Hawaii is the only island state in the U.S., comprised of seven populated islands organized into four major counties: Hawaii, Maui, Honolulu (Oahu), and Kauai. Spanning nearly 11,000 square miles with a land mass of 6,422 square miles, the state is home to 1.4 million residents with 70% living in Honolulu, the most populous county.

Hawaii is one of the most ethnically diverse states with no single majority race (39% Asian, 25% White, 11% Native Hawaiian/Pacific Islander, 2% Black) and a large heterogeneous Pacific Islander and Asian population. Nearly 23% of the population is mixed race with indigenous Native Hawaiians comprising 20.1% of the population (when combined with other races). Also, about 19.3% of all residents are immigrants–mostly from Asia and the Pacific.

The state government is responsible for functions usually performed by counties or cities in other states. Hawaii is the only state, for example, with a single unified public school system. Similarly, Hawaii has no local health departments but has county health offices on the ‘neighbor islands’ to assure services statewide.

The Hawaii State Department of Health (DOH) works to protect and improve the health and environment for all people in the state. The DOH Family Health Services Division (FHSD) uses the federal Title V Maternal and Child Health (MCH) Block Grant (Title V) to improve the health of women, infants, and children, including those with special healthcare needs. FHSD works to promote health equity and uses both life course and multi-generational approaches. To expand its capacity and reach to address population needs, FHSD leverages state and federal grant funds and community partnerships.

For FY 2021, Hawaii identified eleven Title V priorities, adding four additional state priorities in 2021 resulting from the COVID pandemic. The priorities are listed below across the six Title V MCH population domains.

COVID in Hawaii

Hawaii managed the COVID-19 pandemic better than many other states. This was reflected in some of the lowest COVID case numbers, hospitalizations, and deaths in the U.S., despite severe COVID variant surges over 2021-2022. Aptly, the Commonwealth Fund ranked Hawaii number one among states in managing COVID response in June 2022.

Policy: Hawaii’s success relied on the ability to restrict all travel early in the pandemic and the State’s close adherence to Centers for Disease Control (CDC) safety guidelines and cautious loosening of safety mandates/restrictions. Governor David Ige acted swiftly in 2020 at the first signs of travel-related cases, issuing the first of 21 COVID-related emergency proclamations in March 2020. Mandatory shutdowns of non-essential services; stay-at-home orders; self-quarantine for all travel within and entering the state; limitations on gatherings; mandated mask wearing; and physical distancing were ordered to reduce disease spread. The State also implemented active COVID-19 testing and contact tracing.

The State cautiously relaxed COVID restrictions to reopen the economy, including the launch of the Hawaii Safe Travels program in October 2020, requiring proof of vaccination or a negative COVID test to avoid quarantine for all travelers. A severe COVID Delta variant surge in summer 2021 followed by another winter Omicron surge delayed lifting of all COVID restrictions till March 2022. Hawaii was the last state in the U.S. to end an indoor mask mandate although masks were still required for public schools through the remaining school year.

COVID: The state reported a cumulative 283,574 COVID-19 cases and 1,482 deaths as of June 2022. Compared to June 2021, cases increased 585% and deaths increased 172%, reflecting the effects of the surges related to COVID variants. The Omicron surge led to a wave of infections greater in magnitude than the Delta wave; however, hospitalizations and deaths were far lower than 2021 levels. Hawaii’s cumulative death rate of 99/100,000 is the lowest in the country.

COVID highlighted long-standing disparities with Native Hawaiian, Filipino, and Pacific Islanders experiencing higher rates of infection and death. With targeted messaging and concerted outreach to these communities, disparities have improved somewhat. Pacific Islanders remain overrepresented in total cases but whites are now also overrepresented. Sadly, Pacific Islanders and Filipinos are still much more likely to die of COVID-19 than other ethnic groups.

Vaccinations: The coordinated actions by Hawaii state, county and private healthcare partners also contributed to Hawaii’s successful COVID management by expanding the availability of testing, vaccinations, and therapeutics. As of July 2022, 79.3% of Hawaii’s population was fully vaccinated, the sixth highest rate in the U.S., with another 40% receiving a booster dose. An estimated 78% of youth ages 12-17 years old and 40% of children 5-11 years old have been fully vaccinated.

Economic Impact of Closures: Initial COVID shutdown saw an unprecedented contraction of the state’s economy:

• There was a 98.8% decrease in travelers to the state in April 2020.
• Hawaii’s unemployment rate rose from 2.1% in March 2020 to 21.9% in one month, the lowest to the highest rate in the country.
• Food banks in the state reported serving 60% more people than prior to the pandemic.
• Enrollments for government assistance soared with a 50% increase in SNAP food assistance and 28% increase in Medicaid from April 2020 to March 2021.
• Schools transitioned to distance learning and those without access to internet or WiFi were left with limited or no access to educational, health, or social resources.

Recovery: In 2021, the economy made an astounding turn around fueled by an unexpected domestic tourism rebound, with visitor arrivals reaching nearly 90% of 2019 levels. Unemployment came down sharply; however, many workers who left the labor force during the pandemic have not returned, resulting in a very tight labor market. An unprecedented level of federal spending provided essential support for the state economy. Direct aid to state and local governments offset significant budget shortfalls. Direct stimulus payments, expanded unemployment insurance, entitlement supports, and subsidies helped to maintain personal income through 2020-21. Continued recovery remains uncertain given everchanging factors: rising inflation, record high home prices and rents, flat international visitor market, and the course of COVID variants.

Response: The Department of Health (DOH) worked tirelessly to protect and inform the public about prevention, treatment, and resources for those experiencing hardship. Materials, PSAs, and media releases included translations in languages of vulnerable communities and culturally tailored messaging. DOH coordinated the statewide development and dissemination of COVID safety practices, data, resources, and funding throughout the prolonged pandemic response.

Title V Programs/Services: Though the pandemic, Title V programs continued to embrace flexibility in response to changes in service delivery, population needs, and new norms. Programs shared relevant guidance, resources, and messaging to help community partners and families during COVID. Although hampered by vacancies in critical data positions, FHSD continued monitoring/collecting data in new partnerships with university researchers. Programs supported more efforts to address health disparities, exacerbated by the pandemic. FHSD also acknowledged existing public health and healthcare workforce needs to minimize burnout and staff turnover.

In 2021, Title V programs, as reported in Form 5a, continued to see declines in direct client services with a 32.7% reduction over 2019 numbers. The 2021 decrease was not consistent across all program and population groups and also reflects the loss of Title X Family Planning funding. Other public health services, as reported in Form 5b, reflect a 37.4% increase in outreach to adults and a 47.5% increase in outreach to children compared to 2019. This was largely due to more media initiatives to provide critical updates on services and health messaging/guidance.

5-Year Plan Changes for 2021-2025

FY 2021 marks the first year of the Title V 5-year project period. Four new state priorities were added last year as a result of pandemic impacts and federal funding opportunities.

• Food Insecurity through WIC services:

• Telehealth expansion to underserved communities
• Pediatric Mental Health Access
• Child Wellness Visits/Immunizations

Revisions to plan strategies and activities continued with delays in the plan implementation as a response to everchanging pandemic circumstance/conditions. Key highlights are provided by domain and priority health issue.

DOMAIN: WOMEN’S/MATERNAL HEALTH

Promote reproductive life planning

• In partnership with the Hawaii Maternal Infant Health Collaborative (HMIHC), Hawaii continues to implement two evidence-based strategies to improve access to healthcare and reproductive decision-making: promote use of the One Key Question® (OKQ) screening approach and increase accessibility to Long-Acting Reversible Contraception (LARC). OKQ training is now offered online with over 1,000 providers trained. Most Hawaii birthing hospitals now stock LARC for same day access.

DOMAIN: PERINATAL/INFANT HEALTH

Promote safe sleep practices

• Conducted a media campaign using TV, radio, and digital ads to promote safe sleep messaging and resources available through the statewide The Parent Line (TPL). TPL staff  were trained on safe sleep information and safe sleep materials (available in 11 languages), which can be mailed or downloaded from the website. Families may also access safe sleep online workshops.

Address Food Insecurity through Improving WIC services

• Partnered with the Hawaii Children’s Action Network and received a Partnership for Children grant to help improve WIC services. A Community Advisory Committee was formed with community programs, university researchers, as well as three WIC parents. Maintaining long-term enrollment of WIC families and addressing underutilization of benefits are the key priorities identified. A research study of WIC families will help identify potential recommendations to pursue.

DOMAIN: CHILD HEALTH

Improve early and continuous screening for developmental delay

• Established a community-based model for development screening, referrals, and supports for children in Maui County, which was funded by the Early Childhood Comprehensive Systems (ECCS) Impact grant. Funding helped to screen over 800 children, create a network of healthcare and service providers to promote developmental screening, and establish a parent leadership council to help guide grant activities.
• Partnered with American Academy of Pediatrics on a Centers for Disease Control (CDC) Act Early grant to promote development screening through trainings of pediatric and other service providers. Projects included training of WIC clinical staff to pilot a developmental checklist, launching a social media campaign with parent social media influencers, and translating education information to reach Pacific Islander populations.

Reduce the rate of child abuse and neglect (CAN)

• Forged critical partnerships to promote evidence-based prevention practices in collaboration with the state’s Child Welfare Services (CWS), Judiciary, Department of Education (DOE), and community service providers. Supported implementation of the CWS five-year Service Plan by sponsoring community-based projects that prevent CAN through family and parenting support programs and activities.
• Supported statewide trainings/information dissemination to increase awareness about adverse childhood experiences and promote trauma-informed care models of practice.
• Maintained MIECHV evidence-based services for at-risk families.

Increase Child Wellness Visits

• Launched a media campaign to promote child wellness visits. Resources and a website were developed to assist families without regular sources of care. Families from the Hawaii Parent Leadership Training Institute tested messaging and appeared in the TV spots. Planning partners included the AAP-Hawaii, state Medicaid program, and Hawaii Children’s Action Network.

DOMAIN: ADOLESCENT HEALTH

Improve adolescent health and well-being

• Partnered with TeenLink Hawaii, a youth-driven, empowerment program, to conduct a survey to identify health issues/concerns for youth during the pandemic. Based on the survey findings, website resources were developed to address priority issues, and a media campaign was launched to promote the TeenLink website using popular social media ‘influencers.’
• Developed a scope of work to partner with the Pacific Islander community to identify needs/resources to support well-being of Pacific Islander youth.

DOMAIN: CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)

Improve transitions to adult healthcare

• Developed a system for transition planning for enrolled Children and Youth with Special Health Needs Section youth using the evidence-based Six Core Elements of Health Care Transition, including guidelines, educational tools, workbook, and database tracking. The system model is being adopted by Kaiser Permanente Hawaii for adolescent services.
• Supported development of an active statewide network of agency/community partners that promote transition services, including the state DOE, Vocational Rehab, and family service organizations through popular in-person events. Many programs were postponed or switched to virtual events in 2021.

DOMAIN: CROSS-CUTTING/SYSTEMS BUILDING

Expand telehealth services to underserved rural communities

• Implement $5M CDC Health Equity grant award to establish 15 new telehealth access points with health and digital navigators in public libraries located in underserved communities statewide.

Expand pediatric mental health care access to underserved rural communities

• Support integration of behavioral health into pediatric primary care practice by establishing a pediatric mental health teleconsultation service, training, and care coordination so pediatric providers can better diagnose, treat, and/or refer children and youth with behavioral health conditions to available services.