Defining localities for health planning: a GIS approach

Distribution of Private Dental Healthcare Facilities in Riyadh City: A GIS-Based Approach

BACKGROUND

The dental healthcare private sector in Riyadh city has been growing rapidly over the past few years; however, there is a lack of information on the accessibility and spatial distribution of private dental healthcare facilities (PDHFs) in the area. This study aimed to evaluate the spatial distribution of PDHFs in Riyadh city in relation to population density in each sub-municipality.

METHODS

The current information regarding the number, location, and operability of PDHFs in Riyadh city was obtained from the Ministry of Health. A total of 632 operating PDHFs were included with the precise location plotted on Quantum Geographic Information System software (version 3.32.1, Essen, Germany) using Google Earth. Four levels of buffer zones-1 km, 3 km, 5 km, and >5 km-were determined. The population statistics and mean monthly individual income per district were gathered from Zadd.910ths. Microsoft Excel (version 16.0, Microsoft, Redmond, WA, USA) and RStudio software (version 4.1.3, Posit Software, PBC, Boston, MA, USA) were used for additional data analysis.

RESULTS

There was an overall ratio of one PDHF per 9958 residents in Riyadh city. Olaya and Maather sub-municipalities had the largest PDHF-to-population ratios: (1:4566) and (1:4828), respectively. Only 36.3% of the city's total area was within a 1 km buffer zone from a PDHF. There was an overall weak positive correlation between the number of PDHFs and the total area in each sub-municipality (r = 0.29), and the distribution of PDHFs was uneven corresponding to the area (G* = 0.357).

CONCLUSIONS

There was an uneven distribution of PDHFs in Riyadh city. Some areas were underserved while others were overserved in several sub-municipalities. Policy-makers and investors are encouraged to target underserved areas rather than areas with significant clustering to improve access to care.

A genetic algorithm-based strategic planning framework for optimising accessibility and costs of general practices in Northland, New Zealand

Shortage of general practitioners (GP) is a challenge worldwide, not only in Europe, but also in countries like New Zealand. Providing primary care in rural areas is especially challenging. In order to support decision makers, it is necessary to first assess the current GP coverage and then to determine different scenarios and plans for the future. In this paper, we first present a thorough overview of related literature on locating GP practices. Second, we propose an approach for assessing the GP coverage and determining future GP locations based on a genetic algorithm framework. As a use case, we have chosen the rural New Zealand region of Northland. We also perform a sensitivity analysis for the main input parameters.

Delineating natural catchment health districts with routinely collected health data from women's travel to give birth in Ghana

Background

Health service areas are essential for planning, policy and managing public health interventions. In this study, we delineate health service areas from routinely collected health data as a robust geographic basis for presenting access to maternal care indicators.

Methods

A zone design algorithm was adapted to delineate health service areas through a cross-sectional, ecological study design. Health sub-districts were merged into health service areas such that patient flows across boundaries were minimised. Delineated zones and existing administrative boundaries were used to provide estimates of access to maternal health services. We analysed secondary data comprising routinely collected health records from 32,921 women attending 27 hospitals to give birth, spatial demographic data, a service provision assessment on the quality of maternal healthcare and health sub-district boundaries from Eastern Region, Ghana.

Results

Clear patterns of cross border movement to give birth emerged from the analysis, but more women originated closer to the hospitals. After merging the 250 sub-districts in 33 districts, 11 health service areas were created. The minimum percent of internal flows of women giving birth within any health service area was 97.4%. Because the newly delineated boundaries are more “natural” and sensitive to observed flow patterns, when we calculated areal indicator estimates, they showed a marked improvement over the existing administrative boundaries, with the inclusion of a hospital in every health service area.

Conclusion

Health planning can be improved by using routine health data to delineate natural catchment health districts. In addition, data-driven geographic boundaries derived from public health events will improve areal health indicator estimates, planning and interventions.

Availability and Affordability of Primary Health Care Among Vulnerable Populations in Urban Kumasi Metropolis: Family Health Perspective

Purpose

Health-related expenditures pose a significant burden on vulnerable populations. This study assessed the availability and affordability of primary health care among disadvantaged populations in urban Kumasi Metropolis, Ghana.

Methods

This study was a descriptive cross-sectional study conducted among multi-level participants of vulnerable populations ≥18 years of age (n=710) constituting the older adults/aged, pregnant women, head porters, sex workers, and other vulnerable groups (people with disabilities and the homeless). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to assess the association between vulnerability and access to health care.

Results

There were significant differences in the availability and adequacy of health care among the vulnerable groups studied. Distance to the source of care was >5 km for majority of the vulnerable groups and the average expenditure on a visit to the health facility was GH¢ 27.04 (∼US$ 5.55 as at January 2019). Challenges to health care among the vulnerable groups included monetary (37.9%), stigmatization (18.6%), and staff attitude (25.9%). Head porters and other vulnerable groups were less likely to view health care as affordable compared with older adults. The difference in the perception of health care affordability was, however, explained by sociodemographic characteristic and health care-related factors.

Conclusion

Despite the introduction of a National Health Insurance Scheme in Ghana, this study highlights challenges in health care access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to adopt other innovative care strategies that may have broader applicability for all populations.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization

BACKGROUND

Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship.

METHODS

This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored.

RESULTS

GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists.

CONCLUSIONS

Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Using geographical information systems and cartograms as a health service quality improvement tool

INTRODUCTION

Disease prevalence can be spatially analysed to provide support for service implementation and health care planning, these analyses often display geographic variation. A key challenge is to communicate these results to decision makers, with variable levels of Geographic Information Systems (GIS) knowledge, in a way that represents the data and allows for comprehension. The present research describes the combination of established GIS methods and software tools to produce a novel technique of visualising disease admissions and to help prevent misinterpretation of data and less optimal decision making. The aim of this paper is to provide a tool that supports the ability of decision makers and service teams within health care settings to develop services more efficiently and better cater to the population; this tool has the advantage of information on the position of populations, the size of populations and the severity of disease.

METHODS

A standard choropleth of the study region, London, is used to visualise total emergency admission values for Chronic Obstructive Pulmonary Disease and bronchiectasis using ESRI's ArcGIS software. Population estimates of the Lower Super Output Areas (LSOAs) are then used with the ScapeToad cartogram software tool, with the aim of visualising geography at uniform population density. An interpolation surface, in this case ArcGIS' spline tool, allows the creation of a smooth surface over the LSOA centroids for admission values on both standard and cartogram geographies. The final product of this research is the novel Cartogram Interpolation Surface (CartIS).

RESULTS

The method provides a series of outputs culminating in the CartIS, applying an interpolation surface to a uniform population density. The cartogram effectively equalises the population density to remove visual bias from areas with a smaller population, while maintaining contiguous borders. CartIS decreases the number of extreme positive values not present in the underlying data as can be found in interpolation surfaces.

DISCUSSION

This methodology provides a technique for combining simple GIS tools to create a novel output, CartIS, in a health service context with the key aim of improving visualisation communication techniques which highlight variation in small scale geographies across large regions. CartIS more faithfully represents the data than interpolation, and visually highlights areas of extreme value more than cartograms, when either is used in isolation.

Geographic health information systems: a platform to support the 'triple aim'

Despite the rapid growth of electronic health data, most data systems do not connect individual patient records to data sets from outside the health care delivery system. These isolated data systems cannot support efforts to recognize or address how the physical and environmental context of each patient influences health choices and health outcomes. In this article we describe how a geographic health information system in Durham, North Carolina, links health system and social and environmental data via shared geography to provide a multidimensional understanding of individual and community health status and vulnerabilities. Geographic health information systems can be useful in supporting the Institute for Healthcare Improvement's Triple Aim Initiative to improve the experience of care, improve the health of populations, and reduce per capita costs of health care. A geographic health information system can also provide a comprehensive information base for community health assessment and intervention for accountable care that includes the entire population of a geographic area.

Defining GP practice areas based on true service utilisation

Where patients who are registered with a general practice actually live (the service utilisation area) often differ from what GPs consider their practice boundaries or catchment area to be, as well as from administrative boundaries. A key aim of primary care commissioners is to allocate resources efficiently and to locate services in such a way that access is convenient for patients. To achieve this robust understanding of practice service utilisation areas and the overlap between practices and administrative areas are essential. We used kernel analysis of the postcodes of over 400,000 registered patients to define GP service utilisation areas. We estimated service utilisation for each of 64 practices for a period of five years (2002-2006) exploring the areas in which 99%, 98%, and 95% of registered patients were expected to live. These service utilisation areas were not coterminous with other practices or with administrative boundaries. We present a simple analytical method to define GP catchment areas that captures the true service utilisation area and identifies the extent of overlap. This is a practical tool that can assist health care commissioning.

Bringing the individual back to small-area variation studies: a multilevel analysis of all-cause mortality in Andalusia, Spain

We performed a multilevel analysis (including individuals, households, census tracts, municipalities and provinces) on a 10% sample (N=230,978) from the Longitudinal Database of the Andalusian Population (LDAP). We aimed to investigate place effects on 8-year individual mortality risk. Moreover, besides calculating association (yielding odds ratios, ORs) between area socio-economic circumstances and individual risk, we wanted to estimate variance and clustering using the variance partition coefficient (VPC). We explicitly proclaim the relevance of considering general contextual effects (i.e. the degree to which the context, as a whole, affects individual variance in mortality risk) under at least two circumstances. The first of these concerns the interpretation of specific contextual effects (i.e. the association between a particular area characteristic and individual risk) obtained from multilevel regression analyses. The second involves the interpretation of geographical variance obtained from classic ecological spatial analyses. The so-called "ecological fallacy" apart, the lack of individual-level information renders geographical variance unrelated to the total individual variation and, therefore, difficult to interpret. Finally, we stress the importance of considering the familial household in multilevel analyses. We observed an association between percentage of people with a low educational level in the census tract and individual mortality risk (OR, highest v. lowest quintile=1.14; 95% confidence interval, CI 1.08-1.20). However, only a minor proportion of the total individual variance in the probability of dying was at the municipality (M) and census tract (CT) levels (VPC(M)=0.2% and VPC(CT)=0.3%). Conversely, the household (H) level appeared much more relevant (VPC(H)=18.6%) than the administrative geographical areas. Without considering general contextual effects, both multilevel analyses of specific contextual effects and ecological studies of small-area variation may provide a misleading picture that overstates the role of administrative areas as contextual determinants of individual differences in mortality.

Spatial modelling of healthcare utilisation for treatment of fever in Namibia

Background

Health care utilization is affected by several factors including geographic accessibility. Empirical data on utilization of health facilities is important to understanding geographic accessibility and defining health facility catchments at a national level. Accurately defining catchment population improves the analysis of gaps in access, commodity needs and interpretation of disease incidence. Here, empirical household survey data on treatment seeking for fever were used to model the utilisation of public health facilities and define their catchment areas and populations in northern Namibia.

Method

This study uses data from the Malaria Indicator Survey (MIS) of 2009 on treatment seeking for fever among children under the age of five years to characterize facility utilisation. Probability of attendance of public health facilities for fever treatment was modelled against a theoretical surface of travel times using a three parameter logistic model. The fitted model was then applied to a population surface to predict the number of children likely to use a public health facility during an episode of fever in northern Namibia.

Results

Overall, from the MIS survey, the prevalence of fever among children was 17.6% CI [16.0-19.1] (401 of 2,283 children) while public health facility attendance for fever was 51.1%, [95%CI: 46.2-56.0]. The coefficients of the logistic model of travel time against fever treatment at public health facilities were all significant (p < 0.001). From this model, probability of facility attendance remained relatively high up to 180 minutes (3 hours) and thereafter decreased steadily. Total public health facility catchment population of children under the age five was estimated to be 162,286 in northern Namibia with an estimated fever burden of 24,830 children. Of the estimated fevers, 8,021 (32.3%) were within 30 minutes of travel time to the nearest health facility while 14,902 (60.0%) were within 1 hour.

Conclusion

This study demonstrates the potential of routine household surveys to empirically model health care utilisation for the treatment of childhood fever and define catchment populations enhancing the possibilities of accurate commodity needs assessment and calculation of disease incidence. These methods could be extended to other African countries where detailed mapping of health facilities exists.

Role of GIS in social sector planning: can developing countries benefit from the examples of primary health care (PHC) planning in Britain?

Social sector planning requires rational approaches where community needs are identified by referring to relative deprivation among localities and resources are allocated to address inequalities. Geographical information system (GIS) has been widely argued and used as a base for rational planning for equal resource allocation in social sectors around the globe. Devolution of primary health care is global strategy that needs pains taking efforts to implement it. GIS is one of the most important tools used around the world in decentralization process of primary health care. This paper examines the scope of GIS in social sector planning by concentration on primary health care delivery system in Pakistan. The work is based on example of the UK's decentralization process and further evidence from US. This paper argues that to achieve benefits of well informed decision making to meet the communities' needs GIS is an essential tool to support social sector planning and can be used without any difficulty in any environment. There is increasing trend in the use of Health Management Information System (HMIS) in Pakistan with ample internet connectivity which provides well established infrastructure in Pakistan to implement GIS for health care, however there is need for change in attitude towards empowering localities especially with reference to decentralization of decision making. This paper provides GIS as a tool for primary health care planning in Pakistan as a starting point in defining localities and preparing locality profiles for need identification that could help developing countries in implementing the change.

Geographic analysis of cardiac interventional services in Alabama

BACKGROUND

Cardiovascular disease is the leading cause of death in the state of Alabama. The purpose of this study was to explore the geographical accessibility of the Alabama population to cardiac interventional services (CISs) for the treatment of acute myocardial infarction.

METHODS

A descriptive ecological study design was used. Census tract-level population census data were used to describe access to CIS in Alabama. Descriptive analysis was conducted within a geographical information system (GIS) and provided empirical measures of travel time, calculated population proportions, and generated maps for visual identification of areas of low access. Descriptive statistics are reported as proportions (percentages) of the population with access by travel time.

FINDINGS

The GIS analysis revealed that 58.2%, 85.9%, and 96.0% of the total Alabama population were within 30-, 60-, or 90-minute travel time, respectively, of a hospital with CIS. Maps provided visualization of CIS coverage areas for Alabama. One distinct area within the Alabama Black Belt was at greater than 90 minutes from a hospital with CIS. This area is known as a mostly black, impoverished population subject to health disparities.

CONCLUSIONS

The GIS showed that 96% of the Alabama population is within 90-minute travel time of a hospital with CIS. For the best outcomes to occur allowing adequate time for symptom recognition, travel time, and 30-minute door-to-needle time, only 85.9% and 58.2% are within 60- and 30-minute travel time, respectively.

Organizational capacity to deliver effective treatments for children and adolescents

Treatment and services research in the general medical sector has emphasized the importance of addressing organizational capacity to improve interventions for patients with chronic conditions. Efficacious interventions for child and adolescent mental disorders without substantial enhancements in mental health organizational capacity will not result in improvements for children. This paper (a) lists some organizational enhancements that have resulted in improved medical care, (b) briefly underscores recent market trends such as state healthcare reform efforts, increased use of electronic records and contracting initiatives that push consolidation of agencies, and (c) describes one example of the organizational development of child behavioral services that will enhance treatment delivery.

Pofessional Practice and Innovation: Geographical Information Systems: An Effective Planning and Decision-Making Platform for Community Health Coalitions in Australia

The development of locally-based healthcare initiatives, such as community health coalitions that focus on capacity building programs and multi-faceted responses to long-term health problems, have become an increasingly important part of the public health landscape. As a result of their complexity and the level of investment, it has become necessary to develop innovative ways to help manage these new healthcare approaches. Geographical Information Systems (GIS) have been suggested as one of the innovative approaches that will allow community health coalitions to better manage and plan their activities. The focus of this paper is to provide a commentary on the use of GIS as a tool for community coalitions and discuss some of the potential benefits and issues surrounding the development of these tools.

An integrated framework for the geographic surveillance of chronic disease

BACKGROUND

Geographic public health surveillance is concerned with describing and disseminating geographic information about disease and other measures of health to policy makers and the public. While methodological developments in the geographical analysis of disease are numerous, few have been integrated into a framework that also considers the effects of case ascertainment bias on the effectiveness of chronic disease surveillance.

RESULTS

We present a framework for the geographic surveillance of chronic disease that integrates methodological developments in the spatial statistical analysis and case ascertainment. The framework uses an hierarchical approach to organize and model health information derived from an administrative health data system, and importantly, supports the detection and analysis of case ascertainment bias in geographic data. We test the framework on asthmatic data from Alberta, Canada. We observe high prevalence in south-western Alberta, particularly among Aboriginal females. We also observe that persons likely mistaken for asthmatics tend to be distributed in a pattern similar to asthmatics, suggesting that there may be an underlying social vulnerability to a variety of respiratory illnesses, or the presence of a diagnostic practice style effect. Finally, we note that clustering of asthmatics tends to occur at small geographic scales, while clustering of persons mistaken for asthmatics tends to occur at larger geographic scales.

CONCLUSION

Routine and ongoing geographic surveillance of chronic diseases is critical to developing an understanding of underlying epidemiology, and is critical to informing policy makers and the public about the health of the population.

An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians

This paper presents an enhancement of the two-step floating catchment area (2SFCA) method for measuring spatial accessibility, addressing the problem of uniform access within the catchment by applying weights to different travel time zones to account for distance decay. The enhancement is proved to be another special case of the gravity model. When applying this enhanced 2SFCA (E2SFCA) to measure the spatial access to primary care physicians in a study area in northern Illinois, we find that it reveals spatial accessibility pattern that is more consistent with intuition and delineates more spatially explicit health professional shortage areas. It is easy to implement in GIS and straightforward to interpret.

A spatial national health facility database for public health sector planning in Kenya in 2008

BACKGROUND

Efforts to tackle the enormous burden of ill-health in low-income countries are hampered by weak health information infrastructures that do not support appropriate planning and resource allocation. For health information systems to function well, a reliable inventory of health service providers is critical. The spatial referencing of service providers to allow their representation in a geographic information system is vital if the full planning potential of such data is to be realized.

METHODS

A disparate series of contemporary lists of health service providers were used to update a public health facility database of Kenya last compiled in 2003. These new lists were derived primarily through the national distribution of antimalarial and antiretroviral commodities since 2006. A combination of methods, including global positioning systems, was used to map service providers. These spatially-referenced data were combined with high-resolution population maps to analyze disparity in geographic access to public health care.

FINDINGS

The updated 2008 database contained 5,334 public health facilities (67% ministry of health; 28% mission and nongovernmental organizations; 2% local authorities; and 3% employers and other ministries). This represented an overall increase of 1,862 facilities compared to 2003. Most of the additional facilities belonged to the ministry of health (79%) and the majority were dispensaries (91%). 93% of the health facilities were spatially referenced, 38% using global positioning systems compared to 21% in 2003. 89% of the population was within 5 km Euclidean distance to a public health facility in 2008 compared to 71% in 2003. Over 80% of the population outside 5 km of public health service providers was in the sparsely settled pastoralist areas of the country.

CONCLUSION

We have shown that, with concerted effort, a relatively complete inventory of mapped health services is possible with enormous potential for improving planning. Expansion in public health care in Kenya has resulted in significant increases in geographic access although several areas of the country need further improvements. This information is key to future planning and with this paper we have released the digital spatial database in the public domain to assist the Kenyan Government and its partners in the health sector.

USING PARTICIPATORY METHODS AND GEOGRAPHIC INFORMATION SYSTEMS (GIS) TO PREPARE FOR AN HIV COMMUNITY-BASED TRIAL IN VULINDLELA, SOUTH AFRICA (Project Accept-HPTN 043)

Recent attempts to integrate geographic information systems (GIS) and participatory techniques, have given rise to terminologies such as participatory GIS and community-integrated GIS. Although GIS was initially developed for physical geographic application, it can be used for the management and analysis of health and health care data. Geographic information systems, combined with participatory methodology, have facilitated the analysis of access to health facilities and disease risk in different populations. Little has been published about the usefulness of combining participatory methodologies and GIS technology in an effort to understand and inform community-based intervention studies, especially in the context of HIV. This article attempts to address this perceived gap in the literature. The authors describe the application of participatory research methods with GIS in the formative phase of a multisite community-based social mobilization trial, using voluntary counseling and testing and post-test support as the intervention.

Targeting HIV clinical training with maps: lessons from the Pacific AIDS Education and Training Center

Public health providers are increasingly called on to do more with fewer resources. Aiming to help HIV clinical training providers in 15 local sites to better target their efforts, the Pacific AIDS Education and Training Center (PAETC) implemented a method for integrating disparate information, such as program-level evaluation and publicly available health services data, into one combined and useful format. The resulting local area profiles were distributed to each training site and were updated annually for 2 years. As a result, local training teams adopted data-based approaches to doing their work. Training managers and faculty reported that data presented in spatial formats (i.e., maps) were most helpful for targeting their outreach and training. In addition to achieving the aim of supporting better programs, the project increased capacity for using data to support all aspects of training and education, from grant writing to strategic planning.

Geomatics in injury prevention: the science, the potential and the limitations

BACKGROUND

Geomatics describes the activities involved in acquiring and managing geographical data and producing geographical information for scientific, administrative and technical endeavors. As an emerging science, geomatics has a great potential to support public health. Geomatics provides a conceptual foundation for the development of geographic information systems (GIS), computerized tools that manage and display geographical data for analytical applications. As descriptive epidemiology typically involves the examination of person, place and time in the occurrence of disease or injury, geomatics and GIS can play an important role in understanding and preventing injury.

AIM

This article provides a background to geomatics for those in the injury prevention field who are unfamiliar with spatial analysis. We hope to stimulate researchers and practitioners to begin to use geomatics to assist in the prevention of injury.

METHODS

The authors illustrate the potential benefits and limitations of geomatics in injury prevention in a non-technical way through the use of maps and analysis.

RESULTS

By analysing the location of patients treated for fall injuries in Central Toronto using GIS, some demographic and land use variables, such as household income, age, and the location of homeless shelters, were identified as explanatory factors for the spatial distribution.

CONCLUSION

By supporting novel approaches to injury prevention, geomatics has a great potential for efforts to combat the burden of injury. Despite some limitations, those with an interest in injury prevention could benefit from this science.

Place and provision: mapping mental health advocacy services in London

The National Health Service (NHS) Executive for London carried out an investigation in 2002 as part of their wider mental health strategy to establish whether existing mental health advocacy provision in the city was meeting need. The project took a two-part approach, with an emphasis on, (a) mapping the provision of advocacy services and, (b) cartographic mapping of service location and catchments. Data were collected through a detailed questionnaire with service providers in collaboration with the Greater London Mental Health Advocacy Network (GLMHAN) and additional health and government sources. The service mapping identified some key statistics on funding, caseloads and models of service provision with an additional emphasis on coverage, capacity, and funding stability. The questionnaire was augmented by interviews and focus groups with commissioners, service providers and service users and identified differing perspectives and problems, which informed the different perspectives of each of these groups. The cartographic mapping exercise demonstrated a spatially-even provision of mental health advocacy services across the city with each borough being served by at least one local service as well as by London wide specialist schemes. However, at local level, no one borough had the full range of specialist provision to match local demographic need. Ultimately the research assisted the Advisory Group in providing commissioning agencies with clear information on the current status of city-wide mental health advocacy services, and on gaps in existing advocacy provision alongside previously unconsidered geographical and service dimensions of that provision.

Defining localities of inadequate treatment for childhood asthma: a GIS approach

BACKGROUND

The use of Geographic Information Systems (GIS) has great potential for the management of chronic disease and the analysis of clinical and administrative health care data. Asthma is a chronic disease associated with substantial morbidity, mortality, and health care use. Epidemiologic data from all over the world show an increasing prevalence of asthma morbidity and mortality despite the availability of effective treatment. These facts led to the emergence of strategies developed to improve the quality of asthma care.

THE OBJECTIVE

To develop an efficient tool for quality assurance and chronic disease management using a Geographic Information System (GIS). GEOGRAPHIC LOCATION: The southern region of Israel. January 1998 - October 2000.

DATABASES

Administrative claims data of the largest HMO in Israel: drug dispensing registry, demographic data, Emergency Room visits, and hospitalization data bases.

METHODS

We created a list of six markers for inadequate pharmaceutical treatment of childhood asthma from the Israeli clinical guidelines. We used this list to search the drug dispensing registry to identify asthmatic children who received inadequate treatment and to assess their health care utilization and bad outcomes: emergency room visits and hospitalizations. Using GIS we created thematic maps on which we located the clinics with a high percentage of children for whom the treatment provided was not in adherence with the clinical guidelines.

RESULTS

81% of the children were found to have at least one marker for inadequate treatment; 17.5% were found to have more than one marker. Children with markers were found to have statistically significant higher rates of Emergency Room visits, hospitalizations and longer length of stay in hospital compared with children without markers. The maps show in a robust way which clinics provided treatment not in accord with the clinical guidelines. Those clinics have high rates of Emergency Room visits, hospitalizations and length of stay.

CONCLUSION

Integration of clinical guidelines, administrative data and GIS can create an efficient interface between administrative and clinical information. This tool can be used for allocating sites for quality assurance interventions.

Asthma and air pollution in the Bronx: methodological and data considerations in using GIS for environmental justice and health research

This paper examines methods of environmental justice assessment with Geographic Information Systems, using research on the spatial correspondence between asthma and air pollution in the Bronx, New York City as a case study. Issues of spatial extent and resolution, the selection of environmental burdens to analyze, data and methodological limitations, and different approaches to delineating exposure are discussed in the context of the asthma study, which, through proximity analysis, found that people living near (within specified distance buffers) noxious land uses were up to 66 percent more likely to be hospitalized for asthma, and were 30 percent more likely to be poor and 13 percent more likely to be a minority than those outside the buffers.

Defining regions for locality health care planning: a multidimensional approach

The increasing significance of the role of the general practitioner (GP) in the British National Health Service, evolving from a provider to purchaser and now a key player in the organisation of Primary Care Groups, suggests the need for GPs to possess more and more information about their registered population. GP catchment areas, though an essential basis for providing GPs with important information such as levels of accessibility to surgery, are rarely clearly or accurately defined. Previous approaches towards the definition of GP catchments have been confined to single regionalisation methods, such as mean distance measures, and are prone to problems of either overestimating or underestimating medical service areas. This problem is compounded by a lack of acknowledgement that the application of contrasting catchment methodologies to a common service population has the potential to yield vastly different results which can have serious implications for health care planning and resource allocation. The lack of sophistication in the definition of medical service areas calls for a new methodology to be considered. In this paper, attention is given to the adaptation of multidimensional regional analytical techniques developed outside the health domain and applied in a Regional Health Authority in Northern Ireland. The technique involves the creation of a Synthetic Data Matrix (SDM) which compares patient to GP flow (affiliation) information aggregated at the Census Enumeration District level across a number of catchment areas created using different methodologies. The SDM is then analysed using a modified version of the European Regionalisation Algorithm to create an optimal set of non-overlapping regions according to pre-defined population size and self-containment criteria. The results, a set of compact, robust and highly self-contained catchments, are extremely encouraging. The paper considers the future potential use of such a methodology for health care planning and highlights areas for further research in this field.

Creating a GIS application for local health care planning in Saudi Arabia

The purpose of this paper is to show how Geographical Information Systems can be used to support health planners on a micro-scale. The first part of this paper discusses the issue that affect local health care planning which include monitoring of catchment area and facilities management. The second part defines GIS and its possible uses in the health care field. The relevant GIS functions have also been explained. The third part of this paper discusses the created GIS application, which is made for a local health centre in Makkah City, Saudi Arabia. In this application, three sets of GIS models have been produced. These are catchment area, patient profile and patient distribution and patient flows models. The created GIS models are produced to help local health planners in their health care decision output.

Using a GIS-based floating catchment method to assess areas with shortage of physicians

This paper presents a geographic information system (GIS) based floating catchment method for identifying physician shortage areas. The traditional designation methods are primarily regional availability measures, which use administrative boundaries such as counties as the basic spatial units for calculating physician to population ratios and designate shortage based on those ratios. Such approaches have been criticized for their inability to account for either the spatial variations of population demand and physician supply within those boundaries or for population-physician interactions across them. The floating catchment method addresses the internal spatial distribution problem by deriving population data from a smaller unit, the census tract. The potential cross border patient-physician interaction is taken into consideration by using circles of reasonable radius around each census tract centroid as the basic spatial units, which can encompass areas on either side of an administrative border. By varying the radius of the catchment circle, this paper demonstrates that the physician to population ratio is scale dependent and that the greatest variability of the ratios and shortages occur at the most local scales (< 20 miles), which argues for using finer spatial resolution data in shortage designation practice.

Making health data maps: a case study of a community/university research collaboration

This paper presents the main findings from a collaborative community/university research project in Canada. The goal of the project was to improve access to community health information, and in so doing, enhance our knowledge of the development of community health information resources and community/university collaboration. The project built on a rich history of community/university collaboration in Southeast Toronto (SETO), and employed an interdisciplinary applied research and action design. Specific project objectives were to: (1) develop via active community/university collaboration a geographic information system (GIS) for ready access to routinely collected health data, and to study logistical, conceptual and technical problems encountered during system development; and (2) to document and analyze issues that can emerge in the process of community/university research collaboration. System development involved iteration through community user assessment of need, development or refinement of the GIS, and assessment of the GIS by community users. Collaborative process assessment entailed analysis of archival material, interviews with investigators and participant observation. Over the course of the project, a system was successfully developed, and favorably assessed by users. System development problems fell into four main areas: maintaining user involvement in system development, understanding and integrating data, bringing disparate data sources together, and making use of assembled data. Major themes emerging from the community/university collaborative research process included separate community and university cultures, time as an important issue for all involved, and the impact of uncertainty and ambiguity on the collaborative process.

Assessing the applicability of GIS in a health and social care setting: planning services for informal carers in East Sussex, England

Informal carers save the state's health and social care services billions of pounds each year. The stresses associated with caring have given rise to a number of short-term care services to provide respite to carers. The Carers (Recognition & Services) Act of 1995 identified formally for the first time, the important role that unpaid carers provide across the community in Britain. The planning of combined health and social care services such as short-term care is a less developed application of geographical information systems (GIS) and this paper examines awareness and application issues associated with the potential use of GIS to manage short-term care service planning for informal carers in East Sussex. The assessment of GIS awareness was carried out by using a semi-structured questionnaire approach and interviewing key local managers and planners across a number of agencies. GIS data was gathered from the agencies and developed within a GIS to build up a set of spatial databases of available services, location of users and additional geo-demographic and topographic information. The output from this system development was presented in turn at workshops with agencies associated with short-term care planning as well as users to help assess their perspectives on the potential use and value of GIS. A renewed emphasis on a planned approach to health care coupled with integrated/ joint working with social care creates a need for new approaches to planning. The feedback from planners and users, suggested that a number of key data elements attached to data-sharing may prove to be simultaneously progressive yet problematic, especially in the areas of ethics, confidentiality and informed consent. A critical response to the suitability of GIS as a tool to aid joint health and social care approaches is incorporated within a final summary.

Car travel time and accessibility by bus to general practitioner services: a study using patient registers and GIS

Accessibility to general practitioner (GP) surgeries was investigated in a population study of East Anglia (Cambridgeshire, Norfolk and Suffolk) in the United Kingdom. Information from patient registers was combined with details of general practitioner surgery locations, road network characteristics, bus routes and community transport services, and a geographical information system (GIS) was used to calculate measures of accessibility to surgeries by public and private transport. Outcome measures included car travel times and indicators of the extent to which bus services could be used to visit GP surgeries. These variables were aggregated for wards or parishes and then compared with socio-economic characteristics of the populations living in those areas. The results indicated that only 10% of residents faced a car journey of more than 10 min to a GP. Some 13% of the population could not reach general medical services by daily bus. For 5% of the population, the car journey to the nearest surgery was longer than 10 min and there was no suitable bus service each weekday. In the remoter rural parishes, the lowest levels of personal mobility and the highest health needs indicators were found in the places with no daytime bus service each weekday and no community transport. The overall extent of accessibility problems and the existence of inverse care law effects in some rural localities have implications for the NHS, which aims to provide an equitable service to people wherever they live. The research also demonstrates the potential of patient registers and GIS as research and planning tools, though the practical difficulties of using these data sources and techniques should not be underestimated.

The application of GIS technology to equitably distribute fieldworker workload in a large, rural South African health survey

A method is presented that has numerous applications to health systems provision in developing countries where limited physical access to primary health care is a major factor contributing to the poor health of populations. An accessibility model within a geographical information system (GIS) is used to predict average inter-homestead walking times and subdivide the study area into units of equal completion time. The method could be used to ergonomically design home-based care and tuberculosis directly observed treatment programmes and inform the siting of health facilities. The paper highlights the use of GIS technology as a powerful tool in developing countries.

Accessibility and spatial distribution of general practice services in an Australian city by levels of social disadvantage

The accessibility and spatial distribution of health services provided by the main source of primary medical care in Australia--the general practice surgery--was investigated by level of social disadvantage of local catchment areas. All 459 general practice surgeries in Perth, an Australian city of 1.2 million residents, were surveyed with a 94% response. Amount of service provision was measured using weekly doctor-hours, available from consulting rooms during opening hours, and associated nurse-hours of service. Access factors were defined as the distance to the nearest surgery, provision of Sunday and evening services, ease of making a same day appointment, bulk-billing, and whether the surgery offered a choice of gender of doctor. There were relatively more surgeries in disadvantaged areas and doctor-hours of service provision were also greater (41.0 h/1,000 most disadvantaged vs. 37.9 h/1000 least disadvantaged). Bulk-billing care, at no direct cost to the patient, was more likely to be provided in most disadvantaged areas compared with least disadvantaged areas (61 vs. 38%). However, populations living in the most disadvantaged areas were less likely to be able to see the local GP at short notice (91 vs. 95%), to have access to a local female GP (56 vs. 62%) or a local service in the evenings (42 vs. 51%). While the overall picture of accessibility was favourable, there was considerable variation in the type of services provided to different socioeconomic groups. Health care planners should investigate the reasons for these differences and advise Government to ensure that access factors affecting publicly funded services are equitably distributed.

Is there a role for GIS in the 'new NHS'?

In this paper we draw on the existing literature to highlight the gap between academic health-based applications of Geographical Information Systems (GIS) and their everyday use within the UK National Health Service (NHS). We provide examples of the operational benefits accruing from using GIS in a range of health care applications whilst acknowledging the limited use of such technologies in strategic health tasks. The implications of recent policy changes for future projected use of such systems are discussed before presenting a research agenda for realising GIS potential within the NHS. The paper concludes by re-emphasising the importance of using GIS in strategic health planning contexts in the light of both recent health-care restructuring and new technological developments in the health service.

[Voronoi s Diagram for defining catchment areas for public hospitals in the Municipality of Rio de Janeiro]

One of the most important pieces of information for health resources planning is the definition of catchment areas for health units. Voronoi Diagrams are a potential technique for this purpose. They are polygons with the property whereby adjacent polygons have their borders located within the same distance of the respective generator points. One possible adjustment to the catchment areas thus defined is the use of weighted Voronoi Diagrams, which result in an improved representation of a health unit's actual capacity. In this study, the 21 public general hospitals in the city of Rio de Janeiro, Brazil, were used as generator points for Voronoi Diagrams. Non-weighted Voronoi Diagrams were initially implemented and then used as the basis for obtaining weighted Voronoi Diagrams, using as weights the annual admission rates estimated for each unit. In the classic Voronoi Diagram case, some catchment areas had similar sizes, although their respective health units had different characteristics. In the weighted case the areas were modified in a way that appeared closer to the actual functioning of the units. The method appeared simple to implement, used easy-to-access data, and did not rely on geopolitical considerations such as existing administrative areas. It thus provided a more realistic picture of a unit's capacity to support basic health programs.

Potential meets reality: GIS and public health research in Australia

Geographical Information Systems-computerised systems for the capture, storage, retrieval, analysis and display of spatial data-have recently been promoted as important tools for the study of public health. Attention must also be given to the issues involved in this relatively new application, especially in Australian conditions. These include the coarse spatial resolution of most health and social data, the propagation of error through the need to use estimates and concordance tables to handle data in mismatched official spatial boundaries, the inflexible analytical capacity of most GIS for the needs of epidemiology, and difficulties in access to data, which are compounded by the absence of a good metadata register. The conflict between the need for spatial precision in GIS and preserving the confidentiality of health data is a salient issue. Medical geographers and public health researchers using GIS must recognise these issues in order to work together and toward extending the use of GIS technology beyond broad ecological and accessibility studies.

Localism in the NHS Quasi-Market

The organisation of the British National Health Service (NHS) has been hierarchical and based on defined geographical areas [for example, health authorities (HAs)]. These areas have formed the basis of local health systems in which the social relations between individuals and agencies were contained within the territorial boundaries of the respective organisation and thereby engendered, in most eases, a degree of trust and cooperation. The introduction of quasi-market mechanisms in the NHS in 1991 inferred that the social relations between local actors were not essential and hence transactions could be independent of them. Economic transactions need not therefore be confined to the local area. However, social relations have continued in various forms since the quasi-market was implemented as manifested through, inter alia, the persistence of localism in the market. Localism is evident, for example, in HA expenditure, which remains highly skewed towards local providers and, it is argued here, is a function of social relations between purchaser and providers. Localism and the social relations associated with it exemplify the relational nature of the quasi-market, which has shown signs of moves towards longer term contracts, risk-sharing and cooperation (rather than competition). Thus, by noting the persistence of localism and social relations, the author suggests that the quasi-market has yet to evince the paradigm shift intended by the 1991 reforms.

The influence of households on drinking behaviour: a multilevel analysis

This paper examines the influence of household membership and area of residence on individual drinking behaviour using a multilevel modelling approach. The effects are investigated using data from the Health Survey for England (HSE) in which multiple interviews were conducted in the same household. With the use of postal address, the data were organised into a hierarchical structure of individuals within households within enumeration districts. After controlling for characteristics of individuals thought to influence or correlate with drinking behaviour, unexplained variation in alcohol consumption was attributed to individual, household and area effects. Household influences on drinking behaviour far outweigh the influences of place of residence. Policies aimed at reducing alcohol consumption, particularly by heavy drinkers, may be best targeted at the household level.