The Hawaii State Department of Health (DOH), Family Health Services Division (FHSD), conducted a comprehensive needs assessment (NA) that informed FHSD and its state and community partners of the health needs of women, infants, children, and families throughout the State. The NA process examined a variety of primary and secondary data sources, engaged both internal and external stakeholders, and followed a structured and collaborative decision-making process. Findings of the NA guided confirmation of Hawaii’s Title V maternal and child health (MCH) priority issues for 2021-2025.

Goal, framework, and methodology

The goal of the NA was to gather a well-rounded picture of the five population health domains, using a comprehensive and inclusive assessment process, so that priority MCH needs could be identified and resources appropriately allocated for the 2021-2025 Title V program cycle.

III.C.2.a(i). The NA framework and process (see Figure 1) were informed by six guiding principles:

• Promote health equity – so that all people and families have the opportunity to attain their highest level of health.
• Consider social determinants of health – the broad social, economic, and environmental factors that must be addressed to promote health and achieve health equity.
• Utilize a life course approach – acknowledges that experiences during critical periods of an individual’s life (e.g., infancy, childhood, adolescence, and childbearing age) can have long-term implications.
• Value the roles of our partners and communities – so that our plans and the system of care are family-centered and community-based.
• Utilize evidence-based/informed practices where possible – while also acknowledging the importance of cultural adaptations/tailoring (and evaluation of those adaptations).
• Focus on primary prevention and early intervention – so the system is not only reactionary, but strives to be upstream and prevention-focused.

The framework below illustrates FHSD’s NA process and methodologies. Phase 1 included planning and a comprehensive environmental scan, reviewing quantitative and qualitative evidence from a variety of secondary sources. Primary data were collected in Phase 2, where professional and family stakeholders were directly engaged for their feedback on Title V activities and visions for a thriving community. Phase 3 brought all the evidence together for synthesis, planning, and reporting. The process mostly followed the 2015 assessment with some revisions based on evaluative comments received from internal and external stakeholders.

     Figure 1. Overview of Hawaii’s five-year needs assessment framework and process

The FHSD leadership team oversaw and coordinated the NA process, identification of priority issues and performance measures, and development of the Title V grant report/application. The team included:

• FHSD administration – Chief, Title V coordinator, FHSD Epidemiologists (for data support);
• Chiefs of Maternal and Child Health Branch, Children with Special Health Needs (CSHN) Branch, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Services Branch;
• FHSD Coordinators on Neighbor Islands;
• Allied programs – Early Childhood Comprehensive Systems, Oral Health; and
• External partners – Family Leader (also Director, Hilopa‛a Family to Family Health Information Center), consultation/technical assistance from University of Hawaii at Manoa Public Health and Indices Consulting, LLC.

III.C.2.a(ii). Stakeholder Involvement

Two community surveys – one for providers, and the other for families/community members – were administered to solicit feedback directly from FHSD stakeholders for the specific purpose of informing the five-year NA. Not only were stakeholders participants of these surveys, they also helped to refine and test the data collection tools. The survey design, methodologies, and overall results are described in the “Data Sources” section.

FHSD partners from various backgrounds are engaged through many other ways, as part of the ongoing Title V NA process. These include contributing to the planning, implementation, and evaluation of specific FHSD activities; receiving FHSD activity updates and providing feedback; partnering via allied and cross-agency/disciplinary workgroups. These means of stakeholder involvement are described in greater detail in the “Title V Program Partnerships, Collaboration, and Coordination” section.

III.C.2.a (iii) Quantitative and qualitative methods to assess strengths and needs of population, and capacity of program and partners

A variety of methods were used to gather a broad array of data, to ensure the comprehensiveness of the NA to determine Hawaii’s Title V priorities and 5-year plan. The following table lists the methods used, following the order described in the NA framework.

III.C.2.a(iv) Data sources

Phase 1, Component 1 – program reviews with staff

Multiple rounds of small meetings were conducted with program staff to reflect on the successes and challenges from the previous five years and assess opportunities/plans to improve health outcomes. During these meetings, quantitative and qualitative performance data were reviewed, as well as supporting documents such as reports from the MCH Evidence Center. Each program’s logic model was also reviewed to identify any necessary changes to strategies, activities, and/or measures.

Phase 1, Component 2 – document review

Major local and national assessments, studies, and strategic plans were reviewed as part of Hawaii’s Title V NA process and are detailed in the Supporting Documents. These reports were selected because the planning and/or data collection occurred concurrently with the Title V NA and their mission or scope overlapped with Title V. It was important to be aware of and incorporate these findings to inform the Title V assessment, avoid duplication when possible, and extend the reach of the Title V assessment to include community and professional stakeholders not normally included in Title V assessment efforts. 

Phase 1, Component 3 – data review

A variety of secondary quantitative sources informed the NA. The primary sources were:

• Federally Available Data (FAD).
• National Survey of Children’s Health (NSCH)
• U.S. Census
• Hawaii Health Data Warehouse (HHDW) including Vital Statistics, Behavioral Risk Factor Surveillance System (BRFSS), Pregnancy Risk Assessment Monitoring System (PRAMS) and Youth Risk Behavior Surveillance System (YRBSS).

Additional data sources are also discussed/identified in other NA phases.

Phase 1, Component 4 – Health Equity Focus

To effectively address health equity in the state, the NA included developing issue briefs on key populations to help inform Title V strategies and plans. Four major communities emerged for additional focus: 1) Compacts of Free Association (COFA) Pacific Island migrants; 2) Immigrants; 3) Homeless/houseless families and youth; and 4) Native Hawaiians. The briefs will be completed in Fall 2020, summarizing quantitative and qualitative data for each group, with the goal of disseminating the information to engage stakeholders in discussions to better serve and work with these communities.

COFA migrants: Post-World War II, the Federated States of Micronesia (Yap, Chuuk, Kosrae, and Pohnpei), the Republic of the Marshall Islands, and the Republic of Palau entered into treaties with the US, known as the Compacts of Free Association (COFA). Under the Compact, COFA migrants are designated as legally residing noncitizen nationals who can freely live, work, and study in the U.S. indefinitely; however, they are not eligible for key entitlement programs (Medicaid, Social Security, disability, and housing programs) with the state assuming most of the costs for services. In 2018, there were approximately 16,680 COFA migrants in Hawaii.

Immigrants: As of 2018, there were 266,147 immigrants in Hawaii, or nearly one-in-five (18.7%) of all residents. This is the 6th-highest of all states. 54.5% are women, and 5.8% are children. There are approximately 45,000 undocumented immigrants in Hawaii (3.3% of the population). The majority are from the Philippines. Hawaii is the only state where women (55%) outnumber men in the unauthorized population. Approximately 7% of K-12 students have at least one undocumented parent.

Homelessness: Hawaii has higher rates of homelessness compared to most other states. In 2020, there were 6,458 homeless people in the State, with the majority on Oahu (4,428), followed by Hawaii County (797), Maui (789), and Kauai (424). After peaking in 2016, homeless rates dropped and have remained consistent since 2018. There are currently 499 homeless family households (76% sheltered, 24% unsheltered).

Native Hawaiians: The Hawaiian people and culture are the indigenous and host community of Hawaii. The Native Hawaiian people have a rich cultural and spiritual base, but also have experienced historical traumas and injustices – all of which contribute to the community’s health status.

The Office of Hawaiian Affairs (OHA) is a public agency responsible for improving the wellbeing of Native Hawaiians. Among its activities, OHA tracks data specific to the population publishing the OHA databook and OHA’s 2018 Haumea report focused on Native Hawaiian Women. Indicators of concern include:

• Native Hawaiian women have the lowest life expectancy (79.4 years) among all females in Hawaii.
• Native Hawaiians have highest rate of infant mortality, 2.3 times greater than Caucasians.
• From 2012-2014, Native Hawaiian mothers of all ages had higher rates of postpartum depression.

Phase 1, Component 5 – FHSD capacity and workforce

In addition to reviewing standard FHSD capacity metrics (e.g., programs, FTEs, vacancies, funding, partnerships, etc.), several other data sources were reviewed related to FHSD’s workforce. The sources are described here, and results are discussed in the “Findings” section.

Quantitative surveys:

• FHSD participated in ASTHO’s 2017 Public Health Workforce Interest and Needs Survey (PH-WINS). PH-WINS is a national survey of public health agency workers that assesses morale, training needs, and worker empowerment.
• FHSD participated 2019 Council of State and Territorial Epidemiologists (CSTE). nationwide survey to assess states’ maternal and child health service capacity during times of crisis/disaster.

Qualitative interviews:

• A 2018 University of Hawaii public health class NA project aimed to inform FHSD’s ongoing efforts related to staff training, continuing education, and workforce development. Interviews with health and administrative professionals across the Division were conducted.

Phase 2, Component 1 – provider surveys

Two community surveys – one for providers, and the other for families/community members – were administered to solicit feedback directly from FHSD stakeholders to inform the five-year NA. Survey designs, methodologies, and overall results are described here, and domain-specific results are presented in the “Findings” section. Survey copies are in the Supporting Documents.

The provider survey was distributed to partner agencies and service-providers, via an online (Survey Monkey) format. The list of providers was generated collectively by Title V program leaders, and therefore reflected a broad array of partners across domains, issues, and communities. The link was open from November 2019 to February 2020. The survey had three sections: 1) demographics about the participant and community(ies) they serve; 2) feedback on overall priority areas; and 3) feedback strategies within each priority area. A copy of the provider survey is in the appendix.

The final email list included 332 stakeholders. A total of 148 completed surveys were received, for a return rate of 45%. The graphs displayed here summarize a few of the demographic variables collected from the participants, including their county of residence.

Providers Surveys – Additional Demographics

(red – top 3 for each questions) 

Phase 2, Component 2 – family/community surveys

The family/community survey was distributed to community members at public events/meetings (e.g., health fairs, community workshops) as well as clients of FHSD services (e.g., WIC clinics). This survey was an abridged version of the provider survey and administered via paper-pencil format. The consumer groups and community events reflected a broad array of people across domains, issues, and communities. The survey was open from September 2019 to January 2020, and had three brief sections: 1) demographics about the participant; 2) feedback on overall priority areas; and 3) a space for open-ended comments.

A total of 500 completed surveys were received. The graph displayed here summarizes the participants’ county of residence.

III.C.2.a(v). Interface of data, final priority needs, and development of action plan

The comprehensive NA led to identifying Title V priorities for which the Action Plan was developed. This was the focus of Phase 3 of the NA – final synthesis, action plan development, and reporting. The process included:

1. Discussion and integration of NA data from Phases 1 and 2.
2. Selection of MCH issues for further review, based on population health domains, link to Title V National Performance Measures (NPM), current State priorities, or emerging issues.
3. Confirmation of overall priority issues, and subsequent confirmation of aligned NPM and other evaluation metrics.
4. Development of the Hawaii Action Plan for the MCH priority issues.

To ensure priority selection was systematic, the following criteria guided the process:

1. Data show needs and challenges. Be information driven (i.e. Hawaii rate worse than the U.S. rate; Hawaii rates worse for specific subgroups, or Hawaii can improve to match the rates of higher performing states.
2. There is community alignment and support. A need may be reflected in other state/community NAs, plans, or initiatives.
3. Viewed through a lens of equity. The process will be open, fair, and equitable. The assessment will be for the State, but will also highlight unique issues for counties, ethnic/cultural groups, and other special populations.
4. Priorities are appropriate for FHSD. FHSD is the lead, or has a major role, and can impact the issue; had the resources (staff, funding) to address the issue.

This section explores the five population health domains, with respect to health status and the results of the NA surveys that were relevant for each domain. The following table documents when survey participants were asked to reflect on Hawaii’s current Title V work, every domain and priority area resonated strongly. Therefore, FHSD could continue work on the current priority areas. Suggestions for possible changes/revisions focused on specific strategies, activities and evaluation measures. The results are still being reviewed for incorporation into future plans.

Title V Needs Assessment Surveys – Current Priorities

(red = top 3 in each column)

Women’s health – population domain overview

An estimated 300,000 women aged 15-49 years live in Hawaii, making up 43% of the female population in the state (Census data). The demographic characteristics of this group generally reflect those of the US, except the state’s race groupings, which has a high proportion of Southeast Asians, Native Hawaiians and Other Pacific Islanders (NHOPI). Thirty percent of Women of Reproductive Age (WRA) in Hawaii are White, followed by Filipino (20%) and Native Hawaiian (17%), with all other races being less than 10%, respectively. Most WRA are married (46%), heterosexual (90%), a high school or college graduate (31%, respectively), and employed (62%) with an annual household income of $75,000 or more (36%).

Statewide trends of key health indicators suggest that WRA in Hawaii are engaged in the healthcare system, and their health status is relatively stable (BRFSS data). Among these women, health insurance coverage is at 91%, with approximately 10% having state-sponsored insurance. There was improvement in the percentage of women who had a preventive medical visit (77%) in 2019, exceeding the state objective of 70%. Further, over 80% of women have a routine Pap smear, breast cancer exam, and cervical cancer screening.

Most WRA in Hawaii use conception for family planning. In 2017, 62% of WRA in Hawaii used one or more contraceptive methods during their most recent sexual encounter; however, it was the lowest percentage among all US women (Guttmacher Institute 2017 report). Most WRA in Hawaii are waiting longer to get pregnant, with birth and fertility rates dropping among women in their 20s and rising among women in their 30s and 40s.

High percentages of Hawaii’s WRA report having good physical and mental health at nearly 90% and 70%, respectively (BRFSS data). However, almost 18% have two or more chronic conditions, and 15% have at least one physical or mental disability. About 51% are current drinkers, and 21% are binge drinkers. Tobacco use is also common among this subgroup – 15% are current cigarette smokers, and 8% are current e-cigarette (vape) users.

Although Hawaii’s WRA are generally healthy, significant differences within racial and ethnic subgroups remain. High-risk groups include low income individuals, younger women, and NHOPIs. Rising trends in obesity and risky health behaviors, particularly younger women, suggest a need for a more statewide focus on their health needs as well as targeted women’s health interventions and programs for this subgroup.

Pregnant women & Infant health – population domain overview

Each year, there are about 18,000 births to Hawaii residents, which remained stable for the past decade (ACS data). In 2018, Hawaii’s birth rate was 11.9 per 1,000 for women aged 15–44 years (similar to the national rate of 11.6) and was highest among those aged 30–34 years (97.9) and 25–29 years (95.9) (NCHS data). Among teen mothers aged 15–19 years, the birth rate is 17.2 per 1,000, which was similar to the U.S rate of 17.4, and highest among NHOPIs.

According to 2012–2015 aggregate PRAMS data, most live births occurred to women who were Asian (31%), Native Hawaiian or part-Hawaiian (28%), White (24%), Filipino (17%), and other races were at 5% or less. Over half (56%) of women had an annual household income at or above 185% of the federal poverty level, suggesting economic stability. Further, most women were married (69%), had private health insurance coverage (52%), and had one or more previous births (66%). Some women relied on state assistance around the time of pregnancy, with 27% having public health insurance and 42% being WIC participants. Statewide 2018 PRAMS data showed that 72% of women initiated prenatal care in the first trimester of pregnancy, which was a significant decrease from 2015 when it was 77% (FAD data). Pregnant women less than 20 years of age, uninsured or on Medicaid, with a high school education or less, and NHOPI were less likely to start early prenatal care.

In 2017, severe maternal morbidity was 82.6 per 10,000 hospitalizations in Hawaii, which was not significantly different from the U.S. rate of 70.9 (FAD data). However, among their infants, the rate of infants dying before their first birthday is trending upward over the past five years. The infant mortality rate in Hawaii fluctuated since 2011 from 5.3 deaths per 1,000 live births, to 6.8 in 2018, with a significant increase between 2014 (4.5) to current. This upward trend is concerning because it surpassed the Healthy People 2020 objective (6.0).

Breastfeeding, or at least breastfeeding initiation, is common in Hawaii and is essentially unchanged for eight years. In 2016, 89% of infants were ever breastfed (FAD data). A lesser proportion of mothers continue to breastfeed exclusively through six months at 33%; however, it is higher than the U.S. estimate (25%). The latest 2016 PRAMS data showed that 78% of infants are placed on their backs to sleep, but only 20% are placed on an approved sleep surface, and 32% are placed to sleep without soft objects or loose bedding. Disparities in infant safe sleep practices exist for mothers who were 20 years or younger, at or below the 185% of the federal poverty level, and Native Hawaiian.

An assessment of Hawaii’s maternal and child health indicators suggest that pregnant women and their infants are faring as well as those nationwide. However, there are observed differences between subgroups that require close examination and focused public health efforts. These data show that health disparities are commonly highest among low-income individuals, younger mothers, those with a high school education or less, and those who are uninsured or on public insurance. Racial variations exist depending on the indicator, but in general, poorer outcomes are experienced by NHOPI and Blacks.

Child health – population domain overview

In Hawaii, there are approximately 300,000 children under 18 years old, roughly 21% of the total population (Census data). Since 2012, there is a steady decline in the percentage of children under 18 years old. About 31% are classified as being of two or more races (31%), followed by Asian (24%), White (14%), NHOPI (11%), and all other races less than 5%. The economic well-being of Hawaii’s children improved since 2010, with fewer children in poverty (12% in 2018 vs. 14% in 2010), and fewer children whose parents lack secure employment (26% in 2018 vs. 30% in 2010) (Kids Count data). A lower percentage of children in Hawaii (30%) live in single-parent households compared to all U.S. children (35%) (Kids Count data).

The 2020 Kids Count Data Book ranks Hawaii 17th in overall child well-being among all U.S. states. Further, the state ranks 7th in the nation for child health and has shown improvements in several key indicators, such as insurance coverage and child mortality. Hawaii’s child mortality rate decreased among those aged 1 through 9 years, from 18.2 per 100,000 in 2018, to 13.3 in 2019 (FAD data). Also, there was a significant decline in hospitalizations for non-fatal injury for children aged 0–9 years at 77.4 per 100,000 in 2019 from 99.7 in the previous year—this rate is significantly below the national rate of 128.6 (FAD data).

Most of Hawaii’s young children do not receive developmental screening needed to identify and diagnose unmet behavioral and learning milestones. Data from 2017–2018 showed that 36% of children ages 9 through 35 months in Hawaii received a developmental screening in the past year. But, most children in Hawaii access preventive services, including immunizations; however, there are health inequities by age group and race. In 2019, 86% of children aged 1-17 years had a preventive dental visit within the past year (FAD data). However, routine oral health care is markedly lower among children between 1 and 5 years (72%) compared to older age groups.

Other indicators suggest Hawaii’s children have challenges related to maintaining a healthy lifestyle. Among children aged 10–17 years, 12% were considered obese; though this is lower than the U.S. estimate (15%), it highlights a need for better nutrition and more physical activity. Among children aged 6–11 years, less than a quarter (21%) were physically active for at least 60 minutes per day in Hawaii, which was lower than the national average (28%). Safety of the State’s youngest children continues to be a community concern. The 2019 rate of confirmed child abuse and neglect cases per 1,000 children aged 0 to 5 years is 5.5.

Taken together, Hawaii’s children are relatively healthy, and there are positive trends across several key indicators of child health. However, there are disparities in oral care and vaccination rates as well as a high prevalence of childhood obesity. High-risk groups for selected key indicators include low income individuals, younger children, non-Hispanic Whites, and NHOPIs.

Adolescent health – population domain overview

There are an estimated 164,000 adolescents in Hawaii; of those, 84,000 aged 10–14 years and 78,000 aged 15–19 years (Census data). The racial and ethnic profile of adolescents in Hawaii suggests that most are of two or more races, NHOPI, or Asian.

Trends of several health indicators suggest that adolescents in Hawaii are as healthy as most U.S. adolescents. Still, there are health disparities that lead to worse outcomes for certain subgroups. According to data from 2016–2018, 75% of adolescents ages 12-17 years had a preventive medical visit within the past year, which met the 2019 state objective (FAD data). However, adolescents with college-educated parents were more likely to have a preventive visit compared to those whose parents who had completed some college or below; similar differences exist for low-income individuals and non-English language speakers.

Like the U.S. overall, two of the leading causes of adolescent mortality in Hawaii are unintentional injuries, such as motor vehicle-related injuries, and suicide, which is classified as an intentional injury. In 2018, the overall mortality rate for adolescents aged 10–19 years was 25.1 per 100,000, but this estimate was not significantly different from the U.S. estimate (32.2) (FAD data). Data from 2016 to 2018 showed that males had a noticeably higher mortality rate (36.4) than females (19.4), but there were no significant differences across racial groups. YRBS data revealed some insight into potential factors affecting both motor vehicle-related deaths and deaths by suicide among adolescents. It showed that 38% of high school students text while driving a motor vehicle. Also, 30% of high school students had depression within the last 12 months, and 10% attempted suicide resulting in injury or treatment.

The percentage of Hawaii’s adolescents who are engaging in sexual activity remains stable, but their practices of good sexual health seem to be improving. In 2017, 19% of high school students were currently sexually active, with 64% using some form of birth control (YRBS data). A high percentage of adolescents in Hawaii are getting vaccinated against HPV, compared to the U.S. overall. Births among females ages 15-19 in the state reduced significantly from 33.0 per 1,000 in 2010, to 17.2 in 2018, and was similar to the U.S rate at 17.4 (FAD data). However, there are racial variations with NHOPIs and those of multiple races having higher teen birth rates.

There is an observed shift in trends in tobacco use from smoking cigarettes to e-cigarettes (vaping). In 2017, 23% of high school students reported smoking cigarettes; however, almost double (42%) were vaping (YRBS data). Current e-cigarette use is significantly higher among Hawaii’s adolescents than those nationwide (13%).

Adolescents in Hawaii face some health challenges, but in general, maintain overall good health status. There are observed disparities among low-income individuals, non-English language speakers, NHOPIs, those of two or more races, and those in households with parents who have some college education or less.

Children with special health needs (CSHN) – population domain overview

According to data from the 2017–2018 National Survey of Children’s Health (NSCH), 13% of children ages 0-17 years in Hawaii have special needs, compared to the national estimate of 18%. Almost half (49%) are classified as other race, followed by Asian (17%), White (12%), Black (1%), and 21% Hispanic/Latino (NSCH). There is no significant difference in race and ethnicity between CSHN and children without special health needs in the state. Among CSHN, there are more males (61%) than females—a trend that is also observed nationally. A high percentage of CSHN (98%) have health insurance, with 66% using primarily private insurance for medical services and 27% using public insurance. Most CSHN live in two-parent households (66%), have at least one adult in the home with a college degree or higher (49%), and live in a home with an annual income at 200-399% of the federal poverty level (43%), suggesting some economic stability. Despite these demographic similarities, each family with a CSHN has its unique challenges and concerns because of the different types of special needs a child can experience.

Receiving adequate medical care and being in home and school environments that are free of neglect and abuse are essential to each child’s development. From 2017 to 2018, nearly half (45%) of CSHN ages 0-17 in Hawaii had a medical home, which was similar to the national estimate (43%) but lower than the Healthy People 2020 objective (52%) (FAD data). Among this group, a relatively small percentage (17%) are in a well-functioning system of care that integrates a family-centered home with comprehensive needs-specific medical attention; however, this percentage is similar to those nationwide (14%). During the same period, among children ages 3-17 with a mental or behavioral condition, 54% received treatment or counseling, suggesting that most children acquire the psychological care they need, but there is room for improvement.

Of concern, 2017-2018 data show that only a quarter of adolescents with and without special health care needs, ages 12 -17 years, received services needed to make transitions to adult health care (24.7%).

Based on key health indicators, most CSHN in Hawaii are adequately insured and live in households that are conducive to having access to medical care and treatments tailored to their health needs or disability. Although the small number of CSHN in the state did not allow for examining differences by demographic characteristics, disparities may exist in specific vulnerable populations, such as low-income individuals and NHOPIs.

Survey results for the five domains

Provider surveys included a section for participants to offer input on Title V priority strategies and activities. For each national and state performance measure, participants were provided with the current strategies and asked, “Are these the right/best strategies for Hawaii to focus on in the next five years?” Participants were allowed to provide comments on the existing strategies or suggest new ones. The following table summarizes the feedback for all the NPM strategies across the five population domains.

The Hawaii State Department of Health (DOH) is a major administrative agency of the Hawaii State Government, with the Director of Health appointed by and reporting directly to the Governor (see Figure 2).  DOH has three administrations, including the Health Resources Administration (HRA).  Divisions within HRA include FHSD, which is responsible for administration of Title V funding.  FHSD houses the MCH, CSHN, and WIC Branches, and the Office of Primary Care and Rural Health, all of which are codified within the Hawaii Revised Statutes. Organizational Charts for the Executive Branch of State Government, DOH and FHSD are in report Section IV Organizational Chart).

Title V is considered the “umbrella” for FHSD’s work to improve the health of women, infants, children and adolescents, and other vulnerable populations and their families. FHSD’s working principles are to: be data-driven; monitor outcomes and impacts via evaluation; use evidence-based and best/promising practices; engage with the community; examine systems, policy development, and environmental change; use a life course approach; and consistently look at quality improvement.

FHSD programs work to ensure statewide infrastructure for data collection, NA, surveillance, planning and evaluation, systems and policy development, monitoring, provision of training, and technical assistance to assure quality of care. Thus, FHSD can address each of the population health domains through its many programs (see figure below).

FHSD has 283 FTE staff, of which 21.15 FTE are Title V-funded, and 44 FTE are located on Neighbor Islands.

*Includes vacant positions.

FHSD’s administration, branches, and programs include:

FAMILY HEALTH SERVICES DIVISION: Matthew Shim, PhD, MPH. Dr. Shim holds degrees in Psychology, Public Health, and a Doctorate in Epidemiology. He has served as Division Chief since 2016.

CHILDREN WITH SPECIAL HEALTH NEEDS BRANCH: Patricia Heu, MD, MPH, pediatrician, has served as Branch Chief since 1997.

MATERNAL AND CHILD HEALTH BRANCH: Kimberly Arakaki, MSCP, has served as Branch Chief since 2016, and prior to that was the DOH Case Management and Information Services Branch Chief from 2007. She has nearly 30 years of experience working with individuals with developmental disabilities and their families.

WIC SERVICES BRANCH: Melanie Murakami, MPH, RDN, has been with the Branch since 2000, and has served as WIC Director and Branch Chief since 2018.

DISTRICT HEALTH OFFICES (DHOs): DOH programs on the Neighbor Islands are administered by three DHOs for Hawaii, Maui, and Kauai Counties. Each DHO has a Family Health Services Coordinator (Registered Nurse) responsible for FHSD services (Children with Special Health Needs, Early Intervention, Maternal and Child Health, WIC). Each office may have other responsibilities and projects/activities specific for their communities (e.g., Maui DHO oversees program staff for the federal ECCS grant).

TITLE V FAMILY LEADER: Leolinda Iokepa is the Director for Hilopaa F2FHIC; Co-Director for Hawaii’s MCH LEND Program; Coordinator for Family Voices of Hawaii; AMCHP Family Delegate and a parent of a young adult with special needs. She is active in the NA process and planning of Title V MCH/CSHCN priorities and FHSD activities over the past 15 years.

ROLE OF PARENTS: Parents serve on advisory boards and as program consultants, and in the case of WIC, as paid peer breastfeeding counselors. Family input is sought through surveys including client service satisfaction and other types of input (see Family Partnership section).

Several other quantitative and qualitative data sources were reviewed related to FHSD’s workforce status and needs. The sources were introduced in the “Data Sources” section, and the results are discussed here.

Quantitative surveys:

ASTHO’s Public Health Workforce Interest and Needs Survey (PH-WINS) – The most recent data available for FHSD are from 2017. A total of 916 Hawaii DOH employees completed the survey. Of those, 30 (3.3%) were from FHSD. While there are data limitations, the Division’s major results are summarized below:

• 25% reported having plans to retire by 2023, another 31% were considering leaving within the next year for reasons other than retirement.
• 87% reported satisfaction with their job, but only 59% were satisfied with the organization and 50% were satisfied with their pay.
• The top three training needs for both supervisory and non-supervisory staff were budget and financial management (63%), systems and strategic thinking (63%), and change management (60%).

Recommendations included succession-planning, investing in training for the existing workforce, workplace policies/practices that support job satisfaction and improve retention, and improving employee engagement.

Council of State and Territorial Epidemiologists (CSTE) – In 2019, FHSD participated in CSTE’s nationwide survey to assess states’ MCH service capacity during a time of crisis/disaster. At the time of the survey, two full-time epidemiologists were affiliated with FHSD. They are generally supported by the larger DOH and external partners but may not be routinely activated during preparedness drills and activities. However, this may be reflective of the funding supporting each position (e.g., funding may be specific to evaluation of FHSD programs).

Qualitative interviews:

In fall 2018, a University of Hawaii graduate public health class conducted a NA project to inform FHSD’s efforts related to staff training and workforce development. The students conducted 14 interviews with health and administrative professionals across the Division representing a range of positions and backgrounds. The findings are summarized below:

• Current training opportunities within FHSD are either standardized (e.g., HR requirements) or highly specific to the responsibilities and subject matter of staff or units. Current trainings were valuable, but also time-consuming and expensive. Additionally, challenges with dissemination of opportunities, as well as format, were found to limit participation. A few of the standardized trainings emerged as opportunities for coordinated division-wide growth, if redesigned/redeveloped.
• There is a need to build public health competencies at all staff levels. Many employees come from a clinical or service delivery background, often with degrees in social work, psychology, or a related field. While these experiences are valuable, these professionals may be unfamiliar with core public health concepts such as the social determinants of health, research methods, data analytics, and epidemiology. Interviewees also stressed the importance of building strategic and cross-cutting skills, including leadership training opportunities. Several managers expressed that it can be difficult to gauge leadership skills in the hiring process and challenging to teach these skills on the job. Other identified areas for skills-building included budgeting, project management, policy engagement, data translation, and communication.
• The interviews also revealed some challenges with recruitment into the workforce. For example, there is no clear pathway for recent MPH graduates to enter lower-level positions, which is a barrier for cultivating the next generation of public health professionals.

In summary, workforce needs and challenges for FHSD and Title V include:

• Vacancies in key epidemiology positions, including the CDC MCH Epidemiology Assignee.
• Difficulty in filling Title V-funded positions, due to insufficient Title V funding. There has not been an increase in Title V funding to correspond with salary increases.
• Difficulty in requesting new State general-funded positions due to State economic concerns.
• Strengthening Division-wide organizational identity, culture, and infrastructure to improve communications, collaboration, employee engagement, and other workforce needs.

In addition to the two community surveys, stakeholders from various backgrounds are engaged through other means:

• All Title V programs engage with specific community partners in the delivery of services and implementation of activities. Some of these collaborations are formalized (e.g., MOAs and MOUs), while others are informal (e.g., partners provide content area expertise). In addition, several programs solicit feedback from partners to inform planning, implementation, and evaluation of their strategies and activities.
• Collaboration often occurs across FHSD and Title V programs. Efforts in recent years were made to leverage resources and connections across programs and streamline service delivery and communication.
• Community partners are engaged via cross-agency/system workgroups or taskforces. FHSD convenes and/or provides leadership for some of these groups.
• Many FHSD partners participated in other NA studies within the last several years and expressed their priorities, strengths, needs, and limitations. FHSD incorporated these findings, given how broadly family health intersects with other public health issues, and to avoid overburdening partners and the general community with multiple assessments. Therefore, other organizations’ NAs and strategic plans are considered, as discussed in the “Data sources – Phase 1, Component 2 – document review” section, and detailed in the Supporting Documents.

The following table captures the broad array of FHSD program partnerships and collaborations over the past five years by Title V population domains.

Identifying priorities and linking to measures

Phase 3 of the NA brought together the findings from the secondary data sources, unique needs reported by stakeholders, and the agency capacity of FHSD. Four criteria guided the priority selection process:

1. Data show needs and challenges
2. There is community alignment and support
3. View through a lens of equity
4. Priorities are appropriate for FHSD

The NA confirmed that FHSD should continue to build on the progress made to date on the current priority areas, but improvements could be made on strategies, activities, and measurement of outcomes/impacts.

As each priority area and its strategies/activities were confirmed, measures were selected which aligned with the inputs (resources and activities) and desired outcomes. Logic models were developed for each priority area to guide this alignment process (drafted during the 2015-2020 grant cycle and updated during the current NA). The logic model organizes the components of a project including resources, activities, and outcomes/impacts, in addition to showing the interactive relationships among components. Resources are the assumptions underlying a program, and the necessary infrastructure for implementation. Strategies/Activities were developed with feedback from stakeholders, and when implemented, result in Short-Term Outcomes (including the Strategy Measure). Longer-Term Outcomes (including the National Performance Measure and National Outcome Measures) refer to the intended effects of cumulative program components and describe the targeted population and system changes for each program. Contextual Conditions refer to considerations such as culture, rurality, health and service gaps, and socioeconomic conditions that must be considered as we work to engage stakeholders and develop/implement the program components.

Hawaii will continue to engage stakeholders and technical assistance to evaluate and revise the five-year plan to assure the effectiveness of the strategies selected.

Changed and emerging issues/needs

During the 2015-2020 funding cycle, Hawaii’s Title V program included telehealth and children’s oral health as priorities. Developing telehealth capacity across Hawaii Title V programs was a state performance measure which achieved substantial success over the last five-year period. Consequently, this priority will not be carried into the 2021-2025 funding cycle. Staff and stakeholders are grateful for the telehealth infrastructure put into place, especially given the recent move to online/virtual activities during the pandemic. Telehealth activities will now be incorporated into the remaining Title V priorities.

Children’s oral health will continue through general support and collaboration with external organizations but will not be a formal Title V priority for the next funding cycle. Since completion of the Centers for Disease Control and Prevention (CDC) oral health infrastructure grant in August 2018 and no continued availability of program funding, FHSD does not have the resources needed to advance statewide efforts. FHSD will continue to partner with oral health stakeholders through the State Oral Health Coalition and will continue to seek funding to rebuild the state oral health program.

Several data sources from the NA highlighted new and/or emerging issues, including mental health, behavioral health, substance use, bullying prevention, and housing. While these topics are important for the State MCH population and have direct impact on Title V work, FHSD is not the state-designated lead for these issues. Therefore, FHSD will actively collaborate with the appropriate point-of-contacts for these topic areas including:

• DOH Behavioral Health Administration that includes child/adolescent mental health, adult mental health, and alcohol and drug abuse,
• DOH Emergency Management Services and Injury Prevention System Branch that includes violence, injury, and suicide prevention, and
• the Department of Human Services, state leader for homelessness, to support child and family health services and initiatives.

FHSD will continue NA efforts including data analysis, publication and dissemination of data findings, and engagement of stakeholders including youth and families to respond to emerging needs and concerns.