Health Care Experiences of Native Hawaiian or Pacific Islander Adults
Introduction
There are about 1.5 million people in the U.S. who identify as Native Hawaiian or Pacific Islander (NHPI) alone or in combination with another race or ethnicity, but their experiences are often missing from analyses or conflated with Asian American adults. NHPI adults face persistent disparities in health and health care, which, in part, reflect specific challenges such as geographic isolation, limited access to linguistically accessible and culturally competent care, and social and economic inequities.
To help address gaps in data and information on NHPI people’s experiences, KFF conducted seven virtual focus groups between June-August 2024 to learn about NHPI peoples’ experiences with racism, discrimination, and health. The groups were conducted by NHPI moderators and informed by representatives from several organizations serving NHPI people (see Methodology for more details). This work complements KFF’s 2023 Survey on Racism, Discrimination, and Health which was part of a major effort to document the extent and implications of people’s experiences with racism and discrimination, particularly with respect to interactions with the health care system. A companion issue brief provides key data on NHPI peoples’ health and health care use.
The themes that emerged in the focus groups were often a reflection of disparities identified in analysis of existing federal and state data, and in many cases were consistent with findings about the health care experiences of other groups of color from the Survey on Racism, Discrimination, and Health. Highlights include:
- While many focus group participants were satisfied overall with their ability to access care when needed, others mentioned barriers including, geographic isolation and limited system capacity, and lack of language access for family members with limited English proficiency. Participants in Hawaiʻi spoke about the lack of resources on the islands and shared stories of being flown to Oʻahu or the continental U.S. to receive specialized or emergency treatment such as chemotherapy or surgery. Some participants described having to translate for family members during health care visits because an interpreter was not available or being provided with interpreters who did not speak their dialect or were unable to fully and accurately interpret information.
- All the participants in the groups shared that they have sought care from Western medical providers, but some also said they sometimes use family or traditional practices either in place of, or in addition to seeking care from Western medical providers. Participants identified a variety of reasons for seeking traditional care including cultural connections and family traditions, mistrust of Western health care practices and providers, and/or a belief that the practices offer a more holistic approach to well-being.
- Participants described how longstanding relationships, connections to the community, and respect for their preferences and traditions contributed to positive experiences with providers, while interactions with providers who lacked these qualities were often viewed negatively. Some participants described negative experiences such as providers assuming things about them, blaming them for a problem, dismissing or ignoring their concerns or cultural traditions. Participants attributed these negative experiences to various factors including their NHPI identity, skin color, appearance, and their health insurance status. Some participants spoke about the consequences of these negative experiences, such as reluctance to seek future care or having their health get worse.
- Participants identified suicide, substance use, and overdose deaths as concerns in their communities, and spoke about how stigma, cultural expectations of strength, and a lack of resources are barriers to seeking mental health care. Some participants also highlighted the difficulty of finding a mental health care provider who understands their cultural background and experiences. Across the groups, participants discussed making efforts to increase communication, reduce stigma, and improve mental health for the next generation.
- Participants suggested a number of ways to improve the health care system for themselves and their families. Some suggestions included enhancing educational resources for patients, training providers to offer culturally competent care, and increased integration of traditional and cultural practices with Western medicine.
Access to and Use of Health Care
Overall, available data show that NHPI adults under age 65 are somewhat more likely than their White counterparts to be uninsured (9% vs. 7%), and uninsured rates range widely within the population from less than one in ten of Chamorro (8%), Samoan (9%), and Native Hawaiian (9%) adults to nearly one in four (24%) Marshallese people. Data also show that NHPI adults face increased barriers to accessing health care, including not having a usual doctor or provider or going without care due to cost, with about one in four (24%) NHPI adults saying they went without a routine checkup in the past 12 months, and one in five (18%) saying they have not seen a provider due to concerns about costs. Some NHPI people also face language barriers, with about one in ten (8%) of NHPI adults reporting that they speak English less than very well, rising to about one in five Tongan (17%) and Fijian (21%) adults and one in three (32%) Marshallese adults. Focus group participants described both positive and negative health care experiences that are consistent with these data.
Insurance Coverage
Most participants had health insurance, but some identified periods of being uninsured and some described difficulties understanding or using their insurance. Participants in the groups were selected to reflect a mix of those with private insurance, Medicaid, and Medicare, as well as some who were uninsured. Reasons participants cited for being uninsured included aging out of their parents’ coverage, facing difficulties with renewing or maintaining their Medicaid eligibility, or difficulty affording the cost of insurance. Among participants who were insured, some said they found it difficult to understand what their health insurance covered, and some expressed concerns about the costs of care even when covered by health insurance. Other participants described experiences in which they or a family member struggled to understand how the U.S. health insurance system works, including lacking familiarity with the concept of paying for health care services. These experiences were mostly described by participants who were themselves or had family members from Micronesia, the Marshall Islands, or Palau, likely reflecting the fact that health care services for people living on these islands are low-cost or free given that they have largely public health care systems that receive funding from the U.S. through the COFA (Compacts of Free Association).
For the first, I think last year, six months I didn’t have insurance, but because I turned 26, so I got off my dad’s health insurance. – Samoan woman, Age 27, Oʻahu
Well, we had Med-QUEST [Medicaid] and then Med-QUEST canceled us because they said our income was too high. My husband is on home dialysis … Every month we had to pay [$930] just to keep him alive. Then Med-QUEST went back into effect because I had the emergency proclamation for the wildfire, and then we got all those bills caught up. – Native Hawaiian woman, Age 54, Hawaiʻi
My grandparents [from Micronesia] don’t understand what insurance is. … Us family members can help out in the home with trying to further break down what are these terms? What is an application? What is insurance? What does it mean to renew your application or to reapply for something? – Micronesian man, Age 29, Oʻahu
Use of Health Care
Participants described using an array of providers including private providers, community clinics, urgent care centers, the emergency room and traditional medicine practitioners to obtain health care. Some participants talked about first trying a home remedy or doing an internet search to assess the importance of seeking care before seeing a provider. While all the participants in the groups shared that they have sought care from Western medical providers, some participants also said they sometimes use family or traditional practices either in place of, or in addition to seeking care from Western medical providers. Participants identified a variety of reasons for seeking traditional care including cultural connections and family traditions, mistrust of Western health care practices and providers, and/or a belief that the practices offer a more holistic approach to well-being. Some participants expressed a desire for Western medicine to integrate more traditional practices within its range of services.
I would say the same just from things that we grew up with, like my grandmother or my aunties, for small stuff. But serious stuff, obviously if one of my kids broke an arm or something like that, then definitely [I would take them to the doctor], but for just common colds and stuff like that, there’s lots of just natural herbs of teas and stuff that I have always used in our family that are better than anything over the counter. – Samoan woman, Age 41, Oregon
If it’s something like a cut or cough or something just basic, I’ll go to the doctor. But if it’s something that I don’t know, Western medicine cannot fully explain, then I’ll try to seek out some of those things… So I would say it’s probably 80% go doctor and then 20% lāʻau lapaʻau (translation: traditional Hawaiian healing practice/medicine). I’m very glad to have that option because you cannot trust the Western medical system completely. There’s always these holistic things about us that can’t be explained by pure science. – Native Hawaiian man, Age 52, Hawaiʻi
For me, I would, most of the time, ask family members that are in the medical field. And then, sometimes, I would also ask my mom, like the older generation people, on home remedies to help with that, because I would rather do that than actually go to a hospital and get a bill, and especially when you don’t have medical [insurance]. – Samoan woman, Age 41, Utah
… in between (PCP and specialist visits) my grandpa would seek out people from our own community who can do traditional practices. If he was experiencing pain, then he would seek out somebody who could do traditional massage. – Micronesian man, Age 29, Oʻahu
Access to Providers
While many focus group participants were satisfied overall with their ability to access care when needed, some discussed difficulties navigating the health care system and getting access to providers. Participants who were satisfied with their access to care noted things like the ease of getting an appointment, quickly communicating with a provider on MyChart or through telehealth and encountering few problems with their coverage. However, many participants identified challenges with accessing health care for themselves and/or family members, such as understanding how to navigate seeing different types of providers and specialists, including getting referrals as needed. Participants shared that these challenges were especially pronounced among elders in their communities. For example, some participants discussed how elders in their communities didn’t understand that they had to see someone other than their primary care provider (PCP) to receive certain kinds of treatment, or that they had to get a referral from their PCP to see a specialist who could treat them.
We have a family doctor, and we’re always connected on MyChart. And she’s very honest too. Once you shoot a question, and then she’s going to ask what the symptoms are, and then you tell the symptoms, and then she’ll be like, “ER, now.” Or she’s going to be like, “Okay, no, let’s do this, do this,” and then try to deal with it at home before we even connect with that big bill. – Samoan man, Age 41, Alaska
Well, I feel the good thing with [private health system] is it’s so accessible. It’s very easy to navigate. On the other hand, I feel sometimes it’s a revolving door … I’ve had two different PCPs in the last, I don’t know, four years. I never met them because when I’m sick, and I call for an appointment, their next appointment is three weeks from that day. You know what I mean? No, I’m sick now. I’m not sick in three weeks. – Native Hawaiian woman, Age 47, Maui
… if you need something special, you got to call your primary care person, then they got to refer you to the specialist, and then you got to call them to make an appointment. – Native Hawaiian woman, Age 54, Maui
Geographic Isolation and Limited System Capacity
Another challenge to obtaining health care that participants identified was lack of health care system capacity and resources, particularly for those living in Hawaiʻi. Some participants across groups identified concerns about health care system capacity, noting long wait times to get appointments; long wait times at urgent care centers and/or emergency rooms; and difficulty finding available health care providers, including primary care providers. Some also felt that their interactions with providers were often rushed and impersonal due to capacity limitations. Participants in Hawaiʻi also identified challenges related to limited health care resources, including specialty or advanced care, especially on islands other than Oʻahu. Reflecting this and the relative geographic isolation of the islands, some participants described situations in which they or a family member had to be flown to Oʻahu or to the continental U.S. to receive specialized treatment or care that was not available on their island, such as chemotherapy treatment or surgery. Some participants in Hawaiʻi also described long travel times to reach providers, particularly those living in more remote areas of the islands.
For me, I go to urgent care. Only reason is because I’ve been trying to get a primary doctor up in Washington, but I can’t find one. They either aren’t accepting new patients or they don’t take my insurance. – Native Hawaiian woman, Age 57, Washington
And also it was a really big struggle to even get an appointment with your PCP; it was months. By the time I got my insurance and I got my first appointment, was five and a half months later. So this is just to establish care. So it was really bad.– Native Hawaiian woman, Age 54, Hawaiʻi
I recently broke my ankle in January and had to have surgery, and I had to fly to Oʻahu. With a broken leg, fly on the plane, get surgery, fly home same day. He didn’t put me up in the hospital. … And even with my daughter getting her chemo, we’d have to fly her to Kapiʻolani. – Native Hawaiian woman, Age 47, Hawaiʻi
In our hospital on Kauaʻi that they don’t have the staffing. They don’t have the equipment. They don’t have the stuff that we need, so we have to get medevacked out of here. And it is a blessing. … So if we got to take that 45- minute helicopter ride in order to survive, to live, so that we can see our mom tomorrow, we are going to 100% jump on that little helicopter. – Native Hawaiian woman, Age 37, Kauaʻi
Yeah, I definitely have had experiences where I’ve gone and it’s just such a long wait, I end up in the car, and then I’m like, “Let’s just go. There’s no point of us just waiting.” It’s like maybe I’ll just get better soon. I can just treat this at home with some rest. – Samoan woman, Age 27, Oʻahu
Language Access Challenges
Some participants, especially those with older relatives from Micronesia or the Marshall Islands, noted issues with access to and quality of interpreters while seeking health care for family members. Some participants described instances of having to translate for their older family members during their health care visits because an interpreter was not available or provided.1 Some also said they experienced dealing with interpreters who did not speak their dialect or mixed English terms into conversations. One participant highlighted that his grandfather’s Chuukese dialect lacked words for concepts like “insurance” and “application,” illustrating the challenges of language access.
I would have to go with my grandpa is because he didn’t speak any English. So I had to be the interpreter between him and his PCP… Even though I could do it and it was an honor for me to do that for my grandfather, it was extremely difficult for me because I wasn’t born and raised in the island… it was a huge relief when there was somebody there from our background who speaks our dialect and can interpret articulately… We have some Chuukese interpreters who are not fully interpreting everything in our language. They’re mixing in English terms. And for people or the generation of my grandparents, sometimes that’s still confusing even if you’re speaking Chuukese with them … How do you explain an application to them because there’s no word for application in our language. – Micronesian man, Age 29, Oʻahu
… one of my relatives … was going through this health checkup and she doesn’t really know a lot of things. So when she was telling the story of how this incident happened to her, my mom kind of got mad and was like … “Where was your interpreter?” And then she told us that her interpreter didn’t show up. – Micronesian woman, Age 18, Oʻahu
Postponing or Delaying Care
Many participants described instances of themselves or a family member waiting to seek care until a health condition became severe. Participants noted that putting off or avoiding care was particularly common among elders in their communities. In some cases, these delays reflected concerns about cost or difficulty navigating the system, but participants also said it sometimes reflected past negative experiences or mistrust of the health care system. Some reflected on historical mistreatment and abuses of their communities and discussed stark divides between priorities and approaches of Western medicine vs. traditional healing practices. Many participants also talked about a sense of pride and the tendency within their communities to downplay health issues and how this can further contribute to delays in seeking care.
So our people tend not to seek healthcare… If you don’t know about it, then it’s not a problem. … I think maybe it could be a multitude of reasons, not trusting the system. It’s a product of colonization, not wanting to go and seek out Western methods. And then our access to native healing is so limited. It’s not like there’s a clinic down the road that you can go for native healing. – Native Hawaiian woman, Age 47, Maui
We pay insurance, but we don’t want to go to the hospital until we really feel that we have to see a doctor. – Micronesian man, Age 48, Oʻahu
I think me and my family’s relationship with healthcare, especially my dad, would never go to the doctor. He would put it off for as long as possible, whether it’s not believing in them or too expensive or this or that. And so that’s kind of how I grew up trying to avoid the doctor. – Tongan man, Age 29, California
If it’s something more serious, I’ll go to the hospital, but it’s very rare. But with my whole family, the hospital’s usually last resort, insurance or no insurance. It’s just a last resort. Only go when you really need to. – Chamorro woman, Age 26, Washington
I just feel like the older Samoans, they believe that God’s going to cure them if they ask… I strongly believe in prayer, but prayers don’t have X-rays and CAT scans to see what’s really going on inside. God, he hears us, but the doctors are the ones that are going to tell us, “Oh, your liver is on 3%.” – Samoan/Tongan woman, Age 33, Oʻahu
My husband, he works a very strenuous job and he’s always in pain, mostly sore muscles and whatnot, because he does repetitive movement every day. And so he would do stuff at home, for example, stretching, yoga exercises and just basically having our kids step on his back when he’s in pain, just to avoid going to the doctor because he says he can hack it and whatnot. But honestly, how can we afford it if we have to literally meet the deductible before actually our benefits are applied? – Chamorro woman, Age 37, Washington
Experiences in Health Care Settings
Previous KFF research (the 2023 KFF Survey on Racism, Discrimination, and Health) finds that while most adults across racial and ethnic groups report having positive and respectful interactions with their health care providers most of the time, most groups of color report having these experiences less often than White adults. The research further finds that these groups report higher levels of unfair treatment when seeking health care than their White counterparts, and that this leads many to say they prepare for possible insults or feel they must be very careful about their appearance to be treated fairly during health care visits. These negative experiences often lead to reports of worse health, being less likely to seek care, and/or switching providers. The research also highlights the importance of having providers with a shared background, as those who have more visits with providers of the same racial or ethnic background report more positive and respectful interactions.
NHPI focus group participants described having both positive and negative experiences in health care settings, which in many cases were similar to the findings of the survey for adults with other racial and ethnic backgrounds. Positive experiences participants described included having a trusted provider, feeling like they could talk to a provider without judgement, feeling heard and respected, and receiving culturally competent care. Negative experiences were often the opposite: feeling like providers rushed and did not take the time to build trust, not feeling heard or feeling judged, and receiving care that was not culturally competent.
The Role of Trusted Providers
Participants described how longstanding relationships and connections to the community contributed to trusted relationships with providers, while interactions with providers who lacked these qualities garnered lower levels of trust. Several participants who felt their provider interactions were generally positive described having long-term relationships with their or their children’s provider, including seeing the same provider from childhood to adulthood or their children having the same pediatrician they did as a child. Participants expressed that maintaining the same provider over the years made them feel understood on a personal level, beyond just their symptoms and medical history. Participants noted that they felt it easier to build trust when their provider shared their racial and ethnic background and/or had spent time in their community, or when a provider took the time to get to know them and understand their family situation. Some participants expressed challenges communicating with and trusting providers who were not familiar with their local culture or those that did not take time to get to know them and their family beyond their medical symptoms. For example, among participants living in Hawaiʻi, some said they received better care from providers who had lived in Hawaiʻi for some time, rather than newer providers, such as travel nurses, who participants felt were unfamiliar with the local culture. On the continent, participants noted that having a provider from Hawaiʻi or another Pacific Island made them feel more at ease, but that they also felt they could trust providers who took time to listen to them and understand their needs.
So my kids’ doctor is my pediatrician or my family’s pediatrician when we were younger. So she knows the history of what we went through as kids, so she already knows what my kids are potentially looking for. – Samoan woman, Age 24, Oʻahu
Same doctor, same dentist, and they’ve been going ever since they were born. It just goes smooth every time. – Marshallese man, Age 36, Oʻahu
I think with the traveling nurses and the doctors, this is not their home, so they’re just doing their job. They don’t care about your thoughts. They don’t care about your … I think we should do this or can we do that or can you look into this? It’s like I feel they just want to tell you and leave. –
Native Hawaiian woman, Age 54, Hawaiʻi
We had a family doctor, and it was different times though. I get it. But they knew our whole family, and it was just more on a personal level, and we talk story and stuff like that. But nowadays, it’s like clinics, community clinics, or even [health system], it’s like… Or even my daughter’s dentist, it’s just people in and out and they don’t really have a chance to really get to know them. – Native Hawaiian woman, Age 47, Hawaiʻi
My mom, she’s full Samoan, right? And so she just had an episode of COVID, and we went to the ER, and the people that were not from here treated her really bad and ordered her around. And she has Alzheimer’s, so she can’t understand, and it was the folks that come and clean up beds, and then they do the smaller stuff that really made her feel welcome, like, “Auntie, lay down. Oh, just put your arm …” They really showed aloha to my mom. – Native Hawaiian man, Age 52, Hawaiʻi
Feeling Heard and Respected
Participants discussed how trusting their provider allowed them to feel like they could talk freely and share their concerns without judgement. Participants described a range of positive experiences with providers, including feeling like their provider understood them and their family background, that their provider listened to their concerns, that their provider involved them in decision-making about their care, and that their provider respected their family needs and preferences. For example, some participants spoke about how their providers listened to and respected their birth plans when they were in the hospital to give birth. Other positive experiences participants spoke about included having doctors order the labs or tests they thought they needed and not feeling like they were rushed in their interactions with their provider.
… just being heard by her [primary care provider] made me leave there feeling good, feeling hopeful that somebody cares. – Native Hawaiian woman, Age 39, Washington
I just went to the doctors today, my son had a checkup today. They talk story, they’re pretty friendly. They talk about where we live and what kind of stuff we do. And I guess for me, the doctor we have, he tries to relate and he tries to be approachable with us. And for us, it works out. We’re comfortable with our doctor right now. – Native Hawaiian man, Age 31, Oʻahu
… my kids’ pediatrician, she’s a Haole girl (translation: foreigner, not from Hawaiʻi), and she is amazing. She knows my story every time I come back. She knows I adopted my kids from Child Welfare … so she’ll ask those kind of questions when I’m there or when I bring them. She’s like, “Oh, how’s the adoption process going?” And I’m like, “Oh, we’re almost there.” You know what I mean? – Native Hawaiian woman, Age 47, Maui
In contrast to these positive interactions, many participants also described negative experiences in which they felt judged or ignored by a provider. These experiences included feeling judged or blamed for their health issues, not receiving medications they believed they needed, or feeling dismissed and rushed during visits. Others shared experiences of not getting the labs or tests they think they needed and not having information explained to them in an understandable way.
So when I had my third child, I had gestational diabetes. But why is it like that now? That’s the question I asked my doctor, “Why, when the rest of my two was perfectly fine?” She didn’t have an answer, but that’s what made me stop going to the doctors just recently was because everything I’ve told her, she kind of rebelled against it and was like, “No.” – Samoan woman, Age 24, Oʻahu
I feel like because I’m a bigger person, I get overlooked so much because I’m on the bigger side of the spectrum and nobody in where I go to the hospital is a person of color. So I feel like that’s a big thing too. And we kind of just get pushed to the side in the medical field. That’s how I feel in some of the instances where I just have to be really firm on what I want but not do it in a way where I don’t seem that I’m being aggressive too. – Samoan woman, Age 36, California
For me, it was just being dismissive, automatically assuming that I speak Spanish. If I had a dollar every time somebody spoke Spanish to me. – Samoan woman, Age 41, Oregon
Culturally Competent Care
Across the groups, participants said that they valued providers who showed cultural understanding and respect, regardless of the ethnic or cultural background of the provider. Examples of culturally competent care participants discussed included avoiding assumptions based on racial or ethnic background, considering factors beyond just diet and exercise when addressing health concerns, and recognizing the importance of extended family. Some participants also discussed how they appreciated health care providers who respected and didn’t judge participants for turning to family or traditional practices before seeking care when dealing with a health issue.
The positive experience I had with that was just the culturally competent staff members … while my grandma was in the ER, because us Micronesians, we are people of community. So, it’s not just the kids and grandkids who show up, but it’s our extended relatives who show up and they want to know what’s going on and know if she’s okay. And the staff members, I think some of them kind of had a hard time, because they’re like, “Why is there so many people here?” Some of the [other] staff members, they were like, “Oh yeah, come in. Come and check in on her,” and they were wanting to make sure the family was updated on everything that’s going on. And one of the doctors that was in the ER, … he came to our family and said, “I understand that you guys have a big family, but if we could have one point of contact to make sure we can just be in contact with that one person in the family,” which was me because I’m the English-speaking person in my family. … It is comforting to have people who understand your culture and they’re flexible with meeting us halfway to make sure our questions are answered and our needs are being met from my grandma. – Micronesian man, Age 29, Oʻahu
I did find a primary care physician and she’s a Filipina. So right away when I met her, she made me feel really comfortable. And she asked us where we’re from and she found out that we’re from Guam. She related to us, made us feel connected pretty much… She understood what foods we eat and everything. So versus a nurse practitioner that I’ve also seen at that same clinic and he was American. So right away, he was just like, “Well, your blood pressure is really high. We got to put you on medicine, dah, dah, dah, really quick.” That’s it. – Chamorro woman, Age 37, Washington
But it did make a difference just having people that look like you, can relate to you… More just reciprocation. So if I have something to talk about, it’s just a little bit more relevant with somebody who shares that same cultural experiences, whether it be food, what’s good to eat around here … So it just facilitates for me a more trusting, more comfortable environment. – Chamorro/Guamanian man, Age 35, Oklahoma
Many participants also described negative health care experiences due to lack of culturally competent care. As an example, participants discussed how health care providers often blamed their health issues, such as diabetes, on their weight or body type. Many participants spoke about how health care providers focused only on their weight and how losing weight would be a panacea for their health problems—often leaving participants wanting to hear more about other ways to treat chronic conditions, such as taking medication. Other examples included feeling like they were judged by a provider for using traditional practices such as using home remedies.
So the only doctor I have is an OB, and so I’m PCOS, because I’m trying to have kids, and they basically were telling me, “Oh, you just got to lose weight.” And I was like, “Oh, okay.” So I lost like 15 pounds, and I went back and I was like, “Okay, so where are we at now?” And they were like, “You need to lose more weight.” And I was like, “Okay.” – Samoan woman, Age 27, Oʻahu
I mean, I don’t want to sound racist or anything, but the White ones who don’t really understand local, you know, how we do. When we take the kids and they’re like, “Oh, the Vicks is not good for babies,” but it’s like, I’m 34 years old and I’m fine. I’ve used this my whole life. How is it going to only hurt the baby now? – Samoan/Tongan woman, 33, Oʻahu
Reasons for and Consequences of Negative Experiences
Participants attributed negative experiences to various factors, including their skin color, appearance, NHPI identity, how they spoke, and health insurance status. Some participants said they felt they were treated differently or were unable to get tests or labs they thought they needed because they have Medicaid (QUEST in Hawaiʻi) as their insurance. Some participants shared how they felt they had to be careful with their interactions in health care settings due to a fear of being perceived as aggressive or problematic. Several participants told stories about how these negative encounters with providers resulted in poorer health outcomes, reluctance to seek care, switching providers, and/or heightened emotional distress.
And so I definitely feel they treat you a little bit different when you have QUEST [Medicaid] insurance rather than somebody who pays for insurance, and so I definitely see that happening here… It’s like, “Oh, because you get it from the state, and you’re not working. You’re not paying for it,” so they just treat you differently. – Native Hawaiian woman, Age 35, Oʻahu
And this doctor was White, and I know as soon as he walked in the room, of course, he instantly judged me because I look crazy. And my husband didn’t really say a word, and I felt like he totally ignored what I said, and it was too difficult for him to take two seconds out of his time to tell the nurse, “Please swab this, and let’s culture it.” So, my husband lost his toe because of the ignorance of the doctor. So, to me, I feel it’s really bad. We were judged instantly. – Native Hawaiian woman, Age 54, Hawaiʻi
We get pushed to the side a lot. And to me personally, I felt like, is it because I have Medi-Cal [Medicaid]? Is that why I’m just being pushed to the side? It made me feel some type of way. – Samoan woman, Age 36, California
Yeah, I overheard a nurse actually complaining one time about patients having QUEST and how she pays her taxes and how we paying for their medical. I didn’t say, I thought in my own head, I was like, “Oh wow, if she only knew my kid on QUEST,” she didn’t know that… Obviously, after she said that, I didn’t want to tell her. – Native Hawaiian woman, Age 47, Hawaiʻi
They just assume when you have darker skin like, “Oh, you’re just going to be trouble. You’re just going to like this, that, or the others.” Yeah, I felt it in that and other pieces as well. – Native Hawaiian man, Age 52, Hawaiʻi
Mental Health
Overall, data show that about one quarter of NHPI adults (23%) report experiencing any mental illness in the past year, similar to their White counterparts (27%). However, research suggests that a lack of culturally sensitive screening tools that detect mental illness, coupled with structural barriers could contribute to underdiagnosis of mental illness among people of color. Moreover, NHPI people are less likely to receive mental health treatment compared with White people, with 16% of NHPI people reporting receiving treatment in the past year compared to over one in four White people (26%). Previous KFF research found that cost concerns and scheduling difficulties are major barriers to accessing mental health services across racial and ethnic groups. Consistent with these data, focus group participants identified mental health needs among their communities and discussed some of the barriers to accessing care, including stigma, limited resources, and cost.
Participants identified mental health needs and concerns in their communities, including suicide, substance use, and overdose deaths, and described longstanding stigma associated with discussing mental health needs in their communities, describing the topic as “taboo” or “swept under the rug.” Several participants, both in Hawaiʻi and on the continent, shared personal stories of themselves or family members facing mental health issues and the struggles they faced in finding quality care close to where they lived. Participants also emphasized that cultural expectations of strength, especially among men in NHPI communities, create a barrier to recognizing and seeking help for mental health concerns. Some participants noted that mental health issues are often misunderstood by elders, who sometimes tie mental illness to religious beliefs.
I think the topic of mental health awareness is neglected, and I think there’s an area for opportunity there. My biological father, he came here, he came to Hawaiʻi from Pohnpei, but unfortunately he became a victim to suicide because the mental health wasn’t there… I think the topic of mental health awareness is neglected, and I think there’s an area for opportunity there… I think that we need to come up with a way to educate our community about all these mental health sicknesses because that’s not talked about. And if it is talked about in our communities… They don’t really understand the whole idea of it. And prior to Western contact, a lot of our islands were very into spirituality. So that’s another thing that it plays a component in this mental health awareness. – Micronesian man, Age 29, Oʻahu
It’s hard, and I want to say that I found a kanaka (translation: Hawaiian) psychiatrist … and he’s so amazing, Native Hawaiian, he understands the stuff that we go through, and he helped save my life. So, I think there’s a lot of good things, behavioral health, if you can find it… Putting resources into that for our Native Hawaiian and Pacific Islander providers and mental health. It helps saves lives. – Native Hawaiian man, Age 52, Hawaiʻi
… we had this small epidemic that happened on Maui, and it was like every month you had these young boys killing themselves… And it terrified me having, one, a boy. To this day, it terrifies me to see them and some of them I know, and to just be like, “What was so bad? Or did you not have somebody to talk to?” … And I think it goes back to colonization, it goes back to all of that generational trauma that our men are feeling that in this Western world. … – Native Hawaiian woman, Age 47, Maui
Participants noted that, beyond stigma, a lack of resources for mental health support has left many—both themselves, their family members, and friends—without access to mental health care. Participants identified cost concerns and scheduling difficulties as barriers to accessing mental health services and highlighted the difficulty of finding a provider who understands their cultural background and experiences. In the Hawaiʻi groups, participants expressed uncertainty about where to seek help for mental health issues, other than calling a crisis helpline like 988. Some participants said that they felt people in their communities would be hesitant to use crisis hotlines due to stigma or a preference for in-person connections when discussing sensitive topics. In the Hawaiʻi groups, participants pointed out that there is a limited number of mental health care providers on the islands and highlighted logistical difficulties of seeing someone in person due to transportation challenges, particularly in rural areas.
I don’t know, coming from a native perspective, I don’t know if Natives can call a crisis hotline. … We need a human to share that space, I don’t know, to share their spirit, to share their breath. That’s what heals us. – Native Hawaiian woman, Age 47, Maui
One, treat us like we’re your favorite family members and open more mental health clinics because mental health gets swept under the carpet so much, but we don’t have anywhere to focus on it either. – Samoan woman, Age 36, California
… I’ve been trying to tell my PCP, “Well, I’ve been trying to get a hold of the Behavioral Health to see a new counselor and nobody ever calls me back.” So, I think that’s pretty bad. I just came out of a domestic violence situation and sometimes I need somebody to talk to. So, I think that’s pretty rough. – Native Hawaiian woman, Age 54, Nevada
Across the groups, participants discussed the efforts they are taking to increase awareness and understanding of mental health issues within their communities. In the groups, many participants shared the difficulty of conveying mental health issues to their elders and in other languages, noting for example that there are not exact translations available for some terms or conditions in their languages. One participant shared a story of the importance of trusted community leaders in bridging the communication gap between elders and younger community members with a different understanding and approach to mental health. Participants across groups discussed the ways in which they were educating older generations and working to break the cycle of stigma among the next generation by encouraging their children to be more open and communicate their mental health needs.
Yeah, mental health, I feel like it’s not talked about a lot in the Polynesian culture, because old-fashioned, how our parents are, we were told to keep our mouths shut or whatever because it brings shame to the family or whatever the case is. So now, mental health, it’s a very common thing now, because now everybody, all the Polynesians that had childhood trauma, it’s affecting them as an adult now, and now they’re able to speak up. But the majority of them are afraid to speak up, because they’re afraid to upset their old-fashioned parents and don’t want to bring shame to the family or whatever the case might be. – Samoan woman, Age 41, Utah
I think our people are having a hard time accepting the fact that all these things are real. We’re the kind of people that, we tend to think that, “Oh, nope, it’s just faalii (translation: annoyance in Samoan).” When the child is acting up and then we automatically say they’re throwing a temper tantrum or without even knowing that they’re going through something and there’s imbalance with something. It’s either with their thought process or… So, I think acceptance should be the first thing with our people. We need to know that this is real, the feelings and the mental health are real… It’s the same thing with mental health. We don’t think it’s real. We just sugar coat stuff and shove it under the carpet, but once we have acceptance that it’s real, now we can have conversation – Samoan man, Age 41, Alaska
I think especially for men and especially for boys, it is really, really hard to talk about not being okay… I mean, their generation, a lot of them are struggling and they don’t know how to talk about it. So I feel like if we make it less taboo, maybe that’s not so much a cultural thing. But for me, I think that it’s normal to talk about depression and anxiety. I think that we have to start normalizing it because they experience stuff that – Samoan woman, Age 41, Oregon
I have a cousin who recently got diagnosed with schizophrenia and I think he was in critical condition… and there’s no term for schizophrenia in Chuukese… If you tell somebody in our Chuukese community that you’re hearing voices in your head, they’re going to tie that into, there’s a demonic force following you around or you need to go to the church more because there’s demons in your house or something like that… I contacted one of our community leaders … and I asked her, how do I explain schizophrenia in Chuukese because I need to call our aunties and tell them what’s going on with my cousin… So she explained to me how to, there’s no word for it, but she explained how I can interpret the symptoms… then I immediately called up our aunties to explain that to them and they had no clue what was going on. So that’s a lucky thing. That’s a success story for us because we were able to get him help and he is able to get medications now and I think he’s stable. – Micronesian man, Age 29, Oʻahu
Well, in my family, we just talk. I teach my kids, “There’s nothing you can’t tell me.” Always try to approach it with being open. So, it is hard because we have a big ʻohana (translation: family), so my mom, my brother, me, my kids, we all live in the same household… I had a hard time talking to my mom, and she had a hard time talking to her mom, and so I didn’t want that for my kids. I tried to break that cycle where I was open. I told them, “You want to ask me anything?” I always ask them, “How are you feeling?” I always tried not to put a stigma on how you’re feeling. – Native Hawaiian woman, Age 47, Maui
Social Support Networks and Connection to Culture
Participants described varying levels of feelings of connection to their culture and levels of social support, which, in part, reflected where they live. Participants in the Hawaiʻi groups largely said they felt connected to their communities and emphasized connections to the land, food, ocean, and family members living nearby. However, in the continent groups, many participants said they felt disconnected from their culture, especially those who did not live in areas where other Pacific Islanders live. Some participants spoke about how there were fewer opportunities to be connected to their culture living away from the islands, but some also identified ways they maintained connections, including through churches, extended family, sports, and community groups and organizations. In the groups both in Hawaiʻi and on the continent, some participants discussed enrolling in classes on topics like Hawaiian language or hula to learn more about their culture and maintain cultural knowledge and traditions. Across the groups, many participants discussed concerns about passing on their culture and heritage to their children, especially when they felt geographically disconnected from their community. Some participants living in areas without a large Pacific Islander community discussed the importance connecting with other racial and ethnic groups (such as with Black adults or American Indian adults) in creating a sense of belonging.
And I do attend church every Sunday, and church is a big part of our life, especially the Samoan church, but that’s how I stay connected. – Native Hawaiian woman, Age 38, California
After we left Hawaiʻi, it just wasn’t as significantly a part of our life as I wish it had been, and then when my parents split, it was even less then. I was really separated from all of my Samoan family. So I miss that. I miss a lot of that. Some of my happiest memories from my childhood are when I was surrounded by my family, just more familiar with the language and more familiar with the practices. But we all have such a cultural disconnect. A lot of us feel like a lot of hesitation because we don’t speak the language, we don’t understand the practices or what does that entail, what would we have to do? – Samoan woman, Age 41, Oregon
So I’m over here taking online classes for ʻōlelo (translation: Hawaiian language) just so I can raise my son and expose him to it, because my father’s already passed, and so with him being a kumu hula (translation: Hawaiian dance instructor), I grew up very involved in the culture, and I feel like I can only provide so much, because I’m not a kumu hula… That’s where a lot of the history came from that I was taught, and I want my son to be involved, but, like I said, the access is very limited for those of, I would say, Pacific Islander Polynesian descent. – Native Hawaiian woman, Age 43, Washington
Recommendations to Improve Care
Participants offered several suggestions to improve health care experiences in their communities. In Hawaiʻi, many participants emphasized the importance of recruiting and training doctors from the islands, highlighting the value of having providers who are part of the local community. In the groups on the continent, participants discussed the importance of cultural competency training for health care providers and efforts to increase the racial diversity of providers. Participants also expressed support for integrating traditional practices with Western medicine to facilitate a more holistic approach to care. Participants suggested that more education on how to navigate the health care and health insurance systems within their communities could help improve access to care. Participants also said they would like to see health care services become more centralized to help alleviate the logistical burden of seeking specialized care. They also emphasized that increased availability and quality of interpreter services for people with limited English proficiency is important for increasing access to care as well as improve health care experiences.
My magic wand would be recommending that cultural intelligence communications class be mandatory for medical personnel’s education. – Native Hawaiian woman, Age 43, Washington
If the doctor wasn’t from here or the providers aren’t from here to take a culture class on getting used to the culture here so they can be better practitioners. I’ve had experiences where the bedside manner of providers are fantastic. And it ranges, it doesn’t matter the race. And then it ranges all the way to completely awful. – Samoan man, Age 37, Hawaiʻi
More Micronesian staff, more Micronesian nurses and doctors so that they can help be the liaison for all of this complex information that’s being communicated to the patients and their families. – Micronesian man, Age 29, Oʻahu
Well, one thing I would address is more opportunity for doctor’s appointments. Because there’s so many patients and not enough space. I was supposed to see a specialist for my hearing and she said, “Well, we’re already booked out to May of 2025.” – Native Hawaiian woman, Age 54, Nevada