A first-of-its kind study from the University of Hawaii at Manoa examines the significant health disparities faced by residents in rural areas compared to urban areas of the state.

Rural area residents reported having more health challenges and limitations than their urban counterparts, according to the study produced by the University of Hawaii Economic Research Organization. Overall, they rated their health as poorer.

The results are not surprising to researchers, given the many stories of how rural residents struggle for access to health care amid the ongoing doctor shortage and lack of reliable air transportation to get to care. But the state has never had a detailed study looking at those disparities using Hawaii’s own various definitions of “rural” based on its unique geography and demographics.

“The data brings it from just being anecdotal to now we have proof that at the individual level, people are saying, ‘I’m struggling,’” said Ruben Juarez, a UHERO research fellow. “This gives us data and the faces to the names, so to speak, to be able to capture the attention of people that can help us fix this through policy.”

Researchers used data gathered from the UHERO Rapid Healthy Survey — an ongoing, twice yearly health survey — of the same cohort of adult residents.

The survey was initially launched in 2022 to examine the impacts of the COVID-19 pandemic. Data for the most recent study came from a June 2023 survey of 1,571 residents. Of those surveyed, more than 20% identified themselves as living in rural areas.

Researchers found there were disparities between rural and nonrural residents across the board, regardless of gender, age or ethnicity.

Rural residents with disabilities and living below the poverty line, however, appeared to be struggling the most with their physical health.

The report found that in overall health perception, rural residents felt they had 43% lower odds of “excellent,” “very good” or “good” health compared to nonrural residents.

Additionally, it found:

>> Nearly 22% of rural residents rated their health as “fair” or “poor,” compared to fewer than 14% of nonrural residents.

>> Rural residents reported life activities were restricted by physical health an average of 3.8 days a week compared to 2.5 days for nonrural residents. For mental health, the difference was smaller, at an average of 3.1 days a week in rural versus two days in nonrural areas.

>> Rural residents with disabilities in general experienced two more days a week of life activity restrictions due to physical health compared to counterparts in nonrural areas.

>> Less than 40% of rural households below the poverty line reported high overall health compared with more than 50% for nonrural residents.

>> A higher share of the rural sample (23.1%) was made up of Native Hawaiians and Pacific Islanders compared to those in non­rural areas (14.7%).

In order to analyze the disparities, researchers also examined the way “rurality” was defined, which in Hawaii differs significantly from the U.S. continent and is in itself worthy of analysis.

Whereas “rural” on the U.S. continent might be defined by distance to a centralized urban center, this does not apply to the Hawaiian islands. The distance from Molokai to Maui is relatively short but residents cannot just hop in a car and drive there. They need a way to cross the ocean — most likely by air.

The study looked at two different rurality maps for Hawaii.

One considers all of Oahu as nonrural, with most of the rest of Hawaii as rural. The other defines rural areas as all ZIP codes in the state except for East Oahu and some of Central Oahu from Kaneohe in the east to Kapolei in the west, as well as Lihue on Kauai, Kahului- Wailuku on Maui, and Hilo and Kailua-Kona on Hawaii island.

Most of the report’s results were based on the latter definition, as researchers found differences between most of Central and West Oahu compared to the Hono­lulu metro area.

The data show that policy responses should attempt to reduce disparities between rural and nonrural populations with both place-based approaches as well as ones focusing on vulnerable population groups.

It can be useful in advocacy for greater Medicare reimbursements in rural areas or prioritizing investments in areas such as Lahaina, where wildfire survivors are still struggling to access health care.

Funding for the study came from a U.S. Department of Health and Human Services grant awarded to UH’s Rural Health Research and Policy Center.