The impact of the COVID-19 pandemic is unprecedented in this generation and has far ranging impacts across the health, economic, education, and employment sectors in Hawaii. The Overview narrative captures much of the timely available data.

 

Ongoing NA builds upon the method and findings of the 2020 Five-Year Needs Assessment and continues using a mixed methods approach for data collection and evaluation purposes with the same guiding principles: promote health equity; consider social determinants of health; utilize a life course approach; value the roles of our partners and communities; utilize evidence-based/informed practices; and focus on primary prevention and early intervention.

 

In addition to reviewing primary and secondary data sources, NA efforts involved collecting input from staff/programs and engaged external stakeholders in discussions of ever-evolving conditions and emerging needs and changing priorities. The information supports and informs Hawaii’s Title V planning, decision-making, and resource allocation.

 

The Title V Federally Available Data (FAD)[1] continued to serve as the primary data source for ongoing needs assessment. The FHSD research statistician completed most of the data analysis and a summary highlighting trends and subgroup analyses to identify disparities can be found in the Supporting Documents. Because the FAD utilizes the federal race/ethnicity classifications, state vital statistics data may be used to report data for Hawaii detailed ethnicity groups.

 

Services were also contracted to review the data analysis and assist with data interpretation since FHSD epidemiology vacancies persist. The epi assistance, while very helpful, was not available to allow for in-depth review, discussion with staff/stakeholders, or development of more substantive findings. In general, FHSD had difficulty finding qualified epidemiologists who are knowledgeable and experienced working with diverse population-based MCH datasets. Unfortunately, there are no dedicated MCH faculty in Hawaii public health university programs. Thus, data findings and activities have been limited when assessment is a critical public health function.

 

C.1.a. Ongoing Needs Assessment Activities

Several needs assessment activities were completed or in progress through contractual services:

• Title V epi support for this annual report was secured through an epidemiology doctorate graduate from the MCH Center of Excellence at the University of California-Berkeley.
• The University of Hawaii (UH) Center for Disabilities Studies is assessing children and youth with special health needs using data from the National Survey of Children’s Health (NSCH), conducting a survey of youth with special health needs (translated into several languages) and follow-up focus groups.
• Collaboration with the MCH LEND (Leadership Education in Neurodevelopmental and Related Disabilities) program to conduct focus groups with CSHN families as part of research training curriculum were complete. A final report is forthcoming.
• Working with youth through TeenLink Hawaii to assess health concerns during COVID through youth surveys.
• Domestic Violence Action Center using Pacific Islander staff conducted focus groups/interviews with Pacific Islander youth regarding health concerns/issues.
• A Title V program survey was conducted on family engagement activities/needs.
• The PRAMS 2020 data is now available on through the DOH Data warehouse.

 

C.1.b. Summary of Health Status Changes of the MCH Population

Four new state priorities were added in FY 2021 in response to COVID impacts and new federal funding opportunities. All four priorities address health equity and are supported by state and federal data.

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

 

The most recent data suggest that the health status of the MCH population in Hawaii overall remains similar to or better than the national average on many health indicators. However, there are some concerning trends that suggest worsening health in certain key areas. In particular, the increase in severe maternal morbidity (SMM) rate and postpartum depression is concerning. Children’s health status shows some signs of worsening, especially in physical activity and routine vaccinations; some evidence suggests that children’s overall well-being maybe worsening. Adolescent health indicators are generally stable.

 

Persistent racial and ethnic disparities continue. In general, White, Japanese, and Chinese groups fare better on most health outcomes compared to those of Filipino, Native Hawaiian or Other Pacific Islander race, and multiple races. These latter groups tend to fare worse on socioeconomic indicators, reflecting structural discrimination and a need for greater investment/partnership to improve health outcomes.

 

It is important to note that most of the data reviewed does not capture impacts of the COVID pandemic due to time lags or other surveillance limitations. Worsening trends identified are largely pre-COVID with a few exceptions.

 

Women/Maternal Health - An estimated 262,848 women of reproductive age (WRA), aged 15-49 years, live in Hawaii, making up 43% of the female population in the state (ACS). Most WRA in Hawaii are Native Hawaiian (20.8%), followed by White (20.2%) and Filipino (18%), with all other groups under 11%, respectively (BRFSS, 2019). Compared to the state’s population, the proportion of Native Hawaiians and other Pacific Islanders WRA are significantly greater, while the proportions of Whites and Japanese are significantly smaller. Most WRA are married (47%), heterosexual (90%), a high school (30%) or college graduate (34%) and employed (66%) with an annual household income of $75,000 or more (39%).

 

Key health indicators suggest that WRA use the healthcare system and their health status is relatively stable with health insurance coverage at 92% (21% with public insurance). In 2020, 81.1% of women in Hawaii received a preventive medical visit (a slight increase over 2019) and significantly higher than the national estimate (71.2%).

 

Most WRA use conception for family planning and 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.

 

Other WRA health highlights (BRFSS, 2020) include[2]:

• 87% report having good physical health
• 19% have two or more chronic conditions
• 17% report having depressive symptoms
• 16% have at least one physical or mental disability
• 50% are current drinkers with 17% binge drinkers
• 12% are current cigarette smokers and 6% are current e-cigarette (vape) users

Rising trends in obesity and other risky health behaviors, particularly in younger women, underscore the need for preventive healthcare for this population.

 

Perinatal and Infant Health - In 2020, there were 15,780 births to Hawaii residents. In 2019, the fertility rate was 61.1 per 1,000 for women aged 15-44 years (slightly above the national rate of 56.0). Among teen mothers 15-19 years, the birth rate is 13.0 per 1,000, similar to the U.S. rate of 15.4, and is highest among NHOPIs. Despite significant decreases in perinatal deaths, an emerging concern is Hawaii’s increase in severe maternal morbidity (SMM).

 

Most live births occurred to women who were Asian (31%), Native Hawaiian (28%), White (24%), and Filipino (17%). Over half (56%) of women had an annual household income at or above 185% of the federal poverty level. Most women were married (69%), had private health insurance coverage (52%), and had one or more previous births (66%). At pregnancy, 27% of women had public health insurance and 42% were WIC participants. The 2019 rate of prenatal care in the first trimester of pregnancy increased slightly compared to 2020 (from 72% to 73%).

 

The proportion of women who smoke during pregnancy was 1.9%, which was significantly below the national estimate of 5.5%. Those with lower education, WIC recipients, and mothers of Hispanic or multiple races were more likely to smoke. About 6.6% of mothers drank alcohol during pregnancy, similar to the national estimate (7.9%), and 42.4% had a dental visit during pregnancy. Both rates have been relatively stable over the past five years.

 

Data from 2019 indicates severe maternal morbidity (SMM) was 104.8 per 10,000 hospitalizations, similar to 2018 (104.3) but substantially higher than 2017 (84.7). Hawaii’s SMM rate is significantly higher than the U.S. rate of 81.0 (HCUP-SID 2019) and the HP 2030 objective (61.8).[3] Small numbers (146 in 2019) make subgroup analyses difficult. A MCH Alliance for Innovation (AIM) grant to study SMM was awarded to the University of Hawaii John A. Burns School of Medicine. FHSD is assisting with securing access to hospital data for the grant project.

 

The maternal mortality rate was 16.9 per 100,000 live births (aggregated over 2017-2021), an increase over the previous indicator (11.7 for 2016-2020) but close to the HP 2030 objective (15.7). Annual deaths are very small (10-14 annually); thus, the increase does not represent a significant change. Postpartum depression rates have also increased over time (PRAMS). Other indicators being monitored because of concerning rates are infant sleeping environments and disparities in preterm births.

 

Data from 2020 indicated 10.0% percent of births were preterm. Asian (10.2%) or multiple race (10.3%) and Hispanic (10.3%) mothers had significantly higher rates of preterm birth when compared to Whites (7.9%). Those under age 20 (13.1%), 35 years and older (12.8%), or with a high school education (13.5%) also had elevated rates. The rate of early term births (37-38 weeks) was 28.7% and was slightly higher than the national estimate (27.8%). Risk factors for early term birth were similar to those of pre-term birth, although no significant differences were observed among mothers of different age groups.

 

Data from 2019 shows infant mortality decreased (from 6.8 per 1,000 previously to 5.1) but is still up significantly compared to 2016 (4.5). Hawaii’s rate almost met the HP 2030 objective (5.0) and is similar to the national estimate (5.6). Infant mortality was significantly higher for Native Hawaiians (5.8) compared to White (3.2) infants. Sleep-related unexpected infant death (SUID) rates were 111.9 per 100,000 live births (NVSS 2018)[4]; this was a decrease from 2015 (76.0) but similar to the national estimate (90.6). There were 1.1 cases of neonatal abstinence syndrome per 1,000 hospital births (HCUP-SID, 2019), lower than national estimate (6.1) and unchanged since 2014.

 

Low birth weight (LBW) deliveries have remained constant since 2016 (8.1% in 2021, 8.3% in 2016). Data from 2020 indicates rates were statistically higher for Black (10.4%), Asian (9.9%), and NHOPI (9.7%) than White mothers (5.3%) (NVSS). Among very LBW (VLBW) infants, 90.6% were born in a hospital with at least a level III NICU (Vital Statistics 2020-2021). Among low-risk first births, 23% were delivered via cesarean section (NVSS), significantly below the national estimate (25.9%) and meeting the 2030 HP objective (23.6%), but significantly higher than the 2015 estimate (20.3%).[5] Older mothers and those with any health insurance were more likely to receive cesarean sections.

 

Data from 2018 indicates 94.6% of infants were ever breastfed, significantly higher than the national estimate (83.9%). A lesser proportion of mothers continue to breastfeed exclusively through six months at 36.6%, though this rate is still higher than the U.S. estimate (25.8%) (NIS).[6] PRAMS data from 2020 showed that 80.1% of infants are placed on their backs to sleep, with Native Hawaiian (72.9%) mothers less likely to do so than Filipino (81.2%), White (85.3%), Chinese (86.3%), and Japanese (88.3%) mothers; mothers under 20 (69.4%) and 20-24 (72.8%) were also less likely to do so than those 25-34 (81.8%) and 35 and older (93.6%).[7] Only 24.7% of infants were placed on an approved sleep surface, significantly below the national estimate of 36.9% and 2021 state objective of 29.0%. In 2020, 45.9% of infants were placed to sleep without soft objects or loose bedding, lower than the national estimate (52.5%) and the state objective (49.0%); small numbers prevented subgroup analysis.

 

There has been a significant increase in the percent of mothers experiencing postpartum depressive symptoms (13.7% in 2020 compared to 9.0% in 2015, PRAMS); this is similar to national estimate (13.4%). NHOPI mothers were more likely to experience postpartum depression than White mothers.

 

Child Health - There are approximately 296,000 children under 18 years old in the state, roughly 21% of the total population.[8] Since 2012, there has been a steady decline in the percentage of children under 18 years old. Compared to the overall state population, children in Hawaii are more likely to be of two or more races (32% vs 24%), Hispanic or Latino (20% vs 10.7%), or NHOPI (12% vs 10%), and less likely to be Asian (22% vs 38%) or White (13% vs 26%). Prior to the COVID outbreak, the economic well-being of Hawaii’s children in general had been improving since 2010 (14%) with a marginal decrease in the proportion of children in poverty in 2019 (12%) and a larger decrease in children whose parents lack secure employment (24% in 2019 vs. 30% in 2010). A slightly smaller percentage of children in Hawaii (32%) live in single-parent households compared to all U.S. children (34%).

 

Children’s health status improved in some areas but worsened in others. While there was a significant decrease in the child mortality rate and hospitalizations over time, physical activity is lower than national rate. Also, the seasonal influenza vaccination rates declined over time. Hawaii also ranked 26th in overall child well-being among all U.S. states per the 2021 Casey Foundation Kids Count, a large drop from 17th place in 2020. This was due to several factors including rates of children not in school, low birthweight, and single-parent families worsened compared to 2010 and contributed to the decline.[9]

 

Hawaii’s child mortality rate decreased significantly among those aged 1 through 9 years, from 18.2 per 100,000 in 2018 to 10.3 in 2020. This rate was significantly lower than the national estimate (16.0). Hospitalizations for non-fatal injury for children aged 0–9 years declined from 99.7 per 100,000 in 2016 to 72.1 in 2019, significantly below the national rate of 124.2. There were no significant subgroup differences in pediatric injury hospitalization rates.

 

Although most of Hawaii’s young children do not receive developmental screening needed to identify and diagnose unmet behavioral and learning milestones (41.2% in 2019-2020, NSCH), Hawaii’s rate was similar to the national estimate (36.9%) and met the HP 2030 Objective (35.8%).[10]

 

Per 2019-2020 data, children in Hawaii are more likely than children nationally to be insured and able to obtain needed health care: 80.6% insured in Hawaii compared to 66.7% nationally (NSCH). No significant subgroup differences were reported. In this same population, 2.1% were unable to obtain needed health care in the last year, significantly lower than the national rate (3.5%). Children with special health needs (5.9%) were significantly more likely to be unable to obtain needed health care compared to those without special needs (1.5%).

 

The percent of children aged 1-17 years with a preventive medical visit within the past year (79.7%%) was similar to the national average (80.7%). The percent of children with a preventive dental visit (85.6%) was significantly higher than the national average (77.5%). Routine oral health care is markedly lower among children 1 and 5 years (73.4%) compared to older age groups; no other significant differences across subgroups were reported.

 

Other NSCH indicators suggest children have challenges related to maintaining a healthy lifestyle:

• 15.5% of children aged 10–17 years were considered obese, similar to the U.S. estimate (16.2%).
• Less than a fifth (18.7%) of children aged 6–11 years were physically active for at least 60 minutes per day, which was lower than the national average (26.2%).
• 14.8% of children ages 0-17 live in households where someone smokes, similar to the national estimate of 14.0%. Children in lower socioeconomic position and of NHOPI race had elevated exposure to household smoking.

The annual rate of seasonal influenza vaccination has declined significantly over time (59.5% in 2020-2021 compared to 67.0 in 2019-2020 and 71.8% in 2015-2016, NIS), closely matching national rates (58.6%). Disparities exist along socioeconomic lines.

 

Adolescent Health - There are an estimated 161,000 adolescents in Hawaii, and the racial and ethnic profile of adolescents suggests that most are of two or more races, NHOPI, or Asian (Census). Trends of several health indicators suggest that adolescents in Hawaii are as healthy as most U.S. adolescents. Encouraging trends include a significant decrease in non-fatal injury hospitalizations. However, concerning trends include Tdap (tetanus, diphtheria, and acellular pertussis) vaccination rate, which is lower than the national rate. Disparities in health measures require further analysis.

 

Data from 2019-2020 indicated 73.4% of 12–17-year-olds had a preventative medical visit within the past year; this rate was similar to the national estimate of 75.6% (NSCH). Adolescents with college-educated parents (83.8%) were more likely to have a preventive visit compared to those whose parents had completed some college (61.2%). Asians (66.0%) were less likely to have a preventive medical visit than Whites (88.6%).[11] However, adolescents ages 13-17 in Hawaii were significantly less likely (83.7%) than adolescents nationally (90.1%) to have received at least one dose of the Tdap vaccine (NIS, 2020).

 

Data from 2019-2020 indicated only 12.5% of 12–17-year-olds were physically active for at least 60 minutes per day, similar to the national estimate (15.2%). Among 12–17-year-olds, 12.3% bullied others and 31.1% were bullied (NSCH), which was similar to the national estimates. Asians and Hispanics were more likely to be bullied. There were 158.7 hospitalizations for non-fatal injuries per 100,000 10–19-year-olds in 2019 (HCUP-SID), which represents a significant decrease from 2015 (205.2) and is lower than the national rate (204.2). Females, those of Hispanic ethnicity, and younger adolescents were less likely to have injury hospitalizations.

 

The overall mortality rate in 2020 for adolescents aged 10–19 years was 20.9 per 100,000, which was significantly lower than the U.S. estimate of 37.6 (NVSS). Males had a noticeably higher mortality rate (33.0) than females (17.9); there were no significant differences across racial groups. Common causes of adolescent mortality in Hawaii are include motor vehicle injuries (8.6 per 100,000, significantly lower than national estimate of 11.8) and suicide (9.9 per 100,000, similar to national estimate of 11.1). These rates have not changed significantly over time; small numbers prevent subgroup analysis of higher risk groups.

 

The percent of adolescents engaging in sexual activity remains stable; preventive sexual health practices seem to be improving. In 2019, 18% of high school students were currently sexually active, with 84% using some form of birth control (YRBS). A high percentage (84.9%) of adolescents in Hawaii received at least one dose of the HPV vaccine, which is higher than the U.S. overall (75.1%) (NIS 2020); non-Hispanic Asian (86.7%) and those with income 400% or greater of FPL had the highest rates (86.6%). Births among females ages 15-19 in the state reduced significantly from 15.7 per 1,000 in 2019 to 13.0 in 2020 (NVSS) and was similar to the U.S rate at 15.4. Hispanic (22.2), NHOPI (22.7), and teens of multiple races (15.7) had higher birth rates than Asian (3.9) and White (8.5) teens.

 

There is an observed shift in trends in tobacco use from smoking cigarettes to e-cigarettes (vaping). In 2019, 18% of high school students reported smoking cigarettes; however, almost double (48%) were vaping. Current e-cigarette use is significantly higher among Hawaii’s adolescents than those nationwide (13%). The DOH Chronic Disease program has an aggressive anti-vaping messaging and policy initiative to combat this trend.

 

For suicide and depression, 35% of high school students report experiencing depression and 10% attempted suicide within the last 12 months. There are significant disparities by race/ethnicity and county across the risk factors. The 2021 YBRS results will be released in FY 2022. This data supports selection of the Hawaii state performance measure on pediatric mental health. As part of the project, further analysis will be conducted to identify key disparities.

 

Children with Special Health Care Needs (CSHCN) - The population of CSHCN in Hawaii is estimated to be 43,575, which is approximately 14% of the child population under 18 years of age, and 3% of the larger state population. Hawaii’s Title V program focuses on transition to adult health care for this domain.

 

According to data from the 2019-2020 (NSCH), 14% of children ages 0-17 years in Hawaii have special needs, significantly lower than the national estimate (19%). This difference may be due to the small sample size of CSHCN in Hawaii (N=235). About 42% are identified as “other, non-Hispanic” race, followed by Asian (26%), White (14%), and 15% Hispanic/Latino (data on race/ethnicity was missing for about 3% of CSHCN in Hawaii). There is no significant difference in race and ethnicity between CSHN and children without special health needs. Among CSHCN, there are more males (57%) than females (43%), a trend that was not observed nationally.

 

The same percentage of CSHCN in Hawaii (97%) have health insurance compared to non-CSHCN in Hawaii (97%), with 73% using primarily private insurance for medical services, 20% using public insurance, and 3% using both. Most CSHCN live in two-parent households (71%) and have at least one adult in the home with a college degree or higher (63%). About 43% of CSHCN in Hawaii live in a home with an annual income at 400% or greater of the federal poverty level, while 31% have between 200-399%, suggesting some economic stability.

 

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 2019 to 2020, nearly half (48%) of CSHCN ages 0-17 in Hawaii had a medical home, which was similar to the national estimate (47%) but lower than the Healthy People 2020 objective (52%) (FAD). Among this group, a relatively small percentage (20%) are in a well-functioning system of care that integrates a family-centered home with comprehensive needs-specific medical attention; this percentage is higher than the rate amongst CSHCN nationwide (16%), although this difference was not statistically significant.  During the same period, among children ages 3-17 with a mental or behavioral condition, only 50% received treatment or counseling, suggesting that only about half of children acquire the psychological care they need. 

 

Of concern, 2019-2020 data show that only 18% of adolescents with and without special health care needs, ages 12 -17 years, received services needed to make transitions to adult health care.

 

C.1.c. Title V Program Capacity Updates and Changes

Title V programs continue to provide all levels of services statewide. A list of programs is in the Supporting Documents. Through 2021, direct service programs continued to provide telehealth services, staff continued to telework, and continued cross-agency/community partnership remotely. With the loosening of COVID restrictions, all staff returned to the office in April 2022. Some direct services have returned to an in-person option.

 

FHSD has 277 FTE staff, of which 19.55 FTE are Title V-funded, and 42 FTE are located on neighbor islands.

	Total FTE (all funding sources)	Title V FTE*	Hawaii FTE	Maui FTE	Kauai FTE
FHSD	30.0	5	2.0	2.0	2.0
MCH Branch	40.0	6.5	1.0	0	0
CSHN Branch	138.0	8.05	6.0	3.0	2.0
WIC Branch	69.0	0	13.0	7.0	4.0
TOTAL	277.0	19.55	22.0	12.0	8.0

*Includes vacant positions.

 

FHSD’s staffing decreased by roughly 8 FTE, including one Title V funded FTE. The positions were related to the loss of Title X family planning funding and elimination of positions in the Early Intervention program. At the close of 2021 and through 2022, there have been a number of new vacancies with retirements and staff departures.

 

Title V COVID-19 Response. No Title V funds were used for direct COVID-19 disease prevention/control. Two FHSD nurses deployed for COVID are no longer serving in this capacity. The Maui and Kauai RN Supervisors continue to provide reduced COVID-19 support largely for vaccinations and limited contact tracing. In 2022, the FHSD research statistician is providing part-time data support to the DOH Disease Investigation Branch.

 

C.1.d. Title V Partnerships and Collaboration

The Title V program continues to work closely with a diverse set of agency and community partners across population domains. Formal and informal partnerships are in place with other programs within DOH (e.g., Chronic Disease Branch, Child/Adolescent Mental Health); other state and county organizations (Department of Education, Department of Human Services, Executive Office of Early Learning); over 25 healthcare organizations (Shriner’s Hospital, Federally Qualified Health Care Centers); over 35 community-based organizations (Coalition for a Drug-Free Hawaii, Healthy Mothers, Healthy Babies, Hawaii Youth Services Network); and national partners (Centers for Disease Control and Prevention, Department of Agriculture). A list of Title V partners can be found in the 2020 NA summary.

 

C.1.e. Operationalization of 5-Year Needs Assessment

Title V staff issue leaders work to evaluate and revise program practice based on ever-changing healthcare conditions, collaborations with partner agencies/programs, federal guidance, and family input. Staff work collaboratively across programs and with partners to meet short- and long-term outcomes to support improvements in national and state performance measures that impact the Title V national outcome measures.

 

5-Year Plan Changes for 2021-2025

State Priorities: 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 ensured health equity strategies/activities are integrated into all Title V priorities. Activities for the new equity strategies were selected from national presentations/resources (AMCHP, MCH Evidence Center, MCH Workforce Development Center) and Hawaii DOH Health Equity reports.

 

Other Plan Changes: Many planned FY 2021 activities were delayed or revised due to COVID-19 circumstances/conditions. The lack of epidemiology staff hindered more detailed data analysis and also evaluation initiatives. All Title V programs continue ongoing assessment activities through engagement of stakeholders, families, and youth to identify COVID changes.

 

Objective Setting: Hawaii generally did not revise objectives for NPM and SPM since the impacts of COVID are difficult to predict.

 

C.1.f. Changes in Organizational Structure and Leadership

No organizational changes were made to State or DOH structure. Leadership for the Department has remained stable after several changes in FY 2021. A new administration will be elected in November 2022 and DOH appointed leadership will change. This change will not impact the FHSD Chief position.

 

C.1.g. Emerging Public Health Issues

The COVID-19 pandemic remains a dynamic and ongoing public health concern. The ongoing emergence of COVID variants, uncertainty about the state’s economic recovery, and long-term impacts of the pandemic will continue to challenge the health and well-being of Hawaii’s population and healthcare system. The availability of vaccinations, therapeutics, and testing have greatly reduced severe illness and death to date. Continued racial and ethnic disparities that are consistent across multiple domains of health indicators suggest structural racism and discrimination as determinants of health remain an important priority.

 

FHSD will continue to secure services to support ongoing needs assessment with data collection and analysis to monitor health consequences due to COVID. FHSD programs and staff will continue to work with stakeholders (including youth and families) to identify and respond to emerging needs and concerns.

[1] The Title V federally available dataset (FAD) includes data for all Title V National Performance and Outcome Measures. States have the options to utilize other local data sources to provide more timely and disaggregated analysis.

[2] BRFSS is the Behavioral Risk Factor Surveillance System, a survey of adults.

[3] HCUP-SID is the Healthcare Cost & Utilization Project-State Inpatient Databases conducted by the Agency for Healthcare Research & Quality

[4] Note Hawaii Sleep-related SUID death numbers are very small annually (14-19 per year).

[5] NVSS is the National Vital Statistics System

[6] NIS is the National Immunization Survey

[7] PRAMS is the Pregnancy Risk Assessment Monitoring Surveillance

[8] KIDS Count 2020, 2020 Census

[9] Kids Count rankings may not use the most current data and may not reflect worsening health trends in Hawaii but significant improvements in other state health measures. Closer analysis of the data is needed to understand Hawaii’s ranking decline.

[10] NSCH is the National Survey of Children’s Health

[11] The combined data for all Asian categories used in the NSCH maybe masking disparities among more detailed race/ethnicity groups.