An unequal distribution of the human right to health: assessing ethnic health disparities in cardiometabolic disease prevalence among Hawaii’s houseless population

• Date: 04 April 2024
• Pages: 58-74
• DOI: https://doi.org/10.1108/IJHRH-09-2023-0077
• Published date: 04 April 2024
• Subject Matter: Health & social care,Vulnerable groups,Inequalities & diverse/minority groups,Sociology,Race & ethnic studies,Minorities,Multiculturalism,Racial identity,Work,economy & organizations
• Author: Nicholas Fancher,Bibek Saha,Kurtis Young,Austin Corpuz,Shirley Cheng,Angelique Fontaine,Teresa Schiff-Elfalan,Jill Omori

An unequal distribution of the human right

to health: assessing ethnic health disparities

in cardiometabolic disease prevalence

among Hawaii’s houseless population

Nicholas Fancher, Bibek Saha, Kurtis Young, Austin Corpuz, Shirley Cheng,

Angelique Fontaine, Teresa Schiff-Elfalan and Jill Omori

Abstract

Purpose –In the state of Hawaii,it has been shown that certain ethnic minoritygroups, such as Filipinos

and Pacific Islanders, suffer disproportionally high rates of cardiovascular disease, evidence that local

health-care systems and governing bodies fail to equally extend the human right to health to all. This

study aims to examine whether these ethnic health disparities in cardiovascular disease persist even

withinan alreadyglobally disadvantaged group, the houselesspopulation of Hawaii.

Design/methodology/approach –A retrospective chart review of records from Hawaii Houseless

Outreach and Medical EducationProject clinic sites from 2016 to 2020 was performedto gather patient

demographicsand reported histories of type II diabetes, obesity,hyperlipidemia, hypertension and other

cardiovascular diseasediagnoses. Reported disease prevalence rates were comparedbetween larger

ethniccategories as well as ethnic subgroups.

Findings –Unexpectedly, the data revealed lower reported prevalence rates of most cardiometabolic

diseases among the houseless compared to the general population. However, multiple ethnic health disparities

were identified, including higher rates of diabetes and obesity among Native Hawaiians and other Pacific

Islanders and higher rates of hypertension among Filipinos and Asians overall. The findings suggest that even

within a generally disadvantaged houseless population, disparities in health outcomes persist between ethnic

groups and that ethnocultural considerations are just as important in caring for this vulnerable population.

Originality/value –To the best of the authors’ knowledge,this is the first comprehensive study focusing

on ethnic health disparities in cardiovascular disease and the structural processes that contribute to

them, amonga houseless population in the ethnicallydiverse state of Hawaii.

Keywords Cardiovascular disease, Ethnicity, Houselessness, Health disparities,Health-care accessibility

Paper type Research paper

Introduction

Cardiovascular disease (CVD) remains the leading cause of global mortality, with death

rates nearly doubling since 1990 (Roth et al.,2020). The development of serious

cardiovascular conditions such as ischemic heart disease and stroke is well known to be

associated with a larger group of cardiometabolic diseases, including type II diabetes

mellitus (DMII), obesity, hypertension (HTN), and hyperlipidemia (HLD) (Cannon, 2007;

Wilson and Meigs, 2008;Global Burden of Metabolic Risk Factors for Chronic Diseases

Collaboration, 2014). With such grave consequences of uncontrolled CVD, the ability of our

communities to reasonably protect themselves from these cardiometabolic conditions

represents a human right to health that should be granted regardless of age, race, or

gender. This is especially true considering our health systems’ capabilities to prevent, slow,

(Informationabout the

authorscan be found at the

end of this article.)

Received 25 September 2023

Revised 30 November 2023

Accepted 14 February 2024

The authors would like to thank

the Hawaii Homeless Outreach

and Medical Education Project

as well as the John A. Burns

School of Medicine for making

this study possible.

Research funding details: No

funding was received for this

study.

Declaration of interest statement:

The authors have no conflicts of

interest to declare.

Data availabilitystatement: The

full de-identifieddata sets that

supportthe findings of this

studyare available from the

corresponding author, Nicholas

Fancher, upon reasonable

request.

Statement of ethics: This study

was performed with the approval

of the University of Hawaii at

Manoa’s Institutional Review

Board, protocol ID

2019-00823. Our study was

granted a waiver of the informed

consent requirement by the

Institutional Review Board on the

basis that the data was gathered

ina de-identified manner and

posedminimal risk to subjects.

Accessto the Houseless

Outreachand Medical

EducationProject clinic patient

recordswas also authorized by

organizationleaders Dr. Teresa

Schiff-Elfalanand Dr. Jill Omori.

PAGE 58 jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE jVOL. 18 NO. 1 2025, pp. 58-74, ©Emerald Publishing Limited, ISSN 2056-4902 DOI 10.1108/IJHRH-09-2023-0077

and reverse CVD have advanced considerably over the years. Yet, data from the past two

decades have indicated that both CVD and these cardiometabolic risk factors

disproportionately impact certain minority groups in the general population, both globally

and within the USA (Cappuccio,1997;Mensah et al., 2005;Kurian and Cardarelli, 2007;Dal

Canto et al.,2018

). This unequal access to the human rightto health is thought to stem from

both individuals’ socioeconomic determinates of health as well as the failings of the health-

care system to provide accessibleand culturally competent care (Javed et al., 2022).

In Hawaii, specifically Filipinos, Native Hawaiians and other Pacific Islanders are

disproportionately affected by multiple cardiometabolic conditions (Mau et al., 2009;Juarez

et al., 2010;Uchima et al., 2019). For instance, Juarez et al. (2010) found that middle aged

Native Hawaiians were more than three times as likely to be diagnosed with DMII than

Caucasians in Hawaii, while also experiencing significantly higher rates of HTN, HLD and heart

disease. Filipinos and Asian ethnic groups in Hawaii were also found to have higher rates of

HTN than Caucasians across multiple age groups. The houseless are another group known to

have a globally increased prevalence of CVD, often secondary to uncontrolled cardiometabolic

disorders (Child et al., 1998;Hwang and Bugeja, 2000;Aldridge et al., 2019). However, it

remains unclear whether the health disparities based on ethnicity observed in the general

population are sustained even in Hawaii’s houseless population.

The houseless are routinely denied the right to effective preventative health care, leading to

a high dependence on expensive emergency department and inpatient care in the USA

(Hwang et al., 2013). While a lack of insurance or financial resources is typically the most

apparent obstacle, the houseless also often choose to prioritize finding food and shelter

over health care. Many simply avoid care whenever possible because of longstanding

mistrust in the health-care system (Liu and Hwang, 2021), seeking care only when their

health issues have spiraled out of control. In response to the houselessness crisis on Oahu,

the Hawaii Houseless Outreach and Medical Education (HOME) Project was founded

through the John A. Burns School of Medicine (JABSOM) in 2005. It is a student-run and

physician-supervised mobile clinic that provides free care to individuals experiencing

houselessness across the island of Oahu in Hawaii. In 2020, HOME project recorded 1,517

patient visits and filled 1,119 free prescriptions for those in need (Hawaii HOME Project,

2021). More than a decade ago, JABSOMresearchers used HOME project chart records to

show that houseless Native Hawaiians were at increased risk for certain chronic conditions

like asthma when compared to their houseless non-Native Hawaiian counterparts (Yamane

et al., 2010). Since this initial study, HOME project has seen thousands of additional

houseless patients and established multiple new clinic sites, presenting the opportunity to

expand our understanding of key cardiometabolic conditions in this vulnerable population.

Here we present an updated retrospective chart review of CVD and its risk factors among

several houseless ethnic groups in Hawaii, with the goal of better understanding whether

health disparities based on ethnicity persist within the state’s universally disadvantaged

houseless population.

Methods

Study population and cardiometabolic variables

According to Partners in Care –Oahu Continuum of Care’s 2023 Point in Time Count, about

4,000 individuals are experiencing houselessness on the Island of Oahu, of which 59% are

unsheltered. Approximately 86% of these houseless individuals are adults and 57% are

male. Native Hawaiians and PacificIslanders are the largest houseless ethnic group at 35%

of the population, followed by multiracial individuals (21%), Caucasians (14%) and Asians/

Asian Americans (10%). The largest proportion of houseless individuals (27%) is found in

the Waianae region on the west coast of Oahu, followed by the Downtown Honolulu region

(22%) and East Honolulu region (22%). HOME Project operates multiple clinic sites in the

Downtown Honolulu regionas well as one clinic at a major shelter in the Waianae region.

VOL. 18 NO. 1 2025 jINTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE jPAGE 59