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 (38% Asian, 25% White, 10% Native Hawaiian/Pacific Islander, 2% Black). Nearly 23% of the population is mixed race with Native Hawaiians comprising 6.1% of the population. Also, about 18.7% 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 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.

Hawaii identified eight priorities for 2016-2020 based on the 2015 needs assessment spanning the six Title V population domains.

Ongoing Needs Assessment: COVID in Hawaii

The 2020 5-year Title V needs assessment was completed in January 2020 prior to the Novel Coronavirus Disease 2019 (COVID-19) pandemic. A brief overview of the pandemic in Hawaii and its impacts follows.

Hawaii managed the COVID-19 pandemic better than many other states. This reflects Hawaii’s ability to place restrictions on travel early in the pandemic and the State’s close adherence to federal safety guidelines and recommendations.

Policy: Governor David Ige acted swiftly issuing the first of 21 COVID-related emergency proclamations on March 4, 2020, at the first signs of travel-related cases, preceding the federal government’s response to the pandemic on March 13. The governor’s proclamation directed the State and counties to implement a mandatory stay-at-home order; self-quarantine for all persons entering the state and traveling between counties; limited non-essential business, restaurants and bars, and gatherings; and mandated safe practices including mask wearing and physical distancing to reduce the spread of COVID-19. The State also implemented active COVID-19 testing and contact tracing. County proclamations followed with added restrictions based on disease levels in coordination with the State.

Course of the Disease: The actions by state and county officials throughout 2020 resulted in limited cases and the lowest number of deaths in the U.S. In 2020, Hawaii suffered a case spike during the summer that delayed loosening of out-of-state travel restrictions until late September. After another smaller December holiday increase, virus numbers trended downward until a recent July 2021 spike due to the Delta variant. Overall, COVID-19 cases and deaths were minimized. The state reported a cumulative 36,250 COVID-19 cases statewide and 508 deaths as of June 26, 2021. Hawaii’s cumulative death rate of 38/100,000 has been the lowest in the country. Like most states, initial deaths were largely confined to the elderly; however, Hawaii was largely successful in limiting outbreaks at long-term care (LTC) and congregate settings. Dramatic disparities were seen with Native Hawaiian, Filipino, and Pacific Islanders experiencing higher rates of infection and death. Since December, Hawaii is among the states furthest along in vaccination, priming the state’s economic recovery.

Economic Impact: Disruptions from the pandemic resulted in a 98.8% decrease in travelers to the state in April 2020. Hawaii’s unemployment rate was the highest in the country at 22% in April 2020; it has improved as the economy slowly reopened, but still remains high at 8.0%. The most vulnerable in our communities were most impacted by unemployment. Food banks in the state reported serving 60% more people than prior to the pandemic. Enrollments for government assistance soared: 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 Wi-Fi were left with limited or no access to educational, health, or social resources.

Recovery: The economy has made steady improvements in 2021 fueled by a tourism industry rebound, with visitor arrivals at almost 90% of 2019 levels. However, job recovery continues to lag by 40%. An unprecedented level of federal spending also provided essential support for the state economy. Direct aid to state and local governments offset a significant fraction of budget shortfalls. Housing insecurity threatened many families but were helped by the federal eviction moratorium and assistance to renters and homeowners. Rents, which fell in 2020, have turned upward in 2021, and home prices have continued to reach record highs. Since its low in April 2020, economists estimate Hawaii’s recovery to be 75% of its pre-pandemic status.

Response: The Department of Health 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 efforts were closely scrutinized, lauded and criticized at times by the public and elected officials. In September 2020, DOH leadership changed with the appointment of Dr. Elizabeth Char as director. Title V nursing staff were deployed to assist directly with COVID disease control efforts.

Title V Programs/Services: In 2020, Title V programs as reported in Form 5a saw a 3.8% reduction in direct client services as in-person client visits moved to telehealth and family concerns switched to immediate COVID-related needs. However, client outreach efforts in 2020 reflect a 300% increase over 2019 as FHSD launched more media initiatives to provide critical updates on service availability and health messaging to help families cope with the stressors of the COVID lockdowns. Most Title V program staff moved to telework in 2020. While most programs reported a general increase in partnership collaboration, family engagement efforts proved more challenging during the pandemic.

5-Year Plan Changes for 2021-2025 (FY 2021)

Given the consequences of the pandemic, the Title V priorities were reassessed in FY 2021 and changes made. Three priorities/performance measures will be retired:

• Children’s Oral Health
• Telehealth expansion among Title V programs
• Breastfeeding (deleted in FY 2021)

Four new state priorities were added in FY 2021 as a result of pandemic impacts and new federal funding opportunities. All four priorities address health equity.

• Food Insecurity through WIC services
• Telehealth expansion to underserved communities
• Pediatric Mental Health
• Child Wellness Visits/Immunizations

Health Equity: Hawaii also integrated a health equity strategy into the plans for any Title V priorities without an existing equity component. Activities for the new equity strategies were selected from AMCHP conference presentations and guidance from the MCH Evidence Center.

Other Plan Changes: Many planned FY 2020 activities were delayed/postponed due to COVID. Several priority strategies, activities, and measures were revised in the 5-year plan in response to ever-changing pandemic circumstance/conditions in partnership with community stakeholders. All programs continue ongoing assessment activities to engage stakeholders, families, and youth through the ever-changing pandemic environment.

5-Year Plan (2016-2020): Key Accomplishments

FY 2020 marks the last year of the Title V 5-year project period. This year’s report provides an opportunity to highlight two to three key accomplishments achieved during the plan period by domain and priority.

DOMAIN: WOMEN’S/MATERNAL HEALTH

Promote reproductive life planning

• Implemented two evidence-based strategies from the MCH Bureau Infant Mortality Learning Collaborative that 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).
• Medicaid provider policies promoted use of OKQ by eliminating prior approval to expand contraception coverage and allow for one-year contraception prescriptions, unbundling LARC from delivery charges and hospital stocking.
• Trained over 1,000 healthcare and service providers in OKQ curriculum and most Hawaii birthing hospitals now stock LARC for same day access.

DOMAIN: PERINATAL/INFANT HEALTH

Promote breastfeeding

• Completed and continued implementation of the State Breastfeeding Plan.
• Expanded WIC community-based provider network to increase service availability and access expertise to reach underserved, high-risk populations.
• Provided updated breastfeeding and COVID-19 information during the pandemic for community responders, healthcare workers, and the public.

Promote safe sleep practices

• Promoted adoption of safe sleep policies, protocols, and guidelines following the AAP standards by all the state’s 12 birthing hospitals.
• Policy adoption for mandated annual safe sleep training for all state licensed childcare providers and partnered to develop training/educational materials now used widely by programs/agencies serving families with newborns/young children.
• Partnered with the State Child Care Program and Office of Language Access to translate SS educational materials into 11 languages to broaden outreach efforts to high-risk groups.

DOMAIN: CHILD HEALTH

Improve early and continuous screening for developmental delay

• Completed and continue to disseminate standard guidelines for developmental screening with statewide stakeholders for all programs working with young children.
• Integrated development screening into all state early childhood plans and working collaboratives.
• Established systematic developmental screening data sharing among Title V early childhood programs to assure screening, referral, and follow-up services.
• Established a community-based model for development screening, referrals, and supports for children in Maui County funded by the Early Childhood Comprehensive Systems (ECCS) Impact grant.
• Received Centers for Disease Control funding to partner with Hawaii’s pediatric Act Early Ambassador to promote development screening.

Improve the oral health of children

• Completed the CDC state oral health infrastructure grant, including development of data surveillance plan and publications and completion of the first basic screening surveys of third grade students and Head Start enrollees.
• Rebuilding of the State Oral Health Coalition with formal organizational structure, fiscal agent, and working subcommittees. During the early days of the pandemic, shared critical information on safety protocols and avenues to secure PPE served as a hub to coordinate bulk PPE purchasing and hosted workforce trainings.

Reduce the rate of child abuse and neglect (CAN)

• Forged critical partnerships to promote evidence-based prevention practices and collaboration among the State’s Child Welfare Services (CWS), Judiciary, Department of Education (DOE), and community service providers. Completed the CWS five-year Service Plan with a focus to prevent children from entering the foster care system.
• Supported statewide efforts to increase awareness about adverse childhood experiences and promote trauma-informed care models of practice.
• Maintained MIECHV evidence-based services to at-risk families.

DOMAIN: ADOLESCENT HEALTH

Improve adolescent health and well-being

• Partnered with the Coalition for Drug-Free Hawaii youth network to create a youth-designed Adolescent Resource Toolkit (ART) available via the TeenLink Hawaii website and supported by media campaign using popular social media ‘influencers.’
• Integrated adolescent health information and promotion of annual wellness visits into the federal Personal Responsibility and Education Program (PREP) evidence-based teen pregnancy prevention program serving high-risk youth, including workforce training with youth service providers.

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 2020.

DOMAIN: CROSS-CUTTING/SYSTEMS BUILDING

Promote telehealth throughout Title V programs

• Led by the Genetics program, provided equipment, software, and training to support use of Zoom across FHSD programs, which laid the foundation for a smooth transition to telehealth/telework during the COVID pandemic. Early in the pandemic, telehealth educational videos/trainings were developed for healthcare providers and families, which were used by HRSA nationally to promote use of telehealth.
• Established Project ECHO Hawaii with the Area Health Education Center to use videoconferencing to build healthcare workforce capacity to improve patient access to specialty healthcare in rural communities.