When we break down health outcomes into categories such as cultural values, socioeconomic status, and race and ethnicity we see a large disparity in health needs and outcomes. shows that Native Hawaiian or Pacific Islander (NHPI) people in the US experience substantial disparities in health and health care. And shows that rural residents of Hawaii face many more health challenges than urban dwellers. A researcher at the John A. Burns School of Medicine has shown that aggregation of NHPI and Asian data often misrepresents health issues and socioeconomic status. Bad data leads to poor responses.

Hawaii is not alone. There are many communities in North America where healthcare inequity is an issue. But Hawaii faces a unique set of challenges. By examining these roadblocks to access to healthcare in Hawaii¡ªand looking at menu of solutions, both proven and experimental¡ªwe hope to illuminate opportunities for design to improve health equity and access. As architects and designers, we can be part of the solution in making Hawaii an equitable place for health.

What¡¯s limiting access to healthcare in Hawaii and causing health inequity?

Shortage of healthcare providers: There simply aren¡¯t enough doctors, nurses, and specialists on the islands to serve the population. There is a shortage of healthcare providers, especially in rural areas of the islands. The staffing shortage makes it difficult to provide adequate care to all residents. And this limits access to healthcare in Hawaii.

Roadblocks to new facilities: The lack of staff and resources means that even when authorities identify the need for a new facility, there isn¡¯t much appetite for building one. It¡¯s known that staffing and equipping a facility is a challenge. Efforts to build new healthcare facilities can even face opposition. For example, an attempt to build a second hospital on Maui failed due to concerns about staffing and resource allocation.

Geographic barriers: The Hawaiian Islands are remote. And travel between the islands is usually by air. The smaller islands, such as Molokai and Lanai, have limited flights. This makes it hard for many residents to get to the hospital, particularly in emergency situations. Patients on the neighboring islands often need to be medically transported via helicopter to a Level I trauma center on Oahu. So, geography poses a challenge to access to healthcare in Hawaii.

High cost of living: Goods, services, and housing in Hawaii can cost from 10 to 60 percent more than they do on the mainland. Most things in Hawaii must be shipped in, making them more expensive than on the mainland. Rents are relatively high. The inflated cost of living in Hawaii makes it challenging to attract and retain healthcare providers, which adds to the staffing issues.

Cultural and socioeconomic disparities: The economic inequality in Hawaii partly shapes the healthcare outcomes for those who live here. Nearly one-third of the households in Hawaii had food insecurity issues in 2023. And hunger correlates with diabetes, heart disease, and health issues. Housing is expensive. Four in 10 low-income Hawaiians are homeless or pay more than half their income in rent. Those dealing with housing insecurity tend to have more health issues.

Improving health equity: These challenges highlight the need for innovative solutions and targeted efforts. That approach from healthcare providers can help address access to healthcare in Hawaii and improve health equity across the state. We¡¯re interested in looking at existing approaches that show promise and innovative ideas that have yet to be proven. And we want to ask this question: How can design contribute to better solutions? Interestingly, we see a blend of low-tech and innovative tech making a difference here.

Six approaches we believe can promote health equity and increase access to healthcare in Hawaii

1. Community outreach and engagement

It¡¯s important for healthcare providers to ally with influential community groups. This outreach helps them build trust and make a greater impact. They can promote participation in health programs. They can increase preventive care. They can foster lifestyle changes. During the COVID-19 pandemic, this approach proved successful. Providers reached out to community leaders, which increased vaccination rates in rural areas.

2. Culturally informed design

Healthcare facilities that celebrate Hawaiian heritage and reflect the local culture are more welcoming. More local people will use them. M¨¡lama I Ke Ola Health Center features a mosaic by local artist Monica Morakis. The center¡¯s ¡®olena logo refers to a medicinal plant brought to Hawaii by Polynesian voyagers.

Throughout the clinic, visual elements such as canoes and native plants represent a holistic approach to care. In the spirit of ¡®ohana, M¨¡lama health center promotes wellness and brings healthcare closer to the community.

3. Telehealth and virtual care

Expanding telehealth services to reach remote areas will reduce the need for physical visits. Telehealth increases the frequency of check-ups to help head off chronic disease earlier. As we¡¯ve discussed, there are inpatient staffing shortages. A model of innovative care is virtual nursing, which decreases the physical demands on bedside nurses.

4. Technology integration and artificial intelligence (AI)

Technology is all around us. Senior citizens are tracking their health with apps and smart watches. Young people do medical care through their phones and seldom set foot in a physician¡¯s office. Those in remote areas can reduce the need for inconvenient in-person visits by wearing smart devices to monitor their health conditions. AI-driven medical technology promises to help treatments reach patients faster.

5. Smaller community clinics

Convenience matters. The easier it is for islanders to access healthcare, the more they will use it. By placing smaller clinics in communities, we can reduce the barriers to access. We can make it less intimidating for islanders to get checkups. Neighborhood clinics can serve as multipurpose centers. They can offer wellness programs, preventive care, and activities. For example, the L¨¡na¡¯i Community Health Center in L¨¡na¡¯i City provides services from dentistry to behavioral health. It looks like a Hawaiian plantation home featuring a wide lanai. It has a medicinal herb garden and a large multipurpose room for community activities.

6. Disaggregating data

Better data can help counter structural racism and health disparities. If we don¡¯t know a problem exists, we can¡¯t act on it. We need data that shines a light on NHPI in Hawaii. By disaggregating the data about NHPI populations, we can see health disparities that have been historically obscured. For example, because research lumped Asian islanders in with NHPI populations, it was difficult for researchers to observe that NHPI people were experiencing worse outcomes for cancer.

We believe these strategies can help promote equitable access to healthcare in Hawaii. If we can place healthcare closer to home and make it more culturally relevant and approachable, we can increase access for all islanders.