A Geographic Information System (GIS) can be described as a sophisticated, spatial software that allows for combining different types of data including, but not limited to, demographics, health data, and community resources, all connected by an underlying map. The GIS can then be used to investigate various relationships, trends, and patterns between the different layers of data. In addition to analyzing various secondary data, such as census information or summarized electronic health records, utilizing geospatial technologies, for example, field mapping devices or global positioning system (GPS) units, means that a detailed insight can be gained into the health consequences of any environment. Examples of what one can determine using GIS include which health outcomes cluster around a water course; what is the most effective route for a rural patient to travel to care; or which neighborhoods, and even intersections, generate spikes in pediatric injuries.
There are many GIS applications in both public health and clinical health research. In addition, several other aligned disciplines, such as sociology, social work, urban planning, and geography, use GIS to visualize and analyze geographic data that have a relevance to health phenomena. For example, GIS has been utilized to study heart disease mortality and access to hospitals (Yamashita & Kunkel, 2010); breast cancer and historical exposure to pesticides (Brody et al., 2004); clusters of opioid prescription abuse in New Mexico (Brownstein, Green, Cassidy, & Butler, 2010); obesity and neighbor fast-food outlets (Li, Harmer, Cardinal, Bosworth, & Johnson-Shelton, 2009); and sexually transmitted diseases epidemiologic patterns in Fort Bragg, North Carolina (Zenilman et al., 2002). The appreciation of how space and place intersect with health, and a suite of important, new geospatial technologies have opened new avenues of research and given rise to several multidisciplinary fields including medical geography, geomedicine, health geography, and geographic gerontology. In spite of having different names and sometimes different disciplinary perspectives, these fields all focus on the interrelationships between geographic/environmental attributes and health outcomes.
However, the manner in which our environment affects health and wellbeing is still in its infancy in the nursing literature. This column will provide a basic introduction as to how GIS can be used as a research tool to study various nursing phenomena. We will begin by reviewing selected examples of the relatively few nursing studies that have utilized a GIS.
Examples of GIS Use in the Nursing Literature
Bloch (2011) examined the correlation between the exposure to stressful environments (as indicated by crime rate and poverty) and preterm birth rate in foreign-born and United States (U.S.)-born African American mothers. Bloch studied 2000 U.S. Census data and Philadelphia crime data, using a GIS, to show how stressful neighborhoods are significantly associated with a higher prevalence of preterm birth for foreign-born and U.S.-born black mothers. Bloch established these relationships by geographically manipulating and overlaying data on births, crime, poverty, race, and nativity into common areas (census tracts).
In another example, Madigan, Wiencek, and Vander Schrier (2009) used GIS to examine the availability of community-based, end-of-life care providers to the elderly in rural areas. The researchers created maps for eight states showing the distribution of community-based, end-of-life providers per 1,000 elders at the county level by degree of rurality. The analysis showed that more than 85% of rural counties in Arkansas and Louisiana did not have end-of-life hospice providers. Madigan et al. noted that studies such as theirs provide crucial information for making social-policy decisions.
It is important to recognize that Madigan et al.’s research was conducted at a different geographic scale than that of Bloch’s (2011). Bloch worked with data at the census-tract level while Madigan et al. utilized county-level information. GIS use is multi-scalar, meaning it can be used to analyze data at the coarsest of scales, such as across countries or regions, down to sub-city units, such as identifying patterns on a single street block (Andrews, Cutchin, McCracken, Philips, & Wiles, 2007). For example, it could be used to identify which region of the country suffers the highest pediatric injuries, or where hotspots of such injuries occur within a neighborhood, even down to a single intersection around a certain school.
Other GIS examples in the nursing literature utilize data from professional nursing organizations. For example, following the initiation of the clinical nurse leader role by the American Association of Colleges of Nursing (AACN) in 2004, Stanhope and Turner (2006) used a GIS approach to study the pattern of implementing this innovation in nursing schools and practice sites across the US. Another example involved mapping zip-code, work locations of Psychiatric Mental Health-Advanced Practice Registered Nurses (PMH-APRNs) provided by the American Nurses Credentialing Center (Ghosh, Sterns, Drew, & Hamera, 2011). This interdisciplinary research team used the data to examine the distribution of PMH-APRNs across the US at the county level. They found that there is an uneven distribution of PMH-APRNs and identified implications for future education, clinical practice, and public policy initiatives.
Implications for Nursing Research
Davern and Chen (2010) have argued that advances in scientific research require trying new research methodologies. For nurses, GIS provides an example of such an innovative research methodology. GIS has already been shown to be a reliable tool that can be successfully integrated into research that is focused on the effects of the environment on health outcomes. The promising implications of GIS for nurse researchers suggest it can be used to generate and test hypotheses (Hirshorn & Stewart, 2003; Khan & Skinner, 2003). It can also be used as an exploratory tool– a simple map of a health phenomenon can stimulate discussion and subsequent ideas, even without the addition of a statistical test. In many ways, the usefulness of GIS applications is limited only by the creativity of the researcher.
‘Environment’ is one of the four fundamental domains of nursing, along with the domains of ‘person,’ ‘health,’ and ‘nursing.’ Bloch (2011) suggested that nurses should conduct thorough assessments of the environments of individuals. GIS can help nurses focus on the fundamental concept of environment and help researchers and community stakeholders review the current community resources and deficits in order to promote health. Carlson, York, and Primomo (2011) suggested that GIS is a potent tool for program planners to use in examining the usefulness of, and accessibility to community services. Similarly, Andrews et al. (2007) noted that integrating the principles of gerontology and geography can be used to establish environments that are enabling and healthy, for example, redesigning residential communities to improve physical activity. In this way, nurses can strengthen decision making related to the building of healthier communities and improving the overall health status of individuals and groups.
GIS should also be seen as a tool to facilitate the establishment of new and emerging multidisciplinary collaborative teams. Andrews et al. (2007) commented that the discipline of geographical gerontology still lacks a clear identity; they encouraged GIS users, including nurses, to work as multidisciplinary teams. Nurses are encouraged to become more actively engaged as leaders in the early stages of such evolving fields, especially as their insights provide valuable counterpoints on various health-related issues being studied through a geographic lens.
Recommendations and Summary
There are a variety of resources to help interested nurses find more information about GIS and examples of its applications in health research. The International Journal of Health Geographics is a peer-reviewed, online journal that includes articles focused on GIS applications in health research. In addition, there are several useful texts, such as Geographic Information Systems and Health Applications by Khan and Skinner (2003). Interested nursing students are encouraged to enroll in introductory and advanced GIS classes offered by university geography departments. Additionally, applied research centers, such as the GIS Health and Hazards Lab at Kent State University (www.kent.edu/ghhlab), is designed to help nurture collaborations with any group interested in exploring the use of geospatial technologies. Most local university geography departments will have a member willing to brainstorm with nurses about the applications of GIS for nursing.
In summary, GIS has been utilized in various health-related research projects; researchers who have conducted such studies have recommended GIS as a reliable research methodology. Although widely used in other disciplines, GIS is still at an early stage as a research method in nursing. There is, however, significant potential for using GIS to strengthen nursing research, and we recommend you investigate how maps and mapping can be used in your research.
Jehad Rababah, MSN, RN
Andrew Curtis, PhD, MA, BA
Barbara L. Drew, PhD, PMHCNS-BC