Wilbert M. Gesler

A spatial analysis of county-level variation in hospitalization rates for low back problems in North Carolina.

Hospitalization rates for low back problems vary widely. In previous non-spatial analyses, population-level socioeconomic and health resource characteristics have explained little of the variation in rates. This study examines geographic variation in hospitalization rates for low back problems while controlling for spatial dependence in the data. County-level surgical and medical hospitalization rates were calculated using North Carolina hospital (USA) discharge data from 1990-92. Non-spatial and spatial regression models were estimated using socioeconomic and health resource predictors. Both surgical and medical rates varied significantly among the 100 counties. Non-spatial models explained 62% of variation in log-transformed surgical rates and 66% of variation in log-transformed medical rates; however, residuals showed significant spatial dependence. Spatial lag models were therefore applied. Using simple contiguity spatial weights, surgery rates increased with higher percent urban population, primary care physician density, and discharge rate for other causes, and decreased with higher percent college graduates, percent disabled, occupied hospital bed density, and unoccupied hospital bed density. There was a nonlinear relationship between surgery rates and percent employed in heavy lifting/transportation industries. Medical rates increased with higher other-cause discharge rate and with MRI/CT scanner availability, and decreased with higher percent urban population, percent nonwhite population, percent in heavy lifting/transportation industries, and unoccupied hospital bed density. The results show that population-level socioeconomic and health resource characteristics are important determinants of variation in low back hospitalization rates. Independent of these variables, a separate spatial process produces geographic clustering of high-rate counties. Spatial effects are important and should be considered in small area analyses.

New spaces of inpatient care for people with mental illness : a complex "rebirth" of the clinic ?

This paper examines the implications for design of inpatient settings of community-based models of care and treatment of mental illness. The study draws on ideas from relational geographies and expands interpretations based on Foucaults writing. We analyse material from a case study which explored the views of patients, consultants, and other staff from a new Psychiatric Inpatient Unit in a deprived area of East London, UK. We discuss in particular: the tension between providing a caring and supportive institutional environment and ensuring that patients are returned to the community when they are ready; the links between an acute inpatient facility and its local community; the potential significance of the psychiatric hospital as a relatively stable feature in the otherwise insecure and unpredictable geographical experience of people with long-term mental illnesses. We discuss the relevance of these issues for design of new psychiatric inpatient facilities.

Words in wards: language, health and place

The role of place in medical encounters which involve language is examined using theoretical arguments backed by empirical studies. Links between language and place, health and place and especially language and health are discussed. The language-health link is developed in terms of explanatory models; how language is used in medical encounters; and power, dominance and resistance relationships. Then it is shown how considerations of place enhance knowledge about this link. The paper closes with a set of research questions which focus on the role of place.

Developing socio-spatial knowledge networks: a qualitative methodology for chronic disease prevention.

Chronic disease is a significant and costly social problem. The burden is even more pronounced in communities with high rates of a particular chronic disease. Assessment of health belief systems and the local geographies of health beliefs can assist community health planners to create cost-effective strategic intervention programs where populations are at high risk for chronic diseases. In this paper, we elaborate the concept of socio-spatial knowledge networks (SSKNs) and demonstrate that SSKNs can be useful in informing the design of health care prevention strategies. In our project, we demonstrate how to identify key socio-spatial information for intervention strategies which will prevent or delay the onset of a particular chronic disease, Type 2 diabetes. Our qualitative framework allows us to determine which sites might be best characterized as socio-spatial knowledge network nodes for sharing diabetes information and which sites might be less suited to such exchange. Our strategy explores cross-cultural similarities, differences, and overlap in a multi-ethnic rural North Carolina context through simple techniques such as mapping social networks and sites in which people share their knowledge and beliefs about diabetes. This geographical analysis allows us to examine exactly where health knowledge coincides with other social support, and where such resources may be improved in a particular community. Knowing precisely what people in a community understand about a chronic disease and its treatment or prevention and knowing where people go to share that information helps to (1) identify strategic locations within a community for future interventions and, (2) evaluate the effectiveness of existing interventions. The geographical approach presented here is one that can serve other communities and health practitioners who hope to improve chronic disease management in diverse local environments.

Complementary and Alternative Medicine Use Among Rural Residents in Western North Carolina

This analysis examines prevalence and identifies the predictors of complementary and alternative medicine (CAM) use among adults living in a rural region and analyzes the general health concerns for which rural adults use CAM remedies. Data are from a cross-sectional survey of 1,059 adults residing in 12 nonmetropolitan counties in Appalachian North Carolina conducted in 1999. “Home remedies” is the most extensively used CAM category in this population, with “honey-lemon-vinegar-whiskey and herbs” being the most widely used. The use of specific home remedies is associated with age, gender, and education. Chiropractors are the only widely used alternative therapist. Home remedies are differentially used to treat health conditions.

African American Beliefs About Diabetes

In this presentation, a diabetes explanatory model of rural, African American adults at high risk for diabetes is described. Kleinman’s explanatory model of illness was used as the organizing framework. African American men and women (N = 42), between the ages of 18 and 51, participated. Participants described their knowledge and beliefs about diabetes, preventing diabetes, and whether diabetes could be cured or controlled. A common explanatory model of diabetes was not shared among the participants, and gender and age differences were apparent. Common themes included diabetes “running in families,” “eating too much sugar,” and “not taking care of yourself” as causes of diabetes. Weight and physical activity or exercise were not seen as contributing to the development of diabetes. Participants were not sure if diabetes could be prevented. These results provide information to address primary prevention of diabetes in this at-risk group.

Disease ecology and a reformist alternative: The case of infant mortality

This paper attempts to shed some light on the recent debate between those who advocate a reformed medical geography and those who respond that reform is not necessary. We show that disease ecology and a reformist alternative display certain tendencies in the ways in which they address issues of health and disease. We use the example of geographic variations in infant mortality rates to show how two non-positivist perspectives from social theory, political economy and humanism, support a reformist viewpoint, while also acknowledging the value of a complementary disease ecology approach. Two concepts, the social construction of health and illness and social relevance, are used to portray the political economy approach; humanism is described in terms of the meaning of individual experience and the importance of place. The paper concludes with a discussion of the respective roles of disease ecology and a reformist approach in models of infant mortality and a summary of the main differences between the two perspectives.

The place of chiropractors in health care delivery: A case study of north Carolina

Three perspectives on the place of DCs in the United States health care delivery system were derived from the social science literature; system status, cultural congruence, and utilization patterns. North Carolina was used as a case study site to examine these perspectives from a geographical point of view. It was found that DCs were located in smaller places than MDs. DC/population ratios were associated with white populations and higher incomes, but were not associated with those aged 18-64, rural populations, and religious groups that used touch in healing. DCs were located in more rural and lower income areas than were MDs.

The wineglass model: tracking the locational histories of health professionals

This paper introduces a space-time continuum model to evaluate the effectiveness of programs that encourage recruitment and retention of health professionals. Based on the shape of a wineglass, the model provides a framework to study the locational histories of a cohort of health professionals, both conceptually and quantitatively. A key component of the model is that it measures geographic dispersion over time from a medical school, residency program, or other shared location. Geographic dispersion can be studied in the model through standard deviational ellipses, standard distance, or average distance circles. The model enables analysis through structuration theory, which is used as a guide for analyzing the interplay between human agency (e.g., individual decisions on practice location) and structure (e.g., medical education). Space-time modeling is linked with structuration theory. Variations in the shape of the wineglass reveal how people may be bound by a general structure, yet through lifetime locational decisions may change that structure over space and time. Using data on University of Nebraska alumni, the authors constructed a pilot demonstration to test and confirm the models potential usefulness. In the pilot demonstration, standard deviational ellipses represented the range of physician locations during each year, overlaid on maps of the US. The pilot demonstration indicated the models strength in identifying changing mobility over time, while also pointing to concerns about unevenness in data availability from one year to the next. Further application of the wineglass model could be used toward studying the life histories of health professionals. The impact of community-based training on long- or short-term retention, changes in the mobility of male vs female providers, and the career trajectories of people in different health professions or medical schools are only a few examples of potential future applications of the model.

Geographic Information Systems and Health: An Educational Resource.

Abstract The use of geographic information systems to analyze spatial dimensions of health care and disease ecology is becoming a realistic prospect for investigators in the social sciences. This review of the literature, bringing together a diverse collection of professional and academic journals, can be grouped into four categories: potential, cautionary, preliminary, and application. Enough references have been collected and reviewed to provide instructors with material for a classroom unit about 1) using GIS in a medical geography class: 2) medical applications in a GIS class; or 3) using GIS in classes which have a health and disease component.