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A&p hlth report 2013

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DEPARTMENT OF NATIVE HAWAIIAN HEALTH CENTER FOR NATIVE AND PACIFIC HEALTH DISPARITIES RESEARCH JOHN A. BURNS SCHOOL OF MEDICINE UNIVERSITY OF HAWAI‘I AT MANOA ASSESSMENT AND PRIORITIES FOR HEALTH & WELL-BEING IN NATIVE HAWAIIANS & OTHER PACIFIC PEOPLES -
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DEPARTMENT OF NATIVE HAWAIIAN HEALTHCENTER FOR NATIVE AND PACIFIC HEALTH DISPARITIES RESEARCH

JOHN A. BURNS SCHOOL OF MEDICINEUNIVERSITY OF HAWAI‘I AT MANOA

ASSESSMENT AND PRIORITIES FOR HEALTH & WELL-BEING IN NATIVE HAWAIIANS & OTHER PACIFIC PEOPLES

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CONTENTS

Introduction

Demographic Pro!le of Native Hawaiians & other Paci!c Peoples

Population

Life Expectancy

Health Disparities & Health Care Services

Chronic Conditions

Health Behavior

Primary Care & Enabling Services

Other Determinants of Health

Economic Well-being

Education

Social & Cultural Well-being

Emotional & Spiritual Well Being

Community Speaks of Health Needs

Priority Medical and Health Areas

Needs in Health and Medical Services

Promising Practices

Closing

Mahalo & Acknowledgments

References

1

3

9

22

31

38

40

Needs in Organizational Training to Improve Cardiometabolic Health

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INTRODUCTION

Ulu Hina,

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-Thriving & Enduring

1

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2

DEMOGRAPHIC PROFILE OF NATIVE HAWAIIANS & OTHER PACIFIC PEOPLES

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POPULATION

3

There were remarkable increases in the Native Hawaiian, Paci!c Islander, and Filipino populations between 2000 and 2010.

Paci!c Islanders are one of the fastest growing groups in the state and the nation.

Figure 1. NHPI & Filipino Populations with Percent Change, Hawai’i, 2000 & 2010

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“We are all sort of the same but we must customize [programs & services] according to the culture.”

-Urban Community Health Center

Key Finding:

Promising Trends:

4

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Figure 2. Native Hawaiian as Percent of Total Population by Sub-Region, 2000

“[Through] community health navigation our work with [NHPP serving organizations] enables us to expand efforts to individual groups like halau hula in California. The work with academics in the area of health has helped the whole Pacific Islander community work together.”

-Native HawaiianOrganization of California

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-

5

Figure 3. Population of Groups that Comprise Native Hawaiian and Pacific Islander Populations in U.S., 2010

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Figure 4. Top Ten NHPI Populations in the U.S. (by County), 2012

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6

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Figure 5. Trends in Native Hawaiian Population Count

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Figure 6. Native Hawaiian Population in Continental U.S. (Top 10 Cities)

Population

7

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LIFE EXPECTANCY

Figure 7. Life Expectancy at Birth by Ethnicity, Hawai‘i

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Figure 8. Trends in Infant Mortality Rates by Ethnicity, 1981-2009

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The infant mortality rates for the Native Hawaiians and Filipinos in Hawai‘i have shown clear improvement over the past 25 years.

Life expectancy for Native Hawaiians is 6.2 years lower than the life expectancy for the State, even though Native Hawaiian life expectancy has increased by 11.8 years since 1950.

Key Finding:

Promising Trends:

“Some OB are not willling to accept patients for deliveries if they did not follow the patient for prenatal care. This is problematic for [our] mothers, because it means they will need to drive out of [our community] for all the prenatal visits. That can be expensive if you have a car, or if you don’t it’s even more difficult. Of course this has a negative impact on the mom and baby.”

-Neighbor Island Rural Community Health Clinic

8

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NHPP collectively represent a signi!cant proportion of Hawai‘i’s population. The growing size of this population re"ects high rates of immigration, increase ethnic self-identi!cation, and a young population with high birth rates. In comparison, the NHPI population represents less than one percent of total U.S. population, even though they are one of the fastest growing ethnic populations.

Trends show NHPP life expectancy rates have consistently improved over the past several decades. While these improvements have enabled Filipinos to reach a level of health equity with the overall State of Hawai‘i, Native Hawaiians continue to experience a distinct health inequity.

9

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Figure 9. Mortality Rates for Leading Causes of Death in Native Hawaiian and All Ethnicities, Hawai'i, 2000

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HEALTH DISPARITIES & HEALTH CARE SERVICES

CHRONIC CONDITIONS

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“[We want] interventions that work for heart disease, diabetes, and obesity. Those disease priorities have not changed from the previous needs assessment...but our preference is that it is culturally tailored, and is peer-led NOT clinician led. It has been our experience that there is disbelief or resistance in achieving change when led by a physician. There is more credibility in a peer-led or community health worker led intervention,”

-Native Hawaiian Healthcare System Leader

Over the past decade, Native Hawaiians have reported greater participation in diabetes self-management activities.

Native Hawaiians and Paci!c Islanders have among the highest rates of cardiometabolic disorders, which include obesity, diabetes, and cardiovascular disease.

Key Finding:

Promising Trends:

10

Figure 10. Morbidity and Mortality Risks & Percent of Native Hawaiians by Sub-Region

Source: (Malone, 2005) and (State of Hawaii Primary Care Needs Assessment Data Book, 2009)

Notes: Sub-regions are school districts, Mortality rates are per 100,000 population, “Cumulative

Health Disparity” is the combined rates for morbidity and mortality.

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11

Figure 11. All Heart Disease Mortality Rates per 100,000 population, 1960-2000

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12

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Diabetes Management Education by Ethnicity, Hawaiȧi, 2011

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13

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Figure 13. Percentage of Adults Overweight by Ethnicity, 2008

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Figure 14. Female Breast Cancer Incidence & Mortality by Race/Ethnicity, Hawai'i 1995-2000

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15

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HEALTH BEHAVIOR

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ALCOHOL USE

Figure 15. Behavioral Risks & Percent of Native Hawaiians By Sub-Region, 2005

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Native Hawaiians have a higher chronic disease risk in comparison to other groups resulting from higher prevalence of obesity, smoking, and chronic alcohol use.

Innovative programs have demonstrated the effectiveness of community-based and culturally adapted interventions in helping Native Hawaiians and Paci!c Islanders to better manage their personal health and adopt healthier lifestyles.

Key Finding:

Promising Trends:

--

16

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Figure 16. Smoking Prevalence by Ethnicity, Hawai‘i, 2008

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PHYSICAL ACTIVITY

17

Figure 17. Percent Achieving Recommended Physical Activity Levels by Ethnicity, 2009

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VIOLENCE & VICTIMIZATION

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Figure 18. Percentage of Violence & Victimization among High School Students, U.S., 2009.

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18

PROMISING PRACTICES

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“We are interested in overall health and the value of the cultural side of health practices so we can view the health of the whole person. For example, we would like to have access to lomi via insurance...[using]

insurance as a vehicle of payment.”

-Executive DirectorNon-Profit Organization

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-

19

PILI 'OHANA PARTNERSHIP PROGRAMS: Culturally and community tailored weight loss and weight

maintanance programs that have been scientifically tested through a research team comprised of

individuals from the community and medical school.

KKV HO'OULU 'AINA: Innovative effort by KKV to provide a community park and land-base to

address social and health determinants of the community.

COMMUNITY-BASED GARDENS: The explosion of school and community gardens in Hawaiºi

developed to increase food security, physical activity, and nutritional benefits which often engages

the spiritual, emotional, and cultural connection Pacific Peoples have to the land.

THE NATIVE HAWAIIAN TRADITIONAL HEALING CENTER AT WCCHC: A pioneering approach by a

community health center to intergrate Native Hawaiian traditional healing and cultural education

to the primary care setting.

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PRIMARY CARE & ENABLING SERVICES

HEALTH INSURANCE COVERAGE

There is a 25% shortage of primary care physiciansin Hawai‘i.

Collectively, federally quali!ed community health centers provide primary care to 10% of Hawai‘i’s population – half of which are Medicaid patients and 25% of which are uninsured. The number of patients they serve has increased 110% over the past 10 years.

Key Finding:

Promising Trends:

Promising Practices In the Community

--

-

Table 1. Age-Adjusted Percent Distributions of Insurance Coverage in United States, 2010

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Race/Ethnicity

Under 65 years 65 years of age and over

Private Medicaid Other Uninsured Medicare only

% SE % SE % SE % SE % SE

White

BlackAI/AN

Asian

NHPI

Hispanic/Latino

64.1 0.52 14.7 0.32 3.3 0.15 17.9 0.30 31.6 0.76

44.9 0.82 29.3 0.67 4.7 0.28 21.1 0.53 40.4 1.65

31.5 5.93 21.5 2.51 2.7* 0.82 44.2 7.80 60.5 8.74

67.8 1.28 12.4 0.81 3.1 0.38 16.7 0.81 40.5 2.91

47.6 6.32 27.2 6.41 - - 24.8 6.75 78.9 13.10

38.5 0.76 24.7 0.50 3.0 0.20 33.7 0.61 45.3 1.99

20

HEALTH CARE SERVICES

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Figure 19. Ethnicity of the Patients Served by Community Health Centers, Hawai‘i, 2010

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FINDING SOLUTIONS

Current research shows that instilling lasting behavioral changes, which will establish healthy lifestyles is a complex and dif!cult undertaking. We need to better understand how to support the healthy lifestyle changes people initially make so that they become sustainable over time. We do know broad societal commitment is needed to improve lifestyle patterns. Policy decisions that encourage physical activity (e.g. parks, physical activity programs, community gardens) or deter unhealthy behavior (e.g. soda tax, smoke-free areas) and educational efforts will build on each other. Additionally, special efforts are needed for the populations most at risk, such as NHPP. These efforts must be in-line with the values, beliefs, and practices of these groups. Prevention is the most powerful prescription; barriers to prevention efforts must be dismantled. Resources are needed to provide early intervention programs that will facilitate improvements in family and individual lifestyle choices.

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22

OTHER DETERMINANTS OF HEALTH

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“ The burdens of [health] issues are carried by the community...it is [our] belief that the community must share in the solutions...which can include addressing the social

determinants of health.”

-Rural Community Health Center

The number of Native Hawaiians enrolled in UH community colleges jumped 53% between 1992 and 2010 going from 13.6% to 28.8%. With investments and innovations being spurred by federal initiatives, community colleges are providing important pathways to advanced education and economic opportunities.

The Native Hawaiian labor force has less people with college degrees and graduates in higher wage !elds, such as technology, science, and business.

Key Finding:

Promising Trends:

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23

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Figure 20. Age-Adjusted Percent Distributions of Health-Related Conditions in U.S. 2010

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Figure 21. Occupations of NHPI in Hawai‘i by Sex and Median Hourly Rates

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25

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EDUCATION

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26

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Table 2. University of Hawai‘i – Native Hawaiian Attendance

:V\YJL!���)HS\[ZRP�L[�HS���������

Figure 23. Trends in Native Hawaiians as a Percentage of Total University of Hawai‘i Enrollment

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School of Medicine

Psychology Department

School of Human Nutrition, Food & Animal Sciences

School of Nursing & Dental Hygiene

School of Social Work

Health School or Department 8QLYHUVLW\�RI�+DZDLȧLDW�0ąQRD

(N)

NH Majored in College/School

(N)

NH Majored in College/School (%)

497

294

185

665

301

39

25

23

96

63

8.0

8.5

12.0

14.0

21.0

27

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28

SOCIAL & CULTURAL WELL-BEING

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Figure 24. Student Alignment with Key Hawaiian Concepts, Percent in Agreement

:V\YJL!���2HTLOHTLOH�:JOVVSZ����� �

“ Create a welcoming refuge, kipuka, for patients, clients, and community members to lay down [their] cares. Making them feel safe and

respected is at the core.”

-Urban Community Health Center Leadership

Continued promotion of traditional values, such as lokahi, ‘ohana, and aloha, strengthen the resilience, identity, and social connectedness of Native Hawaiians and Paci!c Islanders and contribute to their physical, mental, and spiritual health.

Hawaiian youth are reconnecting with traditional Hawaiian values and practices, such as relationship to land and its natural resources.

Key Finding:

Promising Trends:

-

29

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--

- -

30

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The NHPP labor force needs more individuals in the high wage !elds of science, technology and business to boost individual and family income levels. Creating educational and professional pathways into these !elds can be done through various means such as focused scholarships, internships, and educational enrichment programs. Successful models can be found in the educational initiatives implemented in University of Hawai‘i’s community colleges. These institutions have demonstrated impressive gains in reaching and teaching NHPP. Often a key element has been a focus on Native history and cultural practices, which appear to encourage bi-cultural success; an ability to achieve excellence in both NHPP and western environments.

FINDING SOLUTIONS

EMOTIONAL & SPIRITUAL WELL-BEING*VYL�J\S[\YHS�]HS\LZ�ZOHYLK�I`�5/70�PUJS\KL�MHTPS �̀�JVTT\UP[ �̀�ZWPYP[\HSP[ �̀�HUK�H�OVSPZ[PJ�]PL^�VM�SPML�

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--

31

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Figure 25. Map of Ulu Network Organizations, 2013

“Diabetes, obesity, heart disease, long term effects of pulmonary disease; problems remain the same, but it has gotten bigger.

-Neighbor Island

Health Leader

32

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PRIORITY MEDICAL AND HEALTH AREAS

33

Table 3: Top Community Medical Concerns Identified by Ulu Network Leaders

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“ The health center's patient base in general is more complex...the more difficult patients who have been

'fired or let go' from other providers end up at the health center."

-Community HealthCenter Leader

Diabetes

Condit ion Percentage (%)

83.3

53.3

53.3

53.3

30.0

Heart Disease

Obesity

Mental & Behavioral Health

Hypertension

Substance Abuse

Cancer

Asthma

Dental Health

Tobacco/Smoking

30.0

23.3

20.0

20.0

16.7

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NEEDS IN HEALTH AND MEDICAL SERVICES

- -

PROMISING PRACTICES

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“PCMH has brought good things, such as patient

navigators [and] case managers.”

-Community Health Center Executive DIrector

;̂ V�JHYKPVTL[HIVSPJ�OLHS[O�PUP[PH[P]LZ�KL]LSVWLK�[OYV\NO�WHY[ULYZOPWZ�IL[^LLU�ZL]LYHS�<S\�5L[^VYR�

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HUK� PUJVYWVYH[PVU� VM� 5H[P]L�/H^HPPHU� J\S[\YL� PU[V� [OLPY� VYNHUPaH[PVUHS� J\S[\YL� HUK� ZLY]PJLZ�� 22=�

^HZ� ZLLU� HZ� H� SLHKLY� PU� [OL� HZZPTPSH[PVU� VM� [OL� ZVJPHS� KL[LYTPUHU[Z� VM� OLHS[O� PU[V� [OLPY� ZLY]PJL�

KLSP]LY`�Z[YH[LNPLZ�HUK�[OL�\ZL�VM�5/77�ILSPLMZ�HUK�WYHJ[PJLZ�PU�[OLPY�WYVNYHTTPUN��(KKP[PVUHSS �̀�[OL�

VYNHUPaH[PVU»Z�WYVTV[PVU�VM�[OL�YLSH[PVUZOPW�VM�YL[\YUPUN�[V�[OL�ºHPUH��SHUK��HUK�OLHS[O�PZ�ZLLU�HZ�H�

IVSK�HUK�PU[LYLZ[PUN�HWWYVHJO�MVY�H�*/*��^OPJO�HZ�VUL�5LPNOIVY�0ZSHUK�TLTILY�Z[H[LK��YLZ\S[LK�PU�

[OL�¸KL]LSVWTLU[�VM�WO`ZPJPHUZ�HZ�[LHJOLYZ�¹����������������

35

-

-

36

Table 4. Top Priorities for Organizational Training to Improve Cardiometabolic Health

Cardiometabolic Disease Training

Training and Informational Needs Percentage (%)

36.7

33.3

23.3

23.3

23.3

Cultural Competency Training

Nutritional & Healthy Diet Training

Motivational Interviewing Training

Behavioral Change & Goals Setting Training

Exercise Programs and Information 16.7

NEEDS IN ORGANIZATIONAL TRAINING TO IMPROVE CARDIOMETOBOLIC HEALTH

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“Actionable messages or simple messages that will be consistent directions for the patients and community and can be communicated consistently from providers to receptionist.”

-Neighbor Island Ulu Network Member

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FINDING SOLUTIONS

Integrated primary care delivery through approaches such as the Patient Center Medical Home, was identi!ed as foundational to improved outcomes. These health improvements could be enhanced in several ways. One way is with greater support for prevention programs such as PILI ‘Ohana, and another way is providing training of health professionals in cultural competency with NHPP. Community leaders were interested in new models to enhance culturally aligned health services or environments, such as traditional Native Hawaiian healing, but wanted more guidance, technical support, and !nancial resources to enable implementation. They noted the patients they serve responded well to the Land, Food and Health initiative that combine patient education with Paci!c Peoples relationship to land. Innovation pioneered in organizations such as Kokua Kalihi Valley Comprehensive Health Center and Wai‘anae Comprehensive Health Center are successful models that can be replicated at other sites.

37

-

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38

Improvements in health status will come through:

FINDING SOLUTIONS

-

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;OPZ�W\ISPJH[PVU�I`�[OL�<UP]LYZP[`�VM�/H^HPºP��1VOU�(��)\YUZ�+LWHY[TLU[�VM�5H[P]L�/H^HPPHU�/LHS[O�HUK�

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MYVT�[OL�5H[PVUHS�0UZ[P[\[L�VM�4PUVYP[`�/LHS[O�HUK�/LHS[O�+PZWHYP[PLZ�VM�[OL�5H[PVUHS�0UZ[P[\[LZ�VM�/LHS[O�

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P�RH�7VUV�M\UKZ�MYVT�;OL�8\LLU»Z�/LHS[O�:`Z[LTZ��;OL�JVU[LU[�PZ�ZVSLS`�[OL�YLZWVUZPIPSP[`�VM�[OL�

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MAHALO AND ACKNOWLEDGMENTS

40

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