Abstract
Native Hawaiians and Other Pacific Islanders (NHOPI) suffer from a number of poor health outcomes, such as high rates of overweight status, obesity, hypertension, and high rates of asthma and cancer mortality. In addition to a disproportionate burden of illness, barriers to health care access and utilization also exist. This study examines the effect of health insurance coverage on the health status of NHOPI in comparison to Asians. To analyze this relationship, the study uses the Behavioral Risk Factor Surveillance System (BRFSS) 2012 data and logistic regression. Findings show insured NHOPI were significantly more likely than insured Asian Americans to report poor or fair health after sequential cumulative adjustments of socioeconomic, lifestyle and behavioral factors, history of diagnosed diseases, and access to care (OR: 1.66, 95% CI:[1.34, 2.05]). Health insurance alone will not eliminate the present disparities experienced by NHOPI. Other barriers prohibit health care access for NHOPI that should be considered in the investigation and development of strategies to increase healthcare access and eliminate health disparities for NHOPI.
Introduction
According to the United States (US) Census Bureau, there are an estimated 1.4 million Native Hawaiian and Other Pacific Islanders (NHOPI) currently living in the US.1 This population suffers from the highest rates of heart disease, hypertension, asthma, cancer incidence and diabetes in comparison with all other ethnicities. Despite having some of the highest healthcare needs, they also continuously experience barriers to accessing healthcare and utilizing quality services. 2–4 In comparison to the majority population, NHOPI experience extreme health disparities indicated by high mortality rates and low life expectancies as a result of colonization and historical trauma. Colonial forces prohibited the transmission of language, culture, and traditional practices resulting in significant damage to health, education, and social well-being.2–5 These outcomes are argued to make the history of colonial oppression a key determinant of health for NHOPI.
Health services are essential to treatment and prevention of illness. The Institute of Medicine defines quality health services as, “appropriate care at the appropriate time by the appropriate provider.”6 Access to healthcare and health outcomes are often determined by factors beyond health insurance coverage, including those related to individuals, their families, communities, and the healthcare system.7 With the passage of the 2010 Affordable Care Act (ACA), there has been much focus on restructuring the US healthcare system and placing a strong emphasis on providing affordable insurance.8 However, eliminating the barriers of financial access may not necessarily improve access to quality healthcare. This paper explores if health outcomes are comparable between NHOPI and Asian patients when insurance coverage is the same and other variables are controlled.
Methods
This study examines the relationship between health status, health care access, and health outcomes for Native Hawaiians and Other Pacific Islanders (NHOPI) compared to Asians. Asians are the comparison population because they experience the greatest positive health outcomes and lowest mortality and disease prevalence rates.9 Human subjects research exemption was obtained for this project from the University of Hawai‘i Institutional Review Board (#21928).
Secondary data analysis was conducted using the 2012 Behavioral Risk Factor Surveillance System (BRFSS) data set. The BRFSS is an annual, state-based, random-digit dialed household telephone survey of the non-institutionalized US civilian population aged ≥ 18 years. As the world's largest telephone survey, this system provides a key source of data specifically related to health risk behavior, a history of disease, and access to healthcare. With assistance from the Centers of Disease Control (CDC), this national survey is conducted monthly in all 50 states, the District of Colombia, US Virgin Islands, Puerto Rico, and Guam. The final sample included 3,021 Native Hawaiians and Other Pacific Islanders and 10,479 Asians living in the United States and affiliated US Territories.
Access to healthcare is quantified using four core questions in the BRFSS survey. The four healthcare outcome measures include: (1) did the respondent had health care coverage in the form of health insurance, prepaid plans, or government plans such as Medicare; (2) did the respondent experience a health care cost barrier in the past 12 months; (3) did they have a usual source/provider for healthcare (defined as having at least one person they considered a personal doctor); and (4) did the respondent visit a doctor for a routine checkup in the past year. Socio-demographic variables include: gender, marital status, employment status, age, education level, and household income. These factors are conceptualized as a broad set of social determinants for health and healthcare. Lifestyle and behavioral factors assessed include: current status on smoking, drinking, and weight. These variables represent lifestyle risk factors that may affect individual beliefs, behaviors, and needs associated with healthcare.
Self-reported health measures include general health status categorized as “good” or “better” and “fair” or “poor.” These are conceptualized as perceived health need factors that underlie health-seeking behaviors.
History of diagnosed conditions include whether the respondent had ever been told by a doctor, nurse, or other health professional that they had diabetes, heart attacks, angina or coronary heart disease, stroke, kidney disease or depression. These factors represent physician-evaluated health-need factors that may influence one's access and utilization of healthcare in ways that are different from perceived health need factors.
A bivariate analysis was used to compare health care access, demographics, lifestyle, socioeconomic status, health status, and history of disease indicator variables between NHOPI and Asians. Additionally, this study employed χ2 goodness of fit tests to evaluate if the proportions differed comparing NHOPI and Asians.
A logistic regression was performed to assess the unadjusted odds of reporting fair or poor health only among those with health insurance coverage. Additional analyses were carried out to determine the adjusted effects of reporting fair or poor health and each socioeconomic, lifestyle, disease state, and health status factor stratified by ethnicity. Additional analyses were also carried out with fair or poor health as the outcome adjusting for ethnicity and including individually socioeconomic status, lifestyle, or disease state. The results are reported as odds ratios (OR) with an OR > 1 indicating exposure is associated with higher odds of an outcome. Additionally, 95% confidence intervals are provided as an indicator of statistical significance in the association between variables if it does not overlap with the null value (OR=1). All statistical analyses were performed using STATA version 13 (College Station, TX).10
Results
Table 1 and 2 describe provide a descriptive analysis of Asian and NHOPI populations as distinct groups based on the socioeconomic, lifestyle and behavioral factors, self-reported health status, and prior diagnosed conditions. Native Hawaiians and Other Pacific Islanders in the US are more likely to be unemployed (17.4% vs 9.1), have less than a high school education (53.0% vs 22.2%), and live below the Federal Poverty Line (FPL) (18.2% vs 9.4%) than US Asians. NHOPI also reported greater prevalence of diabetes (10.9% vs 8.2), heart disease (4.1% vs 2.3%), depression (12.4% vs 7.2%), kidney disease (4.1% vs 2.0%), heart attacks (4.8% vs 2.3%), and stroke (3.3% vs 1.9%). Additionally, NHOPI reported higher rates of having fair or poor health (22.5% vs 11.1%), being obese (71.0% vs 42.6%), smoking (24.0% vs 9.5%), and heavy drinking (7.8% vs 3.4%), when compared to Asians.
Table 1.
Socio-demographic Factors for NHOPI and Asians
| Socio-Demographic Factors | NHOPI (N=3,021) | Asian (N=10,479) |
| n(%) | n(%) | |
| Sex | ||
| Male | 1,322 (43.8%) | 4,994 (47.7%) |
| Female | 1,699 (56.2%) | 5,485 (52.3%) |
| Marital Status | ||
| Married | 1,326(44.1%) | 6,068 (58.4%) |
| Not Married | 1,679 (55.9%) | 4,332 (41.7%) |
| Employment Status | ||
| Employed | 1,694 (82.6%) | 6,463 (90.9%) |
| Unemployed | 356 (17.4%) | 648 (9.1%) |
| Age | ||
| 18–65 | 2,680 (88.7%) | 8,768 (83.7%) |
| 65+ | 341 (11.3%) | 1,711 (16.3%) |
| Education Level | ||
| HS Graduate | 1,414 (47.0%) | 8,085 (77.8%) |
| Did not Graduate | 1,592 (53.0%) | 2,310 (22.2%) |
| Income | ||
| Above FPL | 2,178 (81.8%) | 8,169 (90.6%) |
| Below FPL | 485 (18.2%) | 850 (9.4%) |
Table 2.
Lifestyle and Behavioral Factors, Health Status, and History of Disease for NHOPI and Asians
| NHOPI (N=3,021) | Asian (N=10,479) | |
| n(%) | n(%) | |
| Lifestyle and Behavioral Factors | ||
| Obesity | 2,039 (71.0%) | 4,211 (42.6%) |
| Smoking | 710 (24.0%) | 965 (9.5%) |
| Heavy Drinking | 223 (7.8%) | 331 (3.4%) |
| Self-Reported Health Status | ||
| Good or Better | 2,333 (77.5%) | 9,286 (88.9%) |
| Fair or Poor | 679 (22.5%) | 1,163 (11.1%) |
| Prior Diagnoses Factors | ||
| Diabetes | 327 (10.9%) | 856 (8.2%) |
| Coronary Heart Disease | 122 (4.1%) | 239 (2.3%) |
| Depression | 372 (12.4%) | 751 (7.2%) |
| Kidney Disease | 124 (4.1%) | 204 (2.0%) |
| Heart Attack | 143 (4.8%) | 238 (2.3%) |
| Stroke | 100 (3.3%) | 198 (1.9%) |
Table 3 summarizes the differences between healthcare access, barriers, and utilization by health insurance coverage for US NHOPI compared to Asians. NHOPI are significantly more likely to experience a cost barrier to accessing healthcare when compared to Asians (P<.001). This relationship persists between those with insurance (Asian: 8.1% vs NHOPI: 14.7%) and those without insurance (Asian: 33.1% vs NHOPI: 41.4%). Additionally, uninsured NHOPI (40.9%) are significantly less likely to obtain an annual checkup when compared to Asians (46.8%).
Table 3.
Healthcare Access, Barriers, and Utilization by Health Insurance Coverage for NHOPI Compared to Asians
| Personal Health Care Provider | Experience of a Cost Barrier | Annual Routine Checkup | ||
| Insured | Asian | 7,614 (84.0%) | 733 (8.1%)** | 6,321 (71.7%) |
| NHOPI | 2,058 (84.0%) | 361 (14.7%)** | 1,721 (71.1%) | |
| Uninsured | Asian | 567 (43.3%) | 432 (33.1%)** | 573 (46.8%)* |
| NHOPI | 222 (42.0%) | 221 (41.4%)** | 208 (40.9%)* |
P<.05,
P<.001
Table 4 compares these two ethnic groups under the condition of both holding insurance and indicates the change in odds of NHOPI, compared to Asians, experiencing fair or poor health after adjusting for each group of summary variables. The unadjusted odds of insured NHOPI reporting fair or poor health as compared to Asians was 2.38 (95% CI: [2.12, 2.67]). The socioeconomic factors meaningfully reduced the self-reported health status odds ratio (OR) for insured NHOPI by 20.2%, as compared to Asians (OR: 1.90; 95% CI: [1.59, 2.28]). The same trend was shown for factors related to prior diagnosed diseases with a 13.4% reduction (OR: 2.06; 95% CI: [1.81, 2.34]), lifestyle and behavioral factors with a 19.7% reduction (OR: 1.91; 95% CI: [1.68, 2.17]), and access to healthcare with a 4.6% reduction (OR: 2.27; 95% CI: [2.01, 2.56]). Adjusting for demographic factors increased the odds of NHOPI reporting fair or poor health as compared to Asians (OR: 2.57; 95% CI: [2.27, 2.90]).
Table 4.
The Odds of Experiencing Fair or Poor Health among Those with Health Insurance Coverage After adjusting for Each Summary Variable for Insured NHOPI Compared to Insured Asians
| Unadjusted | Adjusted | |||||
| OR | P-value | 95% CI | OR | P-value | 95% CI | |
| Demographic Factors (n=11,465) | ||||||
| Odds NHOPI (compared to Asians) | 2.38 | .000 | (2.12, 2.67) | 2.57 | .000 | (2.27, 2.90) |
| Female | 0.86 | .008 | (0.76, 0.96) | |||
| Age | 1.03 | .000 | (1.03, 1.04) | |||
| Married | 0.77 | .000 | (0.69, 0.86) | |||
| Socioeconomic Status (n=6,983) | ||||||
| Odds NHOPI (compared to Asians) | 2.38 | .000 | (2.12, 2.67) | 1.90 | .000 | (1.59, 2.28) |
| Employed | 0.54 | .000 | (0.42, 0.69) | |||
| < HS Education | 1.74 | .000 | (1.45, 2.09) | |||
| Income < FPL | 2.07 | .000 | (1.59, 2.70) | |||
| History of Disease (n=11,238) | ||||||
| Odds NHOPI (compared to Asians) | 2.38 | .000 | (2.12, 2.67) | 2.06 | .000 | (1.81, 2.34) |
| Diabetes | 3.85 | .000 | (3.29, 4.49) | |||
| Coronary Heart Disease | 1.89 | .000 | (1.38, 2.59) | |||
| Depression | 2.98 | .000 | (2.52, 3.53) | |||
| Kidney Disease | 3.57 | .000 | (2.72, 4.69) | |||
| Heart Attack | 1.51 | .011 | (1.10, 2.09) | |||
| Stroke | 2.69 | .000 | (1.98, 3.66) | |||
| Lifestyle Factors (n=10,416) | ||||||
| Odds NHOPI (compared to Asians) | 2.38 | .000 | (2.12, 2.67) | 1.91 | .000 | (1.68, 2.17) |
| Obesity | 1.60 | .000 | (1.42, 1.80) | |||
| Smoking | 1.75 | .000 | (1.50, 2.05) | |||
| Heavy Drinking | 0.62 | .002 | (0.46, 0.85) | |||
| Access to Care (n=11,121) | ||||||
| Odds NHOPI (compared to Asians) | 2.38 | .000 | (2.12, 2.67) | 2.27 | .000 | (2.01, 2.56) |
| Health Care Provider | 1.56 | .000 | (1.29, 1.87) | |||
| Annual Checkup | 1.46 | .000 | (1.27, 1.67) | |||
| Cost Barrier | 2.26 | .000 | (1.80, 2.45) | |||
Table 5 demonstrates the final model after adjusting for all four groups of summary variables. The unadjusted odds ratio of experiencing a healthcare cost barrier for insured NHOPI compared to insured Asians was 2.38 (95% CI: [2.12, 2.67]). After controlling for demographic factors, socioeconomic status, lifestyle and behavior factors, access to healthcare, and history of prior diagnosed diseases, the fully adjusted odds of reporting fair or poor health among those NHOPI with health insurance coverage was 1.66 (95% CI:[1.34, 2.05]).
Table 5.
The Odds of Experiencing Fair or Poor Health among Those with Health Insurance Coverage After Adjusting for All Summary Variables for Insured NHOPI Compared to Insured Asians
| N=6,130 | Unadjusted | Adjusted | ||||
| OR | P-value | 95% CI | OR | P-value | 95% CI | |
| Odds NHOPI (compared to Asians) | 2.38 | .000 | (2.12, 2.67) | 1.66 | .000 | (1.34, 2.05) |
| Demographic Factors | ||||||
| Female | 0.75 | .003 | (0.62, 0.91) | |||
| Age | 1.03 | .000 | (1.02, 1.03) | |||
| Married | 0.99 | .956 | (0.82, 1.21) | |||
| Socioeconomic Status | ||||||
| Employed | 0.65 | .003 | (0.42, 0.69) | |||
| < HS Education | 1.65 | .000 | (1.45, 2.09) | |||
| Income < FPL | 2.02 | .000 | (1.59, 2.70) | |||
| History of Disease | ||||||
| Diabetes | 3.86 | .000 | (3.29, 4.49) | |||
| Coronary Heart Disease | 1.75 | .043 | (1.38, 2.59) | |||
| Depression | 2.45 | .000 | (2.52, 3.53) | |||
| Kidney Disease | 3.27 | .000 | (2.72, 4.69) | |||
| Heart Attack | 1.37 | .275 | (1.10, 2.09) | |||
| Stroke | 2.27 | .007 | (1.98, 3.66) | |||
| Lifestyle Factors | ||||||
| Obesity | 1.32 | .004 | (1.42, 1.80) | |||
| Smoking | 1.52 | .000 | (1.50, 2.05) | |||
| Heavy Drinking | 0.75 | .159 | (0.46, 0.85) | |||
| Access to Care | ||||||
| Health Care Provider | 1.17 | .252 | (0.89, 1.54) | |||
| Annual Checkup | 1.15 | .180 | (0.94, 1.42) | |||
| Cost Barrier | 1.64 | .000 | (1.27, 2.13) | |||
Discussion
This study examined the association between health insurance, an element for improved access to health care, other barriers to healthcare (cost, having a personal healthcare provider), and self-reported health status between Native Hawaiians and Other Pacific Islanders (NHOPI) and Asians using national BRFSS data. Insured NHOPI were more likely to experience a cost barrier than insured Asians although there was no difference between groups in regard to having a personal healthcare provider. Additionally, uninsured NHOPI were less likely to receive an annual routine checkup as opposed to uninsured Asians. These initial findings confirm that health disparities do exist and are substantiated in NHOPI populations, regardless of health insurance status and if they have a healthcare provider. Likewise, there are significant associations between ethnicity and self-reported health status among insured NHOPI and Asians (OR: 2.38, 95% CI [2.12, 2.67]). These relationships were slightly attenuated, yet still significant, after sequential cumulative adjustment for patient characteristics. This indicates that by individually controlling for socioeconomic factors, history of disease, lifestyle and behavioral factors, and access to healthcare the difference between insured NHOPI and Asians reporting fair or poor health is decreased but not equal. When all those factors are taken into account, insured NHOPI were still 66% more likely to experience fair or poor health as compared to Asians (OR: 1.66, 95% CI [1.34, 2.05]). This indicates that policy makers and healthcare professionals must acknowledge that although having health insurance increases likelihood of having a health care provider and participating in an annual check up, it is not the entire solution or “magic pill” in eliminating health disparities.
As ethnic minorities, NHOPI often experience social marginalization and racial discrimination in the healthcare setting resulting in poor health outcomes.5,6,11–13 Deficiencies in cultural competency, local language skills and communication, as well as conflicting perceptions, attitudes, beliefs, and values toward health and healthcare pose as significant barriers to accessing care. Obtaining health insurance coverage addresses individuals' ability to pay for health services, but health professionals must consider a broader approach to healing to address health outcomes. These social and cultural barriers are confounded by barriers of accessibility and availability of quality healthcare services, thus, worsening health disparities for NHOPI.
Additionally, the results of this study support existing research showing that a higher proportion of Native Hawaiians and Other Pacific Islanders (NHOPI) suffer greater health disparities, health risk behaviors, and lower socioeconomic status when compared to Asians.2–6 This ethnic group has experienced a unique sociopolitical history, and patient utilization and poor health are complicated by the unique cultural and social contexts of NHOPI. Furthermore, findings from this study confirm previous reports stating the importance of utilizing disaggregated data in health research and surveillance in order to effectively identify and address health disparities in this population.14,15 Continued aggregation of Asians with NHOPI creates an inflation of health outcomes and masks the underlying health inequity of the NHOPI population. 14,15
Conclusion
Scholars have recommended mechanisms to address healthcare barriers. For example, minority physicians are more likely to serve in a medically underserved area.16,17 These physicians are successful because they carry similar perspectives in regards to health and wellness and have the ability to tailor health services that are deemed appropriate and acceptable by patients. Several studies have demonstrated a particular correlation between the ethnic concordance (e.g. 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 positive patient-related outcomes, such as satisfaction, provider preference, and quality of care.18,19 NHOPI physicians address all of the provider level barriers to accessing health care relating to judgmental behavior, differing language, and a lack of communication skills, communication style, and cultural knowledge resulting in a stronger patient-provider relationship.14 Because NHOPI physicians carry similar perspectives in regards to health and wellness, they can develop accountability and trust with patients to prevent stigma, marginalization, condescendence, and insensitivity associated with minority populations.5,6,14
In order to ameliorate health disparities evident in NHOPI populations, the authors suggests several recommendations to improve health care access and positive health outcomes for NHOPIs: (1) increasing the number of NHOPI physician applicants, graduate and residency programs, (2) expanding health care in rural areas and neighbor islands, (3) providing financial support for additional direct and indirect costs to obtaining medical care, and (4) incorporating ‘cultural safety’ or cultural sensitivity into medical training. Establishing equity in our healthcare system is something we should all strive for. Providers should aim to serve their patients with care that is appropriate for them and create acceptable medicine that is inclusive rather than exclusive. Future studies should investigate the effectiveness of these strategies to address the unique needs of NHOPI in the health care setting.
There are limitations associated with the BRFSS data set such as data collection protocol as random-digit dial telephone survey that limits participation to those with a household telephone in a service coverage area. Due to the vulnerability and high-risk behaviors associated with some of the questions asked in the BRFSS, self-report biases including social desirability effect and self-evaluation bias as an underrepresentation limit the generalization of the findings. Additionally, the racial categories of Asian and NHOPI represent a heterogeneous group of distinct subpopulations that have unique languages, cultures, and practices that may reflect differences in socio-demographic factors, lifestyle factors and healthcare coverage, access, and utilization. Due to the limitations stated above, the findings from this study are limited to those participants of the BRFSS 2012 survey and may serve as an underestimation of the actual counts. However, this study group can be used as a starting point to determine where further research and greater exploration can be done to better understand the disparities in health care access, barriers, and utilization.
Conflict of Interest
None of the authors identify a conflict of interest.
References
- 1.American Fact Finder, author. Annual Estimates of the Resident Population by Sex, Single Year of Age, Race Alone or in Combination, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2012. United States Census Bureau; 2013. [March 4, 2014]. Available at: http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2012_PEPALL5N&prodType=table. [Google Scholar]
- 2.Bird ME. Health and Indigenous People: Recommendations for the next generation. American Journal of Public Health. 2002;92(9):1391–1392. doi: 10.2105/ajph.92.9.1391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Colomeda LA, Wenzel ER. Medicine keepers: Issues in Indigenous health. Critical Public Health. 2000;10(2):243–256. [Google Scholar]
- 4.Tauali‘i M, Delormier T, Maddock J. Insights in public health: A new and innovative public health specialization founded on traditional knowledge and social justice: Native Hawaiian and Indigenous Health. Hawaii J Med Public Health. 2013;72(4):143–145. [PMC free article] [PubMed] [Google Scholar]
- 5.Tonmy L, Blackstock C. Commentary: Indigenous health special issue. International Journal of Mental Health and Addiction. 2010;8(2):135–144. [Google Scholar]
- 6.Committee on Quality of Health Care in America, Institute of Medicine, author. “Crossing the Quality Chasm: A New Health System for the 21st Century”. Washington, DC: National Academies Press; 2001. [Google Scholar]
- 7.Zuckerman S, Haley J, Holahan J. Health Insurance Access and Health Status of Nonelderly Adults. Urban Institute; 2000. [Google Scholar]
- 8.111th United States Congress, author. The Patient Protection Affordable Care Act. 2010. [March 29, 2014]. http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf.
- 9.Taualii M, Quenga J, Samoa R, Samanani S, Dover D. Liberating Data: Accessing Native Hawaiian and Other Pacific Islander Data from National Data Sets. AAPI Nexus: Asian Americans & Pacific Islanders Policy, Practice and Community. 2011;9(1):49–255. [Google Scholar]
- 10.Version 13, Stata Corporation, College Station, TX, USA
- 11.Andersen R, Newman JF. Societal and Individual Determinants of Medical Care Utilization in the United States. The Milbank Quarterly. 2005;83:1–28. [PubMed] [Google Scholar]
- 12.Hausmann LRM, Jeong K, Bost JE, Ibrahim SA. Perceived discrimination in health care and health status in racially diverse sample. Med Care. 2008 Sep;46(9):905–914. doi: 10.1097/MLR.0b013e3181792562. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Peek ME, Wagner J, Tang H, Baker DC. Self-reported racial/ethnic discrimination in healthcare and diabetes outcomes. Med Care. 2011 Jul;49(7):618–625. doi: 10.1097/MLR.0b013e318215d925. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Juarez DT, Davis JW, Brady SK, Chung RS. Prevalence of Heart Disease and Its Risk Factors Related to Age in Asians, Pacific Islanders, and Whites in Hawai‘i. Journal of Health Care for the Poor and Underserved. 2012;23(3):1000–1010. doi: 10.1353/hpu.2012.0103. (2012) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Juarez DT, Samoa RA, Chung RS, Seto TB. Disparities in health, obesity and access to care among an insured population of Asian and Pacific Islander Americans in Hawai‘i. Hawaii Med J. 2010;69(2):42–46. [PMC free article] [PubMed] [Google Scholar]
- 16.Else I. Native Hawaiian physician location and service to the underserved Hawai‘i. Pacific Health Dialog. 2001;8:312–321. [PubMed] [Google Scholar]
- 17.Withy K, Dall T, Sakamoto D. Hawai‘i physician workforce assessment 2010. Hawaii J Med Public Health. 2012;71(4):6–12. [PMC free article] [PubMed] [Google Scholar]
- 18.Cook C, Kosoko-Lasaki O, O'Brien R. Satisfaction with and Perceived Cultural Competency of Healthcare Providers: The Minority Experience. Journal of the National Medical Association. 2005;97:1078–1087. [PMC free article] [PubMed] [Google Scholar]
- 19.Cooper LAP. The Commonwealth Fund. 2004. Disparities in Patient Experiences, Healthcare Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. [Google Scholar]