Geographical Maldistribution of Native Hawaiian and Other Pacific Islander Physicians in Hawai‘i

Abstract

Background

Native Hawaiians and other Pacific Islanders (NHOPI) have high prevalence of overweight status, obesity, and hypertension, as well as high rates of asthma and cancer mortality. Some barriers to health care delivery for this population are a physician shortage in Hawai‘i and a geographical maldistribution of actively practicing physicians. This study examines the distribution of NHOPI physicians compared to the NHOPI population in Hawai‘i through Geographical Information System choropleth mapping.

Methods

The maps and results were gathered and constructed from Census Tract data from the US Department of Commerce, the Census Bureau, the Physician Workforce Assessment, and the ‘Ahahui o nā Kauka reports.

Results

With the exception of East Honolulu, all areas of Hawai‘i show drastic disparities in the ratio of NHOPI physicians to NHOPI populations as compared to the ratio of total physicians to the total population.

Discussion

Given the NHOPI physician shortage and their geographical maldistribution, this study underscores the importance of increasing the number of NHOPI medical school applicants, graduates, residents, and physicians in permanent active practices in rural areas and the neighbor islands. Current institutional and academic programs, such as the John A. Burns School of Medicine, Imi Ho‘ola, and the Native Hawaiian Center of Excellence, are contributing to resolving some of the health disparities and should consider expanding their efforts.

Background

“Native Hawaiians and Other Pacific Islanders,” or NHOPI, are defined as persons having their origin in any of the original peoples of Polynesia, Micronesia, and Melanesia.¹ According to the 2000 US census, NHOPI represent 0.4% of the US population or an estimated 1.1 million individuals and there are currently 236,815 NHOPI living in Hawai‘i.² NHOPI have a disproportionately higher risk for cardiometabolic disease which includes cardiovascular disease, diabetes, and obesity.³ They also have a higher prevalence of hypertension, asthma, and stroke along with behavioral risk factors for chronic disease development such as drinking and smoking.⁴ In addition, they also experience disproportionate rates of cardiovascular disease and cancer mortality.⁵ Furthermore, Native Hawaiians have the highest age-sex standardized mortality rates and the lowest life expectancy of all groups in the State.⁴

Factors contributing to these health outcomes include limited access to health care, cultural barriers, and poor nutrition and lifestyle.⁶ Withy and Sakamoto found that there is a physician deficit of at least 15%–20% compared to the US mainland, especially in neighboring islands and rural areas of larger NHOPI population.⁷ The maldistribution of physicians in practice, largely centered in urban O‘ahu, further aggravate, poor health care access for these populations. NHOPI residing in rural areas and neighbor islands must travel outside of their communities in order to access necessary medical care. A past study conducted in 2001 showed that Native Hawaiian physicians were more likely to specialize in primary care than non-Native Hawaiian physicians. Additionally, the majority of Native Hawaiian physicians served medically underserved populations⁸

Ethnic Concordance in Health Care

The cultural values of some Native Hawaiians may be incongruous with Western medical practices.⁹ Native Hawaiians who identify with their culture are more likely to obtain care from traditional healers over biomedically-trained physicians.¹⁴ Because Native Hawaiians emphasize spiritual conciliation, herbal supplements, and unity, a greater premium is placed on culturally sensitive and community-based participatory approaches to holistically heal the patient.¹⁰ Furthermore, within the sociocultural context of the problematic “local diet,” which comprises high salt, carbohydrates, meat, and fat intakes, many patients find difficulty in adhering to unrealistic and non-pragmatic foreign dietary plans.¹¹ As a result, physicians with similar cultural and ethnic/racial background as these patients may be able to tailor more appropriate health interventions. Furthermore, several studies have demonstrated a particular correlation between the ethnic concordance (eg, having a Native Hawaiian or Pacific Islander physician caring for a Native Hawaiian or Pacific Islander patient, respectively) of patient-physician interactions and a number of patient-related outcomes, such as satisfaction, provider preference, and quality of care.^12,13 In summary, socioeconomic disparity, lack of cultural understanding, and the physician workforce shortage further challenge proper health care, especially in medically underserved areas.

In this paper, we will examine the extent of Native Hawaiian and Other Pacific Islander (NHOPI) physician distributions in comparison to their respective ethnic population through Geographical Information System choropleth mapping. In addition, we aim to explore the historical trends of NHOPI population growth and potential proposals to ameliorate the growing health disparities and physician shortage in these populations.

Methods

Data were obtained from the sources listed below to determine population and doctors by ethnicity (NHOPI). The results were analyzed as a density ratio measurement from the population and doctor aggregates for (1) the total population of Hawai‘i and (2) the NHOPI population of Hawai‘i.

Geographic Information System Mapping

NHOPI population data and digital base maps were collected from the US Department of Commerce, Census Bureau (data File PL 94-471, 2010). The most current public digital base maps, which include shapefiles at the state, county, zip codes, and census tract levels, were obtained for mapping purposes.¹⁴

The State of Hawai‘i was subdivided into nineteen regions initially based on zip code level health insurance claim data from 2006. Zip codes were combined to represent regions whose resident populations displayed similar healthcare utilization patterns. For the purposes of this paper, these regions were revised to coincide with 2010 census tract boundary and population data released by the US Census Bureau (Figure 1).¹⁵

Figure 1.

Region division of physician usage patterns in Hawai'i based on US Census Tract and health insurance data.

Choropleth maps are quantitative thematic maps and common cartographic techniques are used to display area-aggregated data. In healthcare research, choropleth maps are often used to display a statistic, such as disease rates or risk ratios. Typically, these regions are distinctively shaded according to a color-based classification scheme of varying intensity and communicate how a statistic varies across a geographic area. In this research, Environmental Systems Research Institute (ESRI, Redlands, CA) ArcGIS 9.3.1 software was used to map the ratio of NHOPI physicians to NHOPI populations. A monochromatic progression was used to depict the NHOPI-specific ratios across each region. Lighter shaded areas indicate lower physician-to-population ratios whereas darker shaded areas indicate higher physician-to-population ratios. The physician-to-population ratio was calculated for each region according to the following formula:

ρ_region = (∑Physician FTE_region / ∑Total Population_region) *10,000 where FTE stands for full-time equivalent.

Population data were obtained from the 2010 US Census and aggregated from the census tract level into regional divisions that previously displayed distinct healthcare access patterns within the State of Hawai‘i.⁷ Regions within the State of Hawai‘i were created using healthcare utilization patterns and distance to services (Table 1). As of July 29th, 2011, the US Census Bureau has not released civilian-only population estimates for the State of Hawai‘i.

Table 1.

List of regions utilized in GIS-mapping for physician coverage ratios in NHOPI and total population.

County	Island	Regions
Hawai‘i	Big Island	Kona
Hawai‘i	Big Island	Hilo
Hawai‘i	Big Island	North Hawai‘i
Honolulu	O‘ahu	East Honolulu
Honolulu	O‘ahu	Primary Urban Center
Honolulu	O‘ahu	Ko‘olauloa
Honolulu	O‘ahu	Central O‘ahu
Honolulu	O‘ahu	Ko‘olaupoko
Honolulu	O‘ahu	Ewa
Honolulu	O‘ahu	Wai‘anae
Honolulu	O‘ahu	Wahiawa
Honolulu	O‘ahu	North Shore
Kaua‘i	Kaua‘i	East Kaua‘i
Kaua‘i	Kaua‘i	West Kaua‘i
Maui	Lana‘i	Lana‘i
Maui	Maui	Wailuku-Kahului
Maui	Maui	Kihei-Wailea-Up Country Hana (KWU)
Maui	Maui	Lahaina
Maui	Moloka‘i	Molokai

Physician Workforce Database

The physician workforce assessment database was compiled using a combination of Hawai‘i and national data, the aggregates of which were provided by Kelley Withy and David Sakamoto. Human subjects research exemption was obtained for this project from the University of Hawai‘i Institutional Review Board (#15107).

Ethnicity data from the above mentioned physician workforce database were confirmed, and additional Native Hawaiian physicians were identified using membership data from the ‘Ahahui o nā Kauka report from the Native Hawaiian Center of Excellence. ‘Ahahui o nā Kauka is a non-profit organization of Hawaiian physicians dedicated to improving the health of Native Hawaiians. The Native Hawaiian Center of Excellence is an initiative funded by the US Department of Health and Human Services to promote Native Hawaiian health through education, research, and community initiatives. The remaining physicians were identified through key informants in the Hawaiian physician community.

Results

There are 2,860 FTE physicians practicing in the State of Hawai‘i; the most recent census data indicate a total population of 1,360,301 (including military) for a physician-to-population ratio of 21 per 10,000, with a range of 1.1 (Lāna‘i Island) to 39.9 (Honolulu, O‘ahu, the primary urban center). As demonstrated by the geographic information system mapping, Hawai‘i faces drastic geographical disparities in the total physician coverage (Figure 2). One hundred and eighteen Native Hawaiian physicians were identified providing patient care in Hawaii as of 2010 for a total of 105.5 Full Time Equivalents of care. Of these physicians, 96 graduated from John A. Burns School of Medicine (81%).

Figure 2.

Choropleth ratio representation of Total Physicians to Total Population in Hawai‘i per 10,000.

NHOPI residents make up 26.2% of the total Hawai‘i population and 3.7% of the total Hawai‘i physician workforce, which translates to an average ratio of 2.96 NHOPI physicians per 10,000 NHOPIs. After separating Native Hawaiian physicians from other Pacific Islander physicians, Native Hawaiian physicians make up 3.4% of the total physician workforce and other Pacific Islander physicians make up only 0.3%. These findings indicate a considerable shortage of NHOPI physician FTE compared to the physician coverage of the general population (Figure 3).

Figure 3.

Choropleth ratio representation of NHOPI Physicians to NHOPI Population in Hawai‘i per 10,000.

Physician-to-Population Ratios (Figure 4)

Figure 4.

Comparison of Physician to Population ratio in NHOPI and in Total Population in the State of Hawai‘i per 10,000.

Honolulu (39.9), East Kaua‘i (38.7), Wailuku-Kahului Maui (21.4), and North Hawai‘i Island (19.7) had the highest physician-to-population ratios. Lāna‘i Island (1.1), Wai‘anae O‘ahu (3.8), Wahiawā O‘ahu (5.1), and the North Shore of O‘ahu (5.3) had the lowest physician-to-population ratios. Five additional regions had ratios of less than 10, including East Honolulu, Ko‘olauloa O‘ahu, Central O‘ahu, West Kaua‘i, and Lahaina Maui.

NHOPI Physician Comparisons

One hundred and seven Native Hawaiian physicians were identified providing patient care in Hawaii as of 2010. On average, there are 2.3 NHOPI FTE physicians for every 10,000 NHOPI residents in the state of Hawai‘i. The highest ratio of NHOPI physicians to NHOPI population is seen on the island of Moloka‘i (6.6), while there were zero NHOPI physicians on the island of Lāna‘i, Lahaina Maui, and the North Shore of O‘ahu. Following Moloka‘i, the next highest ratios were observed in East Honolulu (6.1) and Honolulu (6.0), both on the island of O‘ahu, and in Kona (3.9) on the island of Hawai‘i. In addition to the previously stated locations with zero NHOPI FTE physicians, the next lowest ratios were observed on Kihei-Wailea-Up Country-Hana(1.0) of Maui, and the cities of Wai‘anae (0.8), and Wahiawā (0.3) on the island of O‘ahu.

Discussion

Maldistribution of Physicians in Hawai‘i

According to the Hawai‘i physician workforce assessment, the state is short 600 physicians or 15%–20% from that needed to provide services on par with the national average utilization of physician services.⁷ O‘ahu's primary urban center, Honolulu, has the largest physician-to-population ratio in the state with the highest population (430,548) and the largest number of physician FTEs (1,716). Areas such as East Kaua‘i, Wailuku-Kahului and North Hawai‘i have relatively small populations and have adequate physician-to-population ratios. Conversely, in areas such as Lāna‘i (1.1) and Wai‘anae (3.8), the physician FTE is dramatically less in comparison to the region's population. For example, Wai‘anae's population is about 3 times larger than that of East Kaua‘i, but Wai‘anae has less than .01 of the physician FTEs.

This disparity reflects the general maldistribution of physicians, with a predilection for certain rural areas and neighboring islands (Figure 2). Access to healthcare services can be an important determinant of health outcomes. Consequently, people living in districts with lower physician-to-population ratios may experience greater difficulties in receiving proper healthcare. As noted by Aday and Anderson more than three decades ago, access is multi-faceted and relies on a number of components besides the existence of healthcare providers.¹⁶ Economic, organizational, and socio-cultural factors must also be considered to examine possible barriers to access.

NHOPI Physician Comparisons

A total of 118 Native Hawaiian physicians were identified in Hawai‘i, for a total of 105.5 FTEs. Even in the regions with the highest NHOPI physician-to-NHOPI population ratios such as Moloka‘i (6.6), East Honolulu (6.1) and Honolulu (6.0), these ratios are approximately 27 times less than the ratio of total physician-to-population. We observed a general trend (the overall predilection of the geographical maldistribution falling on rural areas and the outer islands) between the regions with the worst ratios: Lāna‘i Island, Wai‘anae, Wahiawā and the North Shore of O‘ahu. This reflects both overall physician workforce shortage and the disparity demonstrated by the low number of NHOPI physicians. It also reveals a substantial demand for services in regions outside of O‘ahu's urban center that tend to be populated heavily by NHOPI patients. In all cases, NHOPI physicians are both too few and maldistributed with respect to the NHOPI population. Again, we see the least favorable physician-to-population ratios are clustered in the neighboring islands and rural communities of O‘ahu (Figure 3).

Of the 23 hospitals in Hawai‘i, ¹³ are located in rural areas. Nine are classified as critical access hospitals by the Flex critical monitoring team. There are currently no level I trauma centers in the state. The Queen's Medical Center, located in Honolulu, designated level II, serves the most patients in the state.¹⁷ Rural communities on O‘ahu rely on two regional health clinics, thus exhibiting gross geographical disparities in terms of access to major health centers. This problem is further compounded for residents on the neighboring islands where transportation to O‘ahu is limited to commercial air flights. In 2009, 90.5% of Native Hawaiian adults self-reported receiving any health coverage in comparison with 92.8% of Caucasians, 93.4% of Filipinos, 95.4% of Japanese, and 92.7% statewide.¹⁸ On O‘ahu, a smaller disparity between urban Honolulu and central and western regions was noted, which implies that physician maldistribution is a factor contributing to limited healthcare access and thus, may worsen health outcomes.

Historical Trend of NHOPI Physicians

In 2001, a study was conducted by Else, et al, in which the practice locations of Native Hawaiian physicians in Hawai‘i was analyzed in comparison to the distribution of the Native Hawaiian population.⁸ The Native Hawaiian physician data used for this study were from a database compiled by the Native Hawaiian Center of Excellence, and was current as of 1998.¹⁹ This study found that only about 4%, or 104 of about 2,400, of practicing physicians in Hawai‘i were Native Hawaiian. In contrast, 18%–22% of the total population of the state was identified by the 1990 US Census as Native Hawaiian. In addition, it was found that a vast majority of Native Hawaiian physicians practice in urban areas, with 72% of those on O‘ahu practicing in Honolulu.

The 2010 census indicates that the number of NHOPI in the general population of Hawai‘i has increased to 26.2%. This study found that Native Hawaiian physicians made up about 3.3% of the total FTE physicians in Hawai‘i, which is similar to the proportion found in the 2001 study (4%). However, this study also found that there is a decrease in the ratio of Native Hawaiian physicians to Native Hawaiians in the total population between 2001 and 2010. The disparity is thus worsening. These findings with regard to Native Hawaiian physician distribution are similar to those from the 2001 study with a majority of Native Hawaiian physicians in the state practicing in urban O‘ahu.

Areas of High Disparities

The high physician-to-population ratios can result from a large population of physicians, a low total population utilizing their services, or a combination of both; the converse is true for low ratios. We aim to highlight these particular areas of high disparities for two reasons: low ratio extremes indicate a drastic shortage of physician coverage and high ratio extremes can mask the reality of health care accessibility through inflating the averages on a statewide level.

As demonstrated by the choropleth mapping, one of the highest ratios of NHOPI physicians to NHOPI population is found in Honolulu (6.0), which hosts the highest number of NHOPI residents in the state (80,338) and contains the single largest population of NHOPI FTE physicians (48.3). Conversely, the second largest NHOPI population in the State of Hawai‘i is located in Wai‘anae on the Leeward Coast of O‘ahu (45,173) and despite having NHOPI population numbers exceeding 50% of the Honolulu, Wai‘anae has 13-fold less NHOPI FTE-physicians to serve its community. The island of Moloka‘i is the only neighbor island to exceed the NHOPI FTE-physician per 10,000 population ratio of 2.1 – 5.0, particularly achieving the highest ratio as well (6.6). Moloka‘i has a ratio of NHOPI physicians to NHOPI population 20 times that of Wahiawā, the region with the smallest ratio (0.3). It was nearly 8 times better than the next smallest ratio in Wai‘anae (0.8).

The worst disparities were noted in Lāna‘i Island, Lahaina, Maui, and the North Shore of O'ahu, regions with no NHOPI physicians at all. Of the remaining regions, two had less than or equal to one NHOPI physician per 10,000 population, namely West Kaua‘i and Kihei-Wailea-Up Country-Hana, Maui. Therefore, nearly 40% of the represented regions had a NHOPI physicians-to-NHOPI population of less than or equal to one. In contrast to the total physician-to-population ratio, whose lowest ratio is 1.1 per 10,000 on Lāna‘i, over half of the regions had greater than 10 per 10,000 population.

Proposed Remedies

The disproportionate ratios of NHOPI physicians to the NHOPI population require a multi-dimensional approach to alleviate physician coverage disparities. Others have proposed a variety of interventions to address the general physician shortages via loan repayment programs, tort/legislative reforms, medical community mentorship and improving professional and financial environments.^7,20,21 With the problems rooted in total number of NHOPI physicians and geographical maldistributions, our proposed solutions focus specifically on institutional and academic reforms in order to (1) increase the number of NHOPI physician applicants, graduate and residency programs, and (2) encourage permanent active practices in rural areas and neighbor islands.

The training of more Native Hawaiian physicians at the institutional level is one component that may play an important role. Since its inception in 1965, the University of Hawai‘i's John A. Burns School of Medicine (JABSOM) has educated 226 Native Hawaiian physicians. Approximately 50% of physicians practicing in Hawai‘i are graduates of JABSOM and the school is well-positioned to have a positive impact on our physician population. In fact, the current study indicates that JABSOM educates 81% of the NH physicians currently practicing in the State. In the last five years JABSOM has demonstrated its success in recruiting, accepting, and ultimately graduating a number of Native Hawaiian applicants but there is always room for improvement. According to data provided by the Office of Student Affairs at JABSOM, in the last five years (2006–2010) only 12% of in-state applicants to JABSOM were of Native Hawaiian descent, indicating that recruitment efforts must be increased to broaden the number of qualified Native Hawaiian students who choose to apply. Within that same period, 23% of in-state Native Hawaiian applicants were admitted (excluding those matriculating through the Imi Ho‘ola [“those who seek to heal”] program) compared to 26% of the total in-state applicant pool. Data on graduation rates are currently limited. Between 2001 and 2006, 42 Native Hawaiian students matriculated at JABSOM (including Imi Ho‘ola students). Within 4 years of matriculation, 39 Native Hawaiian students have graduated, for a minimum graduation rate of 92.9% during that five-year span. These numbers indicate that JABSOM has played a key role in educating Native Hawaiian physicians and must continue to do so in the future.

It is evident that JABSOM has taken on the challenge of increasing the diversity of Hawai‘i's physician workforce by integrating and supporting the Imi Ho'ola Post-baccalaureate and Native Hawaiian Center of Excellence (NHCOE) programs at JABSOM's Department of Native Hawaiian Health. The Imi Ho'ola program is a 12-month post-baccalaureate program that has provided an alternate pathway to medicine for over 200 college graduates for over 30 years. The Imi Ho'ola program accepts individuals of any race or ethnicity who demonstrate a socially, educationally, or economically disadvantaged background and a strong, personal commitment to practice medicine in areas of need in Hawai‘i and throughout the US Affiliated Pacific Islands. Since its inception in 1973, over 200 of the Imi Ho'ola post-baccalaureate program graduates are currently enrolled or have graduated from JABSOM, 40% of whom are Native Hawaiian.

NHCOE has been in existence for 15 years and is funded by the US Department of Health and Human Resources. Their overall mission is to improve the health of Native Hawaiians through education, outreach, research, faculty development and ultimately increasing the number of Native Hawaiian physicians.

Limitations

Although data were collected for the most recent (2010) census on Native Hawaiians as distinct from Other Pacific Islanders, this data had not been released by the US Census Office at the time this paper was written. Data used for population mapping purposes were therefore an aggregate of Native Hawaiian and Other Pacific Islander, as these were the only data that had been released. From the Hawai‘i/Pacific Basin Area Health Education Center practicing physician database, we identified only 8.2 FTE Other Pacific Islanders physicians versus 97.25 FTE Native Hawaiian physicians, which may serve to exaggerate the shortage of Native Hawaiian physicians when looking at the NHOPI composite. Furthermore, civilian-only population data were not available. Further data mapping will be warranted on these two populations separately when such data are made available by the US Census Office.

There is currently no research indicating that Native Hawaiians prefer receiving care from Native Hawaiian physicians or that such race-concordant care leads to better health outcomes in the Native Hawaiian population. By identifying all Native Hawaiian physicians in Hawai‘i and analytically mapping their practice locations to areas in which Native Hawaiians access health care, future steps can be taken to elucidate the extent of these preferences as well as any patterns of quantitative health outcomes that may exist.

By determining the patterns of Native Hawaiian physician service, factors influencing practice location can begin to be addressed. Further research can elucidate those values and priorities that lead physicians to practice in well-served or under-served areas and strategies can then be formulated for attracting more Native Hawaiian physicians to areas of need.

Addenda

Nomenclature and Abbreviations

The following abbreviations are utilized to discuss the relationship and distribution of physician coverage in Hawai‘i based on FTE.

FTE

Full Time Equivalence; an FTE of 1.0 means that the physician practices full-time

NHOPI

Native Hawaiian and Other Pacific Islander

$\frac{\mathrm{NHOPI}\mathrm{Physicians}\left[\mathrm{Number}\right]}{\mathrm{NHOPI}\mathrm{Population}\left[\mathrm{Number}\right]}$

NHOPI physician-to-NHOPI population ratio

$\frac{\mathrm{Total}\mathrm{Physicians}\left[\mathrm{Number}\right]}{\mathrm{Total}\mathrm{Population}\left[\mathrm{Number}\right]}$

physician-to-population ratio

Conflict of Interest

None of the authors report any conflict of interest.