lowest graduation rates.32
Compared to the performance of Native Hawaiian students enrolled in traditional public
schools, those enrolled in culture-based Charter Schools do remarkably better in math and
reading tests, and they have better attendance and engagement in their education.33 Across
both private and public schools, teachers who employ culture-based educational strategies,
compared to those who do not, results in Native Hawaiian students with greater cultural
knowledge and values, stronger cultural identity, greater emotional and cognitive engagement
in their education, and greater sense of place and community engagement.34
15
Committee Members
Lorrin Kim, Chair
Regina Cummings, Facilitator
Shawn Kanaiaupuni
Neil Hannahs
Keopu Reelitz/Malia Taum-Deenik
Mervina Cash-Kaeo
Maenette Benham
Mahina Paishon-Duarte
Kamana‘opono Crabbe
16
Native Hawaiian Health Task Force Policy Recommendations
The Senate Resolution outlined eight areas of concentrations, which yielded 16
recommendations below:
1. Create data sharing policies between state agencies to improve access to these data for
timely and disaggregated analyses to help inform policies and programs aimed at
improving Native Hawaiian health;
Recommendation 1: Establish an online database across state agencies.
2. Propose cost-effective improvements to the environments where Native Hawaiians live,
learn, work, and play;
Recommendation 2: Advocate and plan for median strip/sidewalks and other
infrastructure to increase safety in Native Hawaiian
communities with community input.
3. Propose state legislation to address social and cultural determinants of health in
Hawai‘i;
Recommendation 3: Advocate for a livable wage by 2020.
Recommendation 4: Support paid family leave efforts with a definition of family
that is culturally relevant.
Recommendation 5: Include Pre-Kindergarten in public schools.
Recommendation 6: Establish a directory of Native Hawaiian professionals and
community leaders with an understanding of Hawaiian
culture for Governor-appointed leadership positions to better
incorporate culturally relevant perspectives into statewide
initiatives.
4. Raise awareness and propose programs to advance health equity;
Recommendation 7: Advocate for a portion of the Transient Accommodations
Tax.
Recommendation 8: Establish an environmental and cultural preservation fee
(9.25%) on restaurants and entertainment in hotels.
5. Propose programs and legislative action that will address barriers to access to health
care;
Recommendation 9: Include long-term care options with home-based care in a
statewide insurance program.
17
Recommendation 10: Develop a state-plan to incorporate the United Nations
Declaration of Rights of Indigenous Peoples.
Recommendation 11: Establish school-based health centers.
6. Guide the use of existing collaborations, systems, and partnerships to leverage
resources and maximize outcomes;
Recommendation 12: Develop an undergraduate health sciences academy within
the University of Hawai‘i system in cooperation with
relevant educational institutions to target the recruitment
and retention of Native Hawaiian students.
Recommendation 13: Increase services for Native Hawaiians who come in
contact with the criminal justice system to promote
integration back into the community to reduce recidivism
rates.
7. Propose activities that will support community organizations promoting their own
health on their own terms;
Recommendation 14: Establish a Native Hawaiian Public Policy Advisory Council.
Recommendation 15: Reimburse for culturally appropriate services and
traditional practices.
8. Propose initiatives that will increase preventive services available in Native Hawaiian
communities;
Recommendation 16: Restore adult dental benefits to Medicaid enrollees.
18
Policy Recommendations
I ulu nō ka lālā i ke kumu.
The branches grow because of the trunk.
-‘Ōlelo No‘eau
Using the Nā Pou Kihi cultural framework, the Native Hawaiian Health Task Force strives to
provide recommendations that address various social and cultural determinants of health to
improve the environments in Hawai‘i where people live, work, learn, play, and age. Some major
themes drawn from these recommendations include increasing Native Hawaiian representation
in government, deterring negative community impacts, expanding Medicaid benefits, and
improving public access to state agencies’ databases. In addition to identifying priority
recommendations regarding the eight areas indicated in the senate resolution, the task force
also came up with a listing of ideas for future consideration to further minimize health disparity
gaps and to cultivate community-centered social changes for healthy living in Hawai‘i.
Recommendation 1: Establish an online database across state agencies.
Description: Requesting for an expansion of the current State of Hawai‘i
data-sharing portal to house data from multiple state agencies that can be
accessed by state-registered organizations.
The U.S. government has its own data sharing website (data.gov) and the
White House is collaborating with local governments to make online
resources accessible at the neighborhood-level. There are currently over
192,252 datasets available on the national government website.35 If
Hawai‘i also creates a data sharing website, which includes data from
various neighborhood organizations, the local government can provide
public access to a more complete and reliable dataset.
The State of Hawai‘i launched an Open Data Portal
(dashboard.hawaii.gov) providing state data to increase government
participation and transparency. The portal is currently comprised of over
150 datasets organized into the following six categories 36:
-culture and recreation -environmental protection
-economic development -formal education
-employment -government-wide support
19
More datasets will be continually added to the portal as datasets
are being collected.36
Many companies in Hawai‘i have their own existing online databases or
methods to request data such as Renewable Energy Data for Hawaiian
Electric and UH Institutional Data governance for the UH System.37,38 Yet,
data sharing is specific to each organization and people wanting to access
data across agencies have to visit different websites. It will be more
convenient for data-researchers if the data were compiled into a
centralized online platform.
Recommendation 2: Advocate and plan for median strips/sidewalks and other infrastructure
to increase safety in Native Hawaiian communities with community input.
Description: Seeking to align resources to prioritize the implementation of safety
features such as median strips and sidewalks in communities with higher
populations of Native Hawaiians in a timely manner and including the community
in the process of advocating, planning and implementation of pedestrian safety
features.
All individuals, including Native Hawaiian individuals, should have the
right to safe communities in which to live, learn, work, play and age.
Native Hawaiian communities should be equitably included in the process
of considering concerns of physical safety, community design and the
built environment and concerns of safety related to intimidation,
violence in public areas and other types of harassment. Healthy
communities should engage and promote safe walking and other forms
of physical activity for all, and should involve members of the community,
in addition to law enforcement, local elected officials, businesses, and
others commonly considered in transportation planning processes.39
The highest automotive and pedestrian accidents and fatalities in the
state are in areas with a high concentration of Native Hawaiians, such as
Wai‘anae and Waimānalo. Five year data of EMS attended car crashes
was gathered for Oahu: Waipahu, Wai‘anae, and Makakilo/Kapolei had
the highest number of crashes with 806, 619, and 679 incidences
respectively.40 In addition, Wai‘anae is also the location of the highest
20
number of pedestrian crashes-related deaths: 11% of pedestrian-vehicle
fatalities were in Wai‘anae.40
Improper road crossing or jaywalking is the second leading factor for fatal
pedestrian crashes in Hawai‘i, and efforts towards planning more
sidewalks and crosswalks in neighborhoods with high road fatalities
should be made.41 A recent incident of a Waimānalo hit-and-run further
highlights the need for safer pedestrian sidewalks and marked
crosswalks; the crosswalk where the victim and her two children were hit
lacks [adequate]street lights and stop lights.42
Annual reports of performance standards with benchmarks reflecting
safety along roadways under the jurisdiction of the City and County of
Honolulu are requirements for compliance of the Honolulu Complete
Streets Ordinance. Problem areas and suggested solutions and
recommendations are included in their reports.43 A method of
prioritization of problem areas in Native Hawaiian communities should be
submitted for inclusion for priority planning and funding consideration in
the Transportation Improvement Program (TIP), the Oahu Regional
Transportation Plan (ORTP), and other transportation planning processes.
Similar processes should be designed in each county so that Native
Hawaiian communities ability to safely live, learn, work, play and age are
addressed statewide.
“Healthy communities that promote physical activity such as walking
promote individual physical and mental health, community health and
economic health…. Increasing access to walking can help address health
disparities, which have a profound impact on a person’s quality of life and
lifespan” (America Walks, 2016). Increasing access to walking and other
forms of physical activity in transportation planning is an important
consideration to reducing health disparities in Native Hawaiian
communities.39
Research has shown that improved accessibility and a more welcoming
street environment created by pedestrian safety improvement projects
can generate increases in retail sales in the areas that projects were
implemented. Data on retail sales can be used to potentially activate the
business community in support of appropriately designed projects and
address concerns when appropriate. Well-designed communities with
21
pedestrian safety features can contribute to the economic vitality of
communities.40 Therefore, by improving the safety of pedestrians
through sidewalks, median strips, and other traffic calming measures, we
can increase the economic vitality of neighborhoods as well as the
indirect, cost-effective economic benefits of these improvements, such as
the long-term health benefits of Native Hawaiian communities. Native
Hawaiian communities should be equitably included in the opportunity to
have accessible, welcoming and safe street environments.
Each county in the State of Hawaiʻi has passed policies relating to
complete streets to ensure that transportation facilities or projects are
planned, designed, operated, and maintained to provide safe mobility for
all users.41 The complete streets policy and principles of the City and
County of Honolulu include ten objectives, including applying a context
sensitive solution that integrates community context and the surrounding
environment, including land use, encouraging opportunities for physical
activity and recognizing the health benefits of an active lifestyle, and
recognizing complete streets as a long-term investment that can save
money over time.42 These objectives are in alignment with the
recommendation of the Native Hawaiian Health Task Force, as long as
community input is heralded in consideration of design and functionality.
One of the possible methods of collecting community input could be
including community members in complete streets design charrettes.
The viewpoints of all community members, including Native Hawaiians,
should be considered in addressing concerns, including safety, cultural
and religious practice, age, mobility, and economic considerations.
Furthermore, concerted effort should be made to take steps to involve
and engage Native Hawaiian community members on proposed projects
in communities with a high proportion of Native Hawaiian residents.39
The engagement of community members in the process is a health
promoting practice in itself.44
Recommendation 3: Advocate for a livable wage by 2020.
Description: Requesting for a re-evaluation of the current minimum wage and an
adjustment of the minimum wage into a livable wage.
22
According to the U.S. Department of Housing and Urban Development,
affordable housing means families paying 30% or less than their
household income.45 Even in 2012, 56% of Native Hawaiian or part-
Hawaiian renters are spending at least 30% of their income for housing
expenses.46 Expensive price tags on housing means people need to earn
higher salaries to fulfill their basic needs of living.
For most people, steady income from employment is used to cover the
costs of basic necessities such as food, rent, transportation, and health
care. Under the current labor for money system, Native Hawaiians and
other Pacific Islanders lag behind other ethnic or racial groups with a
12.2% unemployment rate and with 29.8% of the population below 125%
of the poverty level.47,48 With many community members living in
poverty, it is necessary to figure out a plan to pay people livable wages.
Besides earning less than the national average, high living expenses in
Hawai‘i is a crucial factor that explains why Native Hawaiians and Pacific
Islanders experience economic challenges in their daily lives. In 2014, a
person’s average spending amounts to $41,021 which is 10.3% or $3,825
higher than the U.S. average of $37,196.49,50 Higher costs of daily
expenses can become problematic as Native Hawaiians lack living and
housing stability.
Researchers looked into Native Hawaiians’ below average income level
and have proposed the following contributing factors: young median age
of population, larger family size, greater number of single families, lower
number of people in management and professional positions, and fewer
people with bachelor’s degrees or higher.51 With a variety of reasons
determining people’s poverty status, a straight-forward way to assist low-
income families is to gradually increase the minimum wage.
In May 2014, minimum wage increase was signed into law which will
increase wages to $7.75/hour in 2015, to $8.50/hour in 2016, and up to
$10.10/hour in 2018.52 Yet, minimum wage is not a living wage. As the
National Low Income Housing Coalition reports, the hourly wage needed
to afford a two bedroom home in Hawai‘i is $34.22.53 Even with the
minimum wage hike, low-income families will still find it difficult to afford
basic necessities.
23
On O‘ahu, an individual can have an annual income of $54,850 and still
qualify for housing assistance.54 Although there are federal programs
such as the Section 8 Housing Choice Voucher Program to assist “very
low-income families, the elderly, and the disabled to afford decent, safe,
and sanitary housing in the private market,” with 6,196 units of public
housing currently serving families, there are still over 4,556 cases of
homelessness still waiting to be resolved (Navarrette and Derrickson,
2014).55,56
Other organizations also aspire and recognize the need to increase
minimum wage into livable wage. Hawaii Appleseed, Center for Law and
Economic Justice, recently proposed an initiative to increase minimum
wage to $15. The definition of minimum wage is fluid depending on the
changing economy, and it is important that families are given
opportunities to achieve economic stability.
Recommendation 4: Support paid family leave efforts with a definition of family that is
culturally relevant.
Description: Seeking for an expansion of the definition of family and advocating
for paid family leave policy.
The federal Family Medical Leave Act permits unpaid leave and job
protection up to 12 weeks to care for a newborn, a family member, or
personal medical conditions. Keeping in mind of Hawai’i’s unique family
culture, the Hawai‘i Family Leave Law further allows employees 4 weeks
of unpaid leave to care for a parent-in-law or grandparent. Yet, Hawai‘i
currently does not have paid family leave policy, and most employees
cannot take unpaid leave and maintain financial stability.57
Four states in the U.S. have paid family leave, and there is a coalition in
Hawai‘i working on this initiative.58 However, in Hawai‘i we feel that a
broader definition of family is necessary. Not only should parents be able
to take off work to care for immediate family members,
multigenerational families in Hawai‘i should have the option to take care
of extended family members such as their grandchildren or nieces and
nephews.
24
The term hānai is generally used to refer to children taken informally
under custom into another’s home but is not adopted in accordance with
Hawai‘i law.59 In Hawai‘i, members of a family is largely influenced by
cultural factors and an expansion of the definition of family to include
hānai children should be recognized through policy.
Research suggests that families, on average, need an income of twice the
federal poverty threshold to meet basic needs. Children in families with
incomes below $48,016 for a family of four in 2014 are considered low-
income. According to the National Center for Children in Poverty, one-
third of the children in Hawai‘i live in low-income families.60
Mothers with paid leave are 39 % less likely to receive public assistance
after the birth of a child compared to those without paid leave. In
addition, maternity leave is linked to improved child health outcomes
such as increased birth weight and rate of breastfeeding for infants.61
Recommendation 5: Include pre-kindergarten in public schools.
Description: Advocating for the inclusion of pre-K programs in public elementary
schools to lessen the cost burden of early childhood education on parents.
World Health Organization emphasizes that early childhood development
is a major phase in life which determines the quality of health, well-being,
learning and behavior across the lifespan.62 Research further shows that
85% of brain development occurs before the age of 5.63 As early
education plays such a crucial role in children’s health and learning,
efforts should be made to make pre-k programs affordable, such as
including pre-k in public schools.
The Economic Policy Institute reports the average cost of full-time child
care for a 4-year-old in Hawai‘i, either in preschool or at a daycare center,
to be $9,312 per year.63 With staggering costs for pre-kindergarten
programs, many parents may overlook the importance of their child
receiving pre-k education.
The Hawai‘i State Department of Education is in the process of expanding
learning opportunities for children ages prenatal to age five.64 According
to the Hawai‘i State Teachers Association, only certain public elementary
25
schools are selected for pre-k classes, so not all children can take
advantage of this opportunity.65 As of the 2015-2016 school year, there is
still limited pre-k programming available across counties in Hawai‘i with
an average rate of Native Hawaiian preschool enrollment of 8.3%.64
On the Island of Hawai‘i, a new federally funded program offers free pre-
k classes to students at four island charter schools. These students’ family
income is at, or below, 200% of the federal poverty guidelines in Hawai‘i,
showing that efforts have been made to give low-income students the
opportunity to receive high-quality preschool instruction.66 Yet, due to
the high costs of pre-k programs, families who are above the 200% cutoff
of the federal poverty mark should also be offered lesser cost alternatives
to sending their children to schools.
Recommendation 6: Establish a directory of Native Hawaiian professionals and community
leaders with an understanding of Hawaiian culture for
Governor-appointed leadership positions to better incorporate culturally
relevant perspectives into statewide initiatives.
Description: Seeking to establish a registry of Native Hawaiian professionals who
will contribute their leadership for boards, commissions and appointed
positions at the state and county levels of government.
When Native Hawaiian charter school graduates were asked to describe
their leadership roles, most responded that they were related to
intergenerational relationships, teaching the Hawaiian language and
culture and leading when leadership opportunities are available.67
Establishing a registry of Native Hawaiian professionals to be appointed
into leadership positions will broaden the categories under which Native
Hawaiians can serve as leaders and give back to their communities.
The Native Hawaiian and Indigenous Leadership Institute established at
the University of Hawai‘i at Mānoa College of Education specifically
recruits and mentors Native Hawaiian and Indigenous graduate students
to become future leaders in their communities.68 Therefore, Native
Hawaiians with higher educational backgrounds are adequately prepared
for leadership roles, and appointment into a leadership position will give
Native Hawaiian professionals a chance to create positive change.
26
Native Hawaiian leaders have demonstrated their ability to effectively
address the wellbeing of their communities by advocating for cultural
integrity in community health promotion programs.69,70
Currently, Native Hawaiian expertise in cultural practices are valued and
required for certain seats on decision-making bodies, for example in the
areas of tourism, land-use, education and community/economic
development. Native Hawaiians should be involved in the decision
making processes for state governmental actions and for policy decisions,
especially when the policies are designed to directly impact Native
Hawaiian communities the most.
Recommendation 7: Advocate for a portion of the Transient Accommodations Tax.
Description: Allocate a portion of the revenue from the Transient
Accommodations tax to support Native Hawaiian cultural, social, economic, and
educational programs.
The Hawaiian culture is used as a major driver for tourism in the islands.
Many hotels incorporate the Aloha spirit, local entertainers, and native
imagery in the form of paintings and photography to welcome worldwide
visitors. By generously sharing the Hawaiian culture with many tourists, it
is only right for the tourism industry to give back a portion of the revenue
generated to the Hawaiian people.
Millions of tourists visit the Hawaiian Islands annually. In 2015, a record
of 8.6 million visitors came to Hawai‘i.71 Lodging is the largest
expenditure category for visitors, spending $6.3 billion in 2015.71
The Transient Accommodations Tax (TAT) is a 9.25% tax levied on gross
rental income derived from renting living accommodations to a transient
for 180 consecutive days or fewer.72 In fiscal year 2015, the TAT
generated $421 million.73 Portions of the TAT are allocated to the
counties and various special funds relating to tourism and conservation.
The remainder is deposited into the general fund.
Currently, $1,000,000 of the money allocated to the tourism special fund
is earmarked to operate a Hawaiian center and the museum of Hawaiian
music and dance at the Hawai‘i Convention Center. However, this center
27
and museum is currently not in existence. Instead, this money should be
allocated to support organizations and programs that enhance,
strengthen and perpetuate Hawaiian cultural, health, social, economic,
and educational programs.
Recommendation 8: Establish an environmental and cultural preservation fee (9.25%) on
restaurants and entertainment in hotels.
Description: Create a fee similar to the TAT on hotel restaurants and
entertainment. The revenue would be allocated towards programs or projects
that benefit Native Hawaiians.
The maintenance of Hawai‘i’s land and culture is critical to the tourism
industry. Through the marketing of its natural beauty and the Hawaiian
culture, the tourism industry earns billions each yearin 2015, visitors
spent $15.1 billion dollars.71 Programs and projects benefiting Native
Hawaiian wellbeing will also sustain the tourism industry, and thus
funding for these causes should be a priority.
The TAT, which taxes income from transient living accommodations,
allocates part of its revenue to the environmental conservation and
cultural preservation. However, other parts of the tourism industry, such
as restaurants and entertainment in hotels, also benefit from Hawaiian
culture and land. As such, they should be taxed at a similar rate and their
revenues allocated to programs that promote Native Hawaiian wellbeing.
Recommendation 9: Include long-term care options with home-based care in a statewide
insurance program.
Description: Requesting for the inclusion of home-based care as a long-term care
option to make healthcare more affordable.
The Department of Veterans Affairs has a Home Based Primary Care
(HBPC) program benefitting those who need extra care for their medical,
social, or behavioral conditions. With the HBPC program, Veterans Affairs
and Medicare costs were 11.7% lower than projected and the combined
hospitalizations were 25.5% lower than before. Furthermore, patients
reported high satisfaction with access to care under HBPC as well as the
continuity of care.74 With lower expenses and more patient centered
28
care, the general public should also be offered the option of a home-
based long-term care program.
A research study by the Urban Institute determined about 15% of 65-
year-olds will spend, on average, $250,000 on health care expenses.75
Long-term care is required by the elderly as well as younger people with
chronic conditions or trauma, therefore it is necessary to figure out more
affordable care options for our loved ones or even for ourselves.
According to the Hawaii Long Term Care Association, age is the single
most important factor in understanding the need for health resources. In
Hawai‘i, the elderly population (kūpuna) aged 65 and older comprises
15% of the state population and is growing at a much faster pace than
the rest of the nation.76 With a larger elderly population, there will be a
greater need for long-term care services.
In a recent study of the effect of home-based primary care (HBPC) on
Medicare costs and mortality in frail elders, HBPC reduces Medicare costs
while sustaining similar survival outcomes across cases and controls.77
Receiving care at home provides our kūpuna (elders) with a familiar care
setting and eliminates the burden of frequent hospitalizations or skilled
nursing facility expenses.
Caring for our kūpuna is a cultural tradition in Hawai‘i, and Senator Roz
Baker is proposing the idea of creating a first-in-the-nation universal long-
term care insurance program. This benefit will be available to long-term
residents and be paid for by general tax.78 Aging is a natural occurrence,
and by establishing a statewide, insurance-covered, long-term care
program, we are helping those who really need help.
Recommendation 10: Develop a state-plan to incorporate the United Nations Declaration of
Rights of Indigenous Peoples.
Description: Creating a state-level declaration of the rights of indigenous
peoples, based off the framework of the internationally adopted United Nations
Declaration of Rights of Indigenous Peoples (UNDRIP).
The definitions of “Indian tribe,” “tribal sovereignty,” “compact of free
association,” and other current legal definitions and arrangements set by
29
U.S. national and state law do not accurately describe, nor would it be
appropriate to mimic for, Native Hawaiians. Native Hawaiians wish to
explore choosing to self-identify as one of the “indigenous peoples,”
whose rights are described in the UNDRIP.79,80,81 This is in accordance
with the definition of self-determination in international law.
The UNDRIP provides a framework outlining the rights that the state of
Hawai‘i can pursue in regards to taking the necessary steps to
progressively achieving the full realization of the equal right of
indigenous individuals to the enjoyment of the highest attainable
standard of physical and mental health. In addition, pertaining to health,
UNDRIP provides several articles in its framework outlining the rights to
traditional medicines and health practices; rights to all social and health
services, without any discrimination; rights to be actively involved in
developing, improving, and determining heath; rights to protection of
child health; as well as other rights that relate to the social determinants
of health, including but not limited to education, housing, employment,
etc.81 Therefore, by outlining a more holistic view of health as culturally
appropriate for indigenous peoples at the state-level, we will be taking
the multifaceted measures needed to increase access to health care for
indigenous peoples in Hawaiʻi.
One of the most important factors of Native Hawaiian health is the ability
to integrate cultural heritage together with spiritual, emotional, and
physical health, in order to increase wellness.81 By working with the state
to recognize and declare the rights of indigenous peoples and the right to
self-determination, this new policy endeavor will capture the spirit of
cultural appropriateness and health promotion that will increase the
effectiveness of current and future policies that aim to increase wellness
of Native Hawaiians.
Recommendation 11: Establish school-based health centers.
Description: Requesting for more school-based health centers to be built and
operated to provide young people with needed health care while avoiding
disruption in their education.
School-based health centers are designed to help young people get the
healthcare they need, while taking into consideration of factors such as
30
transportation, costs, appointment time, and student confidentiality.
According to Advocates for Youth, studies show that students who use
school-based health centers were less likely to be absent and more likely
to graduate.82 Furthermore, on- campus health centers increase students’
health knowledge as well as usage of healthcare.
An evaluation of students who attend schools with school-based health
centers shows that students decreased their use of hospital emergency
rooms for routine healthcare, helping local and state governments save
significantly on medical expenses.82
School-based health centers offer students affordable health services. In
2014, Hawai‘i opened its first full-service school health center at Kahuku
High and Intermediate. The Ko‘olauloa Health Center is a valuable
resource for students on Medicaid, waiving any out-of-pocket expenses,
as well as offering reduced fees for underinsured students.83 In addition
to medical and dental services, the health center also provides counseling
on stress management and suicide prevention.84
In 2016, two more school-based health centers were opened at Waianae
High and Intermediate Schools. In only two and a half months, health
providers already treated 270 students for cases such as coughs,
abrasions, headaches, and ankle injuries, and 92% of these students were
able to return to class right after treatment.84 More schools should be
considered for future health centers sites as these centers provide
students with immediate and effective care.
Recommendation 12: Develop an undergraduate health sciences academy within the
University of Hawai‘i system in cooperation with relevant educational
institutions to target the recruitment and retention of Native Hawaiian
students.
Description: The University of Hawai‘i system shall implement a program to
improve preparation for careers in the health sciences. The program would
encompass additional supports for indigenous students and first generation
college students to improve success and increase retention.
Current data suggest that Native Hawaiians are less likely to attend
college than other ethnic groups partly due to low levels of preparation
31
and inadequate finances.86 For those Native Hawaiian students who do
attend college, graduation and retention rates are consistently lower
than the general student population. Students also identified a strong
desire to live close to family and participate in family activities and
cultural pressures as factors that contributed to non-completion.87
Multiple studies testing for factors leading to retention identified that the
more involved Native Hawaiian students are in school activities and
interact with faculty members and other peers, the more likely they are
to persist in their education.86 The development of a Health Sciences
Academy with a focus on Native Hawaiian student retention, would
target integration of both the student and their family in school activities.
30% of Native Hawaiian/Pacific Islander children have parents with high
school degrees as their highest education level while 18% have parents
with a bachelor’s degree or higher. During the 2007—08 academic year,
34% of Native Hawaiian/Pacific Islander undergraduate males were
enrolled in postsecondary education, yet smaller sample size of the
Native Hawaiian/Pacific Islander population made it difficult to provide
data for undergraduate completion.88
Health care sector jobs are projected to increase by more than 160% by
2040 and wages are typically more in line with a livable wage for the
State of Hawai‘i.89 However, these jobs typically require a Bachelor’s
degree at minimum, and currently, about 15% of Native Hawaiians or
Pacific Islanders hold bachelor’s degrees.90
Recommendation 13: Increase services for Native Hawaiians who come in contact with the
criminal justice system to promote integration back into the
community to reduce recidivism rates.
Description: Promoting the offering of resources for community members
during their contact with the criminal justice system.
Based on a report from the Justice Policy Institute, Hawai‘i is one of the
top ten states with the highest unemployment rates and corresponding
violent crime rates.91 Many people are either unemployed or earned low
wages prior to their arrests, and unfortunately, prisons do not provide
32
the necessary resources to prepare persons for returning to their
communities.
Native Hawaiians receive longer prison sentences, have greater numbers
of women in prison, and go to prison for drug offenses more often than
other racial or ethnic groups.91,92 These adverse impacts are of great
concern to the Native Hawaiian community, leading to a breakdown of
family culture as well as an accumulation of negative long-term impacts
of poor health and low-wage jobs.91
Native Hawaiians are negatively affected in the areas of physical and
mental health as they receive longer prison sentences than other racial
groups.93 Results from a national survey of inmates’ health levels reveals
that at the local jails level, 38.7% of incarcerated persons suffered from a
chronic medical condition and failed to receive the care they need.
Furthermore, the percentages of local jail inmates taking psychiatric
medication before and after arrest increased from 38.5% to 45.5%.94 To
improve people’s wellbeing, more attention should be provided to the
general population in the area of mental health, and incarcerated
persons should receive needed physical and mental care while in prison.
The National Institute of Justice’s survey approximates that 60-75% of ex-
offenders are unable to find jobs after release.95 Before people end up in
jail, efforts should be made to assist Hawai‘i’s people in getting
employment. Employed persons have a stronger sense of responsibility
which decreases their tendency to participate in criminal activities. This
same mindset of getting people employed should be adapted in helping
incarcerated persons prior to their release. Prisons should offer job-
finding workshops or related services to assist community members on a
smoother transition back into society.
Recommendation 14: Establish a Native Hawaiian Public Policy Advisory Council.
Description: Development of a Native Hawaiian Public Policy Advisory Council to
provide guidance on significant policies impacting Native Hawaiians.
According to the U.S. Department of Health and Human Services Office of
Minority Health, national data shows a concern pertaining to infant
mortality rates (deaths per 1,000 live births). For Native Hawaiians in
33
2002, it was 9.6. This rate was significantly higher than the 4.8 for all
Asian-American/Pacific Islander groups and the 7.0 for all populations.96
With greater numbers of chronic illnesses and deaths, there is a need for
promoting community-centric policies for Native Hawaiians, especially in
the area of health.
Compared to other ethnic groups, Native Hawaiians/Pacific Islanders
have higher rates of smoking, alcohol consumption, and obesity. In 2010,
the cost of chronic disease treatments in Hawai‘i reached $3.6 billion and
is projected to reach $6.7 billion by 2020.97 Furthermore, limited access
to prevention programs led to greater number of cancer, heart disease,
unintentional injuries, stroke and diabetes-related deaths.
During the twenty-seventh legislative session in 2014, Act 155 was
passed to reduce health disparities for Native Hawaiian, other Pacific
Islanders, and Filipino local communities through identifying and
addressing social determinants of health.98 The Office of Hawaiian Affairs
shares the Native Hawaiians’ holistic view of health of unity, the sacred
life force, and harmony or balance which is different from the western
perspective of health.99 The concept of health have different meanings to
different people, and the formation of an advisory council will lead to
community-centered, culturally-integrated policies.
The Native Hawaiian Health Consortium June 2011 Compendium
gathered private, non-profit, state, academic, community health centers
and community-based providers to discuss the current state of Native
Hawaiian health. From this consortium, a recommendation was to have a
federal liaison for Native Hawaiian/Pacific Islander health initiatives
within a federal health agency.82 At that time, health care providers
recognize that Native Hawaiian participation is valuable in the health
planning process. Forming a policy advisory council will further encourage
community input in shaping the future of Native Hawaiian well-being and
community health.
Recommendation 15: Reimburse for culturally appropriate services and traditional
practices.
Description: Requesting for an expansion of insurance company benefits to
include traditional Native Hawaiian practices with health benefits such as hula
34
dancing or canoe paddling.
Kaiser Permanente will be launching a Fit Rewards program, beginning
2017, for members to encourage year-round fitness. After signing up for
membership at a partner gym and paying a $200 annual fee, members
need to commit 45 days of 30 minutes workout sessions to be refunded
the annual fee.100
Hawaii Medical Service Association has a HMSA365 Discounts program to
engage members in health maintenance outside of the doctor’s office.
Some categories included under HMSA’s discount program include tai chi
lessons, Jazz dance classes, acupuncture treatments, hypnotherapy,
meditation sessions, and more.101 Although offering members a wide
range of health maintenance options, there lacks discounts for traditional
cultural practices such as hula dancing or canoe paddling.
In a recent study, kumu hula (hula educators and experts) were
interviewed for their views regarding hula’s relation to health and
wellbeing. Each kumu hula participant expressed the importance of
cultural integrity in health and that hula can be an important cultural
practice to include in cardiovascular disease clinical interventions.69
Currently, there are also community-based health promotion programs
developed and shown to be effective in the areas of weight management
and cardiovascular health. Hula and other traditional practices with
proven health benefits should be considered under insurance companies’
reimbursement programs to offer culturally-integrated health
maintenance options. 102,103
Recommendation 16: Restore Adult Dental Benefits to Medicaid Enrollees.
Description: Appropriates funds to the Department of Human Services to restore
basic adult dental benefits to Medicaid and QUEST Integration enrollees. Among
these strategies are proposals to: (1) Continue to support and expand affordable
and accessible preventive dental care services to Hawai‘i’s low-income
populations; and (2) Expand Medicaid dental services for adults beyond the
limited current coverage for emergencies to include preventive and treatment
services.
35
Poor oral health impacts a person’s ability to eat, speak, work,
communicate, and learn. Unlike other states, Hawai‘i does not have an
ongoing and routine system for assessing the oral health of its residents -
there is no dental public health program with the State Department of
Health.
Hawai‘i received a failing grade of “F” in three recent oral health report
cards published by The Pew Center.104 According to the Department of
Health’s Hawai‘i Oral Health: Key Findings report published in August
2015, there are substantial dental health disparities among low-income
residents, pregnant women, neighbor island counties.105
Fluoride added to community drinking water sources is a safe,
inexpensive and extremely effective method of preventing tooth decay
across all age groups. However, only 11% of Hawai‘i residents have
fluoridated water compared to 75% for the United States as a whole.106
Only 52% of low-income adults in Hawai‘i saw a dentist, compared to
82% of high-income adults.110 Fifty-one percent (51%) of low-income
adults lost teeth due to dental disease, while only 32% of high-income
adults did so.105
Because many Hawai‘i residents are unable to afford dental care or
schedule a dental appointment, they end up seeking care at a hospital
emergency department, although dental services are not generally
available there. In 2012, there were more than 3,000 emergency room
visits due to preventable dental problems, 67% more than in 2006.105 As
a result, aggregate hospital charges for dental emergency visits were
$8,500,000, compared to $4,000,000 in 2006, due in part to the increased
number of visits.107
36
Continued Commitment
The Native Hawaiian Health Task Force is committed to advancing health equity for Native
Hawaiians, and in turn, the health of Hawai‘i’s entire population. Task Force members have
committed to meeting annually to review progress in the above areas as well as a larger list
outlined in a community report to follow. It is our intention that the Native Hawaiian Health
Task Force will continue to advance policy that will positively impact our community and
minimize health disparities in the years to come.
37
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Appendix B
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Chapter
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This essay explores the social and cultural determinants of Kanaka ʻŌiwi (Native Hawaiian) health and the pathways to Mauli Ola (optimal health and wellbeing). Future opportunities for enhancing Mauli Ola explored are the demographic changes in the Kanaka ʻŌiwi population, continuing cultural revitalization efforts, participation in the larger society, and self-determination and the larger international Indigenous movement. Several shared Kanaka ʻŌiwi aspirations important to Mauli Ola are highlighted to include supporting a strong Kanaka ʻŌiwi identity and space, strengthening ‘ohana (family) relations, and ensuring the practice of mālama ‘āina and aloha ‘āina.
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Objective: Native Hawaiians and Pacific Islanders (NHPI) bear an unequal burden of hypertension and cardiovascular disease. Hula, the traditional dance of Hawaii, has shown to be a culturally meaningful form of moderate-vigorous physical activity for NHPI. A pilot study was done in Honolulu, Hawaii, to test a 12-week hula-based intervention, coupled with self-care education, on blood pressure management in NHPI with hypertension in 2013. Method: NHPI with a systolic blood pressure (SBP) ≥140 mmHg were randomized to the intervention (n = 27) or a wait-list control (n = 28). Blood pressure, physical functioning, and eight aspects of health-related quality of life (HRQL) were assessed. Results: The intervention resulted in a reduction in SBP compared to control (−18.3 vs. −7.6 mmHg, respectively, p ≤ 0.05) from baseline to 3-month post-intervention. Improvements in HRQL measures of bodily pain and social functioning were significantly associated with SBP improvements in both groups. Conclusion: Using hula as the physical activity component of a hypertension intervention can serve as a culturally congruent strategy to blood pressure management in NHPI with hypertension.
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To compare the clinical characteristics of Native Hawaiians (NH) and other Pacific Islanders (PI) who are hospitalized with ischemic stroke. Retrospective, cross-sectional analysis of medical records. Tertiary, Primary Stroke Center in Honolulu, Hawaii. Consecutive patients with race/ethnicity identified as NH or PI who were hospitalized for ischemic stroke between January 2006 and December 2012. Age, sex, cardiovascular risk factors, intravenous tissue plasminogen activator (IV-tPA) utilization rate and hospital length of stay. A total of 561 patients (57% NH and 43% PI) were studied. PI were younger (59 ± 13 years vs 62 ± 14 years, P = .002), had higher prevalence of diabetes mellitus (58% vs 41%, P < .0001) and prosthetic valve (6% vs 2%, P = .007), lower prevalence of smoking (14% vs 21%, P = .03), lower HDL cholesterol (38 ± 11 mg/dL vs 41 ± 13 mg/dL, P = .004), and higher discharge diastolic blood pressure (79 ± 15 vs 76 mm Hg ± 14 mm Hg, P = .04) compared to NH. No difference was seen in other cardiovascular risk factors. The IV-tPA utilization rate (5% vs 6%, P = .48) and the hospital length of stay (10 ± 17 days vs 10 ± 49 days, P = .86) were not different between the two groups. Native Hawaiians and other Pacific Islanders with ischemic stroke have modestly different age of stroke presentation and burden of risk factors compared to each other. Disaggregating these two racial groups may be important to unmask any potential clinical differences in future studies.
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To prepare for research studies that would evaluate the impact of hula as part of a clinical intervention, including cardiovascular disease (CVD) prevention and management programs, kumu hula defined as "culturally recognized hula educators and experts," were interviewed. Investigators sought to elicit their views regarding hula's traditional and contemporary connections to health and well-being, assess the cultural appropriateness of such projects, and suggest ways to maintain hula's cultural integrity throughout clinical intervention programs. Six prominent kumu hula from five different Hawaiian Islands participated in semi-structured key informant interviews lasting between 60 and 90 minutes. Each was asked open-ended questions regarding their attitudes, beliefs, and experiences regarding the connections of hula to health as well as their recommendations on maintaining the integrity of the dance's cultural traditions when developing and implementing a hula-based CVD program. All kumu hula endorsed the use of hula in a CVD intervention program and articulated the strong, significant, and enduring connections of hula to health and well-being. Each kumu hula also recognized that health is the full integration of physical, mental, emotional, and spiritual well-being. When care is taken to preserve its cultural integrity, hula may be an effective integrated modality for interventions designed to improve health and wellness.
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Objectives To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders.DesignCase–control concurrent study using Medicare administrative data.SettingHBPC practice in Washington, District of Columbia.ParticipantsHBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania.InterventionHBPC clinical service.MeasurementsMedicare costs, utilization events, mortality.ResultsMean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2-year follow-up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow-up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06, P = .44) or in average time to death (16.2 vs 16.8 months, P = .30).ConclusionHBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls.
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Native Hawaiians/Pacific Islanders experience a high prevalence of overweight/obesity. The Diabetes Prevention Program Lifestyle Intervention (DPP-LI) was translated into a 3-month community-based intervention to benefit these populations. The weight loss and other clinical and behavioral outcomes of the translated DPP-LI and the socio-demographic, behavioral, and biological factors associated with the weight loss were examined. A total of 239 Native Hawaiian/Pacific Islander adults completed the translated DPP-LI through four community-based organizations (CBOs). Changes from pre- to postintervention assessments in weight, blood pressure, physical functioning, exercise frequency, and fat in diet were measured. Significant improvements on all variables were found, with differences observed across the four CBOs. CBOs with predominately Native Hawaiian and ethnically homogenous intervention groups had greater weight loss. General linear modeling indicated that larger baseline weight and CBO predicted weight loss. The translated DPP-LI can be effective for Native Hawaiians/Pacific Islanders, especially when socio-cultural, socioeconomic, and CBO-related contextual factors are taken into account.
Chapter
Proponents of a bill of rights — whether of the constitutional or statutory type — will usually have a vision of what bills of rights can accomplish. Indeed, there may be competing visions. Some will see a bill of rights as affirming a core set of civil and political rights against the possibility of future erosion — essentially ‘process’ rights such as liberty and speech without which a democracy cannot flourish. Others may seek to include new rights that, as they see it, have not been so well reflected in the legal system, or at least not seen as within the province of judges to rule upon. For them, a bill of rights will be designed to transform targeted areas of law and policy, not just to affirm and protect the existing order. Social and economic rights, for example, may be advocated. The aim will be to set new standards to which the state can be held to account. For countries with Indigenous peoples, the idea of Indigenous peoples' rights will assuredly be on the agenda when a bill of rights is mooted. But are these part of the core civil rights, or are they new and developing? Are they affirmatory or aspirational? Is it enough that every person, including every Indigenous person, enjoys the basic rights of participation essential to democracy? Or are there particular rights to which Indigenous peoples are entitled, rights that protect the vitality and autonomy of their group, their worldview, their way of life, and set a new standard against which a state's laws and actions may be measured and, perhaps, found wanting?
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In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.