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1.  Using geographic information systems to identify prospective marketing areas for a special library 
The Center for Disability Resources (CDR) Library is the largest collection of its kind in the Southeastern United States, consisting of over 5,200 books, videos/DVDs, brochures, and audiotapes covering a variety of disability-related topics, from autism to transition resources. The purpose of the library is to support the information needs of families, faculty, students, staff, and other professionals in South Carolina working with individuals with disabilities. The CDR Library is funded on a yearly basis; therefore, maintaining high usage is crucial. A variety of promotional efforts have been used to attract new patrons to the library. Anyone in South Carolina can check out materials from the library, and most of the patrons use the library remotely by requesting materials, which are then mailed to them. The goal of this project was to identify areas of low geographic usage as a means of identifying locations for future library marketing efforts.
Nearly four years worth of library statistics were compiled in a spreadsheet that provided information per county on the number of checkouts, the number of renewals, and the population. Five maps were created using ArcView GIS software to create visual representations of patron checkout and renewal behavior per county.
Out of the 46 counties in South Carolina, eight counties never checked out materials from the library. As expected urban areas and counties near the library's physical location have high usage totals.
The visual representation of the data made identification of low usage regions easier than using a standalone database with no visual-spatial component. The low usage counties will be the focus of future Center for Disability Resources Library marketing efforts. Due to the impressive visual-spatial representations created with Geographic Information Systems, which more efficiently communicate information than stand-alone database information can, librarians may benefit from the software's use as a supplemental tool for tracking library usage and planning promotional efforts.
PMCID: PMC1468423  PMID: 16674819
2.  Challenges in using geographic information systems (GIS) to understand and control malaria in Indonesia 
Malaria Journal  2003;2:36.
Malaria is a mosquito-borne disease of global concern with 1.5 to 2.7 million people dying each year and many more suffering from it. In Indonesia, malaria is a major public health issue with around six million clinical cases and 700 deaths each year. Malaria is most prevalent in the developing countries of the world. Aid agencies have provided financial and technical assistance to malaria-prone countries in an effort to battle the disease. Over the past decade, the focus of some of this assistance has been in the provision of geographic information systems (GIS) hardware, software and training. In theory, GIS can be a very effective tool in combating malaria, however, in practice there have been a host of challenges to its successful use.
This review is based, in part, on the literature but also on our experience working with the Indonesian Ministry of Health. The review identifies three broad problem areas. The first of these relates to data concerns. Without adequate data, GIS is not very useful. Specific problem areas include: accurate data on the disease and how it is reported; basic environmental data on vegetation, land uses, topography, rainfall, etc.; and demographic data on the movement of people. The second problem area involves technology – specifically computer hardware, GIS software and training. The third problem area concerns methods – assuming the previous data and technological problems have been resolved – how can GIS be used to improve our understanding of malaria? One of the main methodological tools is spatial statistical analysis, however, this is a newly developing field, is not easy to understand and suffers from the fact that there is no agreement on standard methods of analysis.
The paper concludes with a discussion of strategies that can be used to overcome some of these problems. One of these strategies involves using ArcView GIS software in combination with ArcExplorer (a public domain program that can read ArcView files) to deal with the problem of needing multiple copies of GIS software. Another strategy involves the development of a self-paced training package that can be used to train individuals
PMCID: PMC305351  PMID: 14613511
3.  A simple method for serving Web hypermaps with dynamic database drill-down 
HealthCyberMap aims at mapping parts of health information cyberspace in novel ways to deliver a semantically superior user experience. This is achieved through "intelligent" categorisation and interactive hypermedia visualisation of health resources using metadata, clinical codes and GIS. HealthCyberMap is an ArcView 3.1 project. WebView, the Internet extension to ArcView, publishes HealthCyberMap ArcView Views as Web client-side imagemaps. The basic WebView set-up does not support any GIS database connection, and published Web maps become disconnected from the original project. A dedicated Internet map server would be the best way to serve HealthCyberMap database-driven interactive Web maps, but is an expensive and complex solution to acquire, run and maintain. This paper describes HealthCyberMap simple, low-cost method for "patching" WebView to serve hypermaps with dynamic database drill-down functionality on the Web.
The proposed solution is currently used for publishing HealthCyberMap GIS-generated navigational information maps on the Web while maintaining their links with the underlying resource metadata base.
The authors believe their map serving approach as adopted in HealthCyberMap has been very successful, especially in cases when only map attribute data change without a corresponding effect on map appearance. It should be also possible to use the same solution to publish other interactive GIS-driven maps on the Web, e.g., maps of real world health problems.
PMCID: PMC131013  PMID: 12437788
4.  Method for mapping population-based case-control studies: an application using generalized additive models 
Mapping spatial distributions of disease occurrence and risk can serve as a useful tool for identifying exposures of public health concern. Disease registry data are often mapped by town or county of diagnosis and contain limited data on covariates. These maps often possess poor spatial resolution, the potential for spatial confounding, and the inability to consider latency. Population-based case-control studies can provide detailed information on residential history and covariates.
Generalized additive models (GAMs) provide a useful framework for mapping point-based epidemiologic data. Smoothing on location while controlling for covariates produces adjusted maps. We generate maps of odds ratios using the entire study area as a reference. We smooth using a locally weighted regression smoother (loess), a method that combines the advantages of nearest neighbor and kernel methods. We choose an optimal degree of smoothing by minimizing Akaike's Information Criterion. We use a deviance-based test to assess the overall importance of location in the model and pointwise permutation tests to locate regions of significantly increased or decreased risk. The method is illustrated with synthetic data and data from a population-based case-control study, using S-Plus and ArcView software.
Our goal is to develop practical methods for mapping population-based case-control and cohort studies. The method described here performs well for our synthetic data, reproducing important features of the data and adequately controlling the covariate. When applied to the population-based case-control data set, the method suggests spatial confounding and identifies statistically significant areas of increased and decreased odds ratios.
PMCID: PMC1526437  PMID: 16764727
5.  Geocoding rural addresses in a community contaminated by PFOA: a comparison of methods 
Environmental Health  2010;9:18.
Location is often an important component of exposure assessment, and positional errors in geocoding may result in exposure misclassification. In rural areas, successful geocoding to a street address is limited by rural route boxes. Communities have assigned physical street addresses to rural route boxes as part of E911 readdressing projects for improved emergency response. Our study compared automated and E911 methods for recovering and geocoding valid street addresses and assessed the impact of positional errors on exposure classification.
The current study is a secondary analysis of existing data that included 135 addresses self-reported by participants of a rural community study who were exposed via public drinking water to perfluorooctanoate (PFOA) released from a DuPont facility in Parkersburg, West Virginia. We converted pre-E911 to post-E911 addresses using two methods: automated ZP4 address-correction software with the U.S. Postal Service LACS database and E911 data provided by Wood County, West Virginia. Addresses were geocoded using TeleAtlas, an online commercial service, and ArcView with StreetMap Premium North America NAVTEQ 2008 enhanced street dataset. We calculated positional errors using GPS measurements collected at each address and assessed exposure based on geocoded location in relation to public water pipes.
The county E911 data converted 89% of the eligible addresses compared to 35% by ZP4 LACS. ArcView/NAVTEQ geocoded more addresses (n = 130) and with smaller median distance between geocodes and GPS coordinates (39 meters) than TeleAtlas (n = 85, 188 meters). Without E911 address conversion, 25% of the geocodes would have been more than 1000 meters from the true location. Positional errors in TeleAtlas geocoding resulted in exposure misclassification of seven addresses whereas ArcView/NAVTEQ methods did not misclassify any addresses.
Although the study was limited by small numbers, our results suggest that the use of county E911 data in rural areas increases the rate of successful geocoding. Furthermore, positional accuracy of rural addresses in the study area appears to vary by geocoding method. In a large epidemiological study investigating the health effects of PFOA-contaminated public drinking water, this could potentially result in exposure misclassification if addresses are incorrectly geocoded to a street segment not serviced by public water.
PMCID: PMC2867955  PMID: 20406495
6.  Creating a replicable, valid cross-platform buffering technique: The sausage network buffer for measuring food and physical activity built environments 
Obesity researchers increasingly use geographic information systems to measure exposure and access in neighborhood food and physical activity environments. This paper proposes a network buffering approach, the “sausage” buffer. This method can be consistently and easily replicated across software versions and platforms, avoiding problems with proprietary systems that use different approaches in creating such buffers.
In this paper, we describe how the sausage buffering approach was developed to be repeatable across platforms and places. We also examine how the sausage buffer compares with existing alternatives in terms of buffer size and shape, measurements of the food and physical activity environments, and associations between environmental features and health-related behaviors. We test the proposed buffering approach using data from EAT 2010 (Eating and Activity in Teens), a study examining multi-level factors associated with eating, physical activity, and weight status in adolescents (n = 2,724) in the Minneapolis/St. Paul metropolitan area of Minnesota.
Results show that the sausage buffer is comparable in area to the classic ArcView 3.3 network buffer particularly for larger buffer sizes. It obtains similar results to other buffering techniques when measuring variables associated with the food and physical activity environments and when measuring the correlations between such variables and outcomes such as physical activity and food purchases.
Findings from various tests in the current study show that researchers can obtain results using sausage buffers that are similar to results they would obtain by using other buffering techniques. However, unlike proprietary buffering techniques, the sausage buffer approach can be replicated across software programs and versions, allowing more independence of research from specific software.
PMCID: PMC3391988  PMID: 22554353
Buffer; Network; Obesity; Physical activity environments; Food environments; GIS; Reliability; Validity; Utility
7.  Interlibrary loan in primary access libraries: challenging the traditional view 
Introduction: Primary access libraries serve as the foundation of the National Network of Libraries of Medicine (NN/LM) interlibrary loan (ILL) hierarchy, yet few published reports directly address the important role these libraries play in the ILL system. This may reflect the traditional view that small, primary access libraries are largely users of ILL, rather than important contributors to the effectiveness and efficiency of the national ILL system.
Objective: This study was undertaken to test several commonly held beliefs regarding ILL system use by primary access libraries.
Hypotheses: Three hypotheses were developed. H1: Colorado and Wyoming primary access libraries comply with the recommended ILL guideline of adhering to a hierarchical structure, emphasizing local borrowing. H2: The closures of two Colorado Council of Medical Librarians (CCML) primary access libraries in 1996 resulted in twenty-three Colorado primary access libraries' borrowing more from their state resource library in 1997. H3: The number of subscriptions held by Colorado and Wyoming primary access libraries is positively correlated with the number of items they loan and negatively correlated with the number of items they borrow.
Methods: The hypotheses were tested using the 1992 and 1997 DOCLINE and OCLC data of fifty-four health sciences libraries, including fifty primary access libraries, two state resource libraries, and two general academic libraries in Colorado and Wyoming. The ILL data were obtained electronically and analyzed using Microsoft Word 98, Microsoft Excel 98, and JMP 3.2.2.
Results: CCML primary access libraries comply with the recommended guideline to emphasize local borrowing by supplying each other with the majority of their ILLs, instead of overburdening libraries located at higher levels in the ILL hierarchy (H1). The closures of two CCML primary access libraries appear to have affected the entire ILL system, resulting in a greater volume of ILL activity for the state resource library and other DOCLINE libraries higher up in the ILL hierarchy and highlighting the contribution made by CCML primary access libraries (H2). CCML primary access libraries borrow and lend in amounts that are proportional to their collection size, rather than overtaxing libraries at higher levels in the ILL hierarchy with large numbers of requests (H3).
Limitations: The main limitations of this study were the small sample size and the use of data collected for another purpose, the CCML ILL survey.
Conclusions: The findings suggest that there is little evidence to support several commonly held beliefs regarding ILL system use by primary access libraries. In addition to validating the important contributions made by primary access libraries to the national ILL system, baseline data that can be used to benchmark current practice performance are provided.
PMCID: PMC35251  PMID: 11055297
8.  New activities and changing roles of health sciences librarians: a systematic review, 1990–2012 
The paper identifies and documents new health sciences librarian activities and roles during the period from 1990–2012.
A systematic review of the literature was conducted using MEDLINE, Library and Information Abstracts, Library Literature, Scopus, and Web of Science. To find new roles that might not yet have been described in the literature, job announcements published in the Medical Library Association email discussion list archives from 2008–2012 were searched. For inclusion, an article needed to contain a substantive description of a new role and/or activity performed by librarians and be in the field of medical or health sciences librarianship. Papers that did not describe an actual (rather than proposed) librarian role were excluded.
New roles identified through the literature search were: embedded librarians (such as clinical informationist, bioinformationist, public health informationist, disaster information specialist); systematic review librarian; emerging technologies librarian; continuing medical education librarian; grants development librarian; and data management librarian. New roles identified through job announcements were digital librarian, metadata librarian, scholarly communication librarian, and translational research librarian. New twists to old roles were also identified: clinical medical librarian, instruction librarian, outreach librarian, and consumer health librarian.
While the main purposes of health sciences librarianship remain the same, the new roles represent major new activities so that, for many librarians, daily on-the-job work is completely different.
This list of new activities should inform students contemplating medical librarianship careers, guide formal and continuing education programs, and encourage other librarians to consider these new services.
PMCID: PMC3794682  PMID: 24163598
9.  Direct observation of neighborhood attributes in an urban area of the US south: characterizing the social context of pregnancy 
Neighborhood characteristics have been associated with poor maternal and child health outcomes, yet conceptualization of potential mechanisms is still needed. Census data have long served as proxies for area level socioeconomic influences. Unique information captured by neighborhood inventories, mostly conducted in northern US and Canadian urban areas, has shown important aspects of the community environment that are not captured by the socioeconomic and demographic aggregated individual statistics of census data. In this paper, we describe a neighborhood data collection effort tailored to a southern urban area.
This study used data from the Pregnancy, Nutrition and Infection (PIN) prospective cohort study to describe neighborhoods where low- and moderate-income pregnant women reside. Women who participated in the PIN study and who resided in Raleigh, NC and its surrounding suburbs were included (n = 703). Neighborhood attributes captured by the inventory included litter, housing condition, road condition, and social interactions that informed theoretical constructs of physical incivility, territoriality and social spaces. US Housing and Population Census 2000 data at the block group level were also assessed to identify the unique contribution of directly observed data. We hypothesize that neighborhood environments can influence health through psychosocial mediated pathways that lead to increased stress, or through disadvantage leading to poor neighborhood resources, or by protective attributes through increased social control.
Findings suggest that directly observed neighborhood attributes distinguished between different types of areas in which low-income pregnant non-Hispanic white and non-Hispanic black women lived. Theoretically informed scales of physical incivilities, territoriality and social spaces were constructed and found to be internally consistent. Scales were weakly associated indicating that these constructs capture distinct information about these neighborhoods. Physical incivilities, territoriality and social spaces scales were poorly explained by traditional census variables used to proxy neighborhood environment.
If neighborhoods influence health through psychosocial mediated pathways then careful detailing of neighborhood attributes that contribute to stress or deterioration, beyond traditional socioeconomic status, are needed. We believe that measuring physical incivility, territoriality and social spaces as expressions of underlying issues of maintenance and social communication make important contributes to this field.
PMCID: PMC1444926  PMID: 16545132
10.  Geographical information system and access to HIV testing, treatment and prevention of mother-to-child transmission in conflict affected Northern Uganda 
Conflict and Health  2007;1:12.
Using Geographical Information System (GIS) as a tool to determine access to and gaps in providing HIV counselling and testing (VCT), treatment (ART) and mother-to-child transmission (PMTCT) services in conflict affected northern Uganda.
Cross-sectional data on availability and utilization, and geo-coordinates of health facilities providing VCT, PMTCT, and ART were collected in order to determine access. ArcView software produced maps showing locations of facilities and Internally Displaced Population(IDP) camps.
There were 167 health facilities located inside and outside 132 IDP camps with VCT, PMTCT and ART services provided in 32 (19.2%), 15 (9%) and 10 (6%) facilities respectively. There was uneven availability and utilization of services and resources among districts, camps and health facilities. Inadequate staff and stock-out of essential commodities were found in lower health facility levels. Provision of VCT was 100% of the HSSP II target at health centres IV and hospitals but 28% at HC III. For PMTCT and ART, only 42.9% and 20% of the respective targets were reached at the health centres IV.
Access to VCT, PMTCT and ART services was geographically limited due to inadequacy and heterogeneous dispersion of these services among districts and camps. GIS mapping can be effective in identifying service delivery gaps and presenting complex data into simplistic results hence can be recommended in need assessments in conflict settings.
PMCID: PMC2228274  PMID: 18053189
11.  Neighborhood-Level Hot Spot Maps to Inform Delivery of Primary Care and Allocation of Social Resources 
The Permanente Journal  2013;17(1):4-9.
Challenges to health care access in the US are forcing local policymakers and service delivery systems to find novel ways to address the shortage of primary care clinicians. The uninsured and underinsured face the greatest obstacles in accessing services. Geographic information systems mapping software was used to illustrate health disparities in Alachua County, FL; galvanize a community response; and direct reallocation of resources.
The University of Florida Family Data Center created “hot spot” density maps of important health and social indicators to highlight the location of disparities at the neighborhood level. Maps were produced for Medicaid births, teen births, low birth weight, domestic violence incidents, child maltreatment reports, unexcused school absences, and juvenile justice referrals. Maps were widely shared with community partners, including local elected officials, law enforcement, educators, child welfare agencies, health care providers, and service organizations. This data sharing resulted in advocacy efforts to bring resources to the greatest-need neighborhoods in the county. Novel public-private partnerships were forged between the local library district, children and family service providers, and university administrators. Two major changes are detailed: a family resource center built in the neighborhood of greatest need and a mobile clinic staffed by physicians, nurses, physician assistants, health educators, and student and faculty volunteers.
Density maps have several advantages. They require minimal explanation. Anyone familiar with local geographic features can quickly identify locations displaying health disparities. Personalizing health disparities by locating them geographically allows a community to translate data to action to improve health care access.
PMCID: PMC3627788  PMID: 23596361
12.  What criteria do consumer health librarians use to develop library collections? a phenomenological study* 
The criteria for determining whether resources are included in consumer health library collections are summarized in institutional collection development policies (CDPs). Evidence suggests that CDPs do not adequately capture all of these criteria. The aim of this study was to describe the resource review experience of librarians and compare it to what is described in CDPs.
A phenomenological approach was used to explore and describe the process. Four consumer health librarians independently evaluated cancer-related consumer health resources and described their review process during a semi-structured telephone interview. Afterward, these librarians completed online questionnaires about their approaches to collection development. CDPs from participating libraries, interview transcripts, and questionnaire data were analyzed. Researchers summarized the findings, and participating librarians reviewed results for validation.
Librarians all utilized similar criteria, as documented in their CDPs; however, of thirteen criteria described in the study, only four were documented in CDPs.
CDPs for consumer health libraries may be missing important criteria that are considered integral parts of the collection development process.
A better understanding of the criteria and contextual factors involved in the collection development process can assist with establishing high-quality consumer health library collections.
PMCID: PMC3988777  PMID: 24860261
13.  Systematic social observation of children’s neighborhoods using Google Street View: a reliable and cost-effective method 
Children growing up in poor versus affluent neighborhoods are more likely to spend time in prison, develop health problems and die at an early age. The question of how neighborhood conditions influence our behavior and health has attracted the attention of public health officials and scholars for generations. Online tools are now providing new opportunities to measure neighborhood features and may provide a cost effective way to advance our understanding of neighborhood effects on child health.
A virtual systematic social observation (SSO) study was conducted to test whether Google Street View could be used to reliably capture the neighborhood conditions of families participating in the Environmental-Risk (E-Risk) Longitudinal Twin Study. Multiple raters coded a subsample of 120 neighborhoods and convergent and discriminant validity was evaluated on the full sample of over 1,000 neighborhoods by linking virtual SSO measures to: (a) consumer based geo-demographic classifications of deprivation and health, (b) local resident surveys of disorder and safety, and (c) parent and teacher assessments of children’s antisocial behavior, prosocial behavior, and body mass index.
High levels of observed agreement were documented for signs of physical disorder, physical decay, dangerousness and street safety. Inter-rater agreement estimates fell within the moderate to substantial range for all of the scales (ICCs ranged from .48 to .91). Negative neighborhood features, including SSO-rated disorder and decay and dangerousness corresponded with local resident reports, demonstrated a graded relationship with census-defined indices of socioeconomic status, and predicted higher levels of antisocial behavior among local children. In addition, positive neighborhood features, including SSO-rated street safety and the percentage of green space, were associated with higher prosocial behavior and healthy weight status among children.
Our results support the use of Google Street View as a reliable and cost effective tool for measuring both negative and positive features of local neighborhoods.
PMCID: PMC3537178  PMID: 22676812
Systematic social observation; Google Street View; neighborhood disorder; neighborhood deprivation; antisocial behavior; body mass index
14.  Standards for hospital libraries 2002 
The Medical Library Association's “Standards for Hospital Libraries 2002” have been developed as a guide for hospital administrators, librarians, and accrediting bodies to ensure that hospitals have the resources and services to effectively meet their needs for knowledge-based information. Specific requirements for knowledge-based information include that the library be a separate department with its own budget. Knowledge-based information in the library should be directed by a qualified librarian who functions as a department head and is a member of the Academy of Health Information Professionals. The standards define the role of the medical librarian and the links between knowledge-based information and other functions such as patient care, patient education, performance improvement, and education. In addition, the standards address the development and implementation of the knowledge-based information needs assessment and plans, the promotion and publicity of the knowledge-based information services, and the physical space and staffing requirements. The role, qualifications, and functions of a hospital library consultant are outlined. The health sciences library is positioned to play a key role in the hospital. The increasing use of the Internet and new information technologies by medical, nursing, and allied health staffs; patients; and the community require new strategies, strategic planning, allocation of adequate resources, and selection and evaluation of appropriate information resources and technologies. The Hospital Library Standards Committee has developed this document as a guideline to be used in facing these challenges.
Editor's Note: The “Standards for Hospital Libraries 2002” were approved by the members of the Hospital Library Section during MLA '02 in Dallas, Texas. They were subsequently approved by Section Council and received final approval from the MLA Board of Directors in June 2002. They succeed the Standards for Hospital Libraries published in 1994 and the Minimum Standards for Health Sciences Libraries in Hospitals from 1983. A Frequently Asked Questions document discussing the development of the new standards can be found on the Hospital Library Section Website at
PMCID: PMC128964  PMID: 12398254
15.  The role of the academic medical center library in training public librarians*† 
Purpose: This project enhanced access to and awareness of health information resources on the part of public libraries in western Pennsylvania.
Setting/Participants/Resources: The Health Sciences Library System (HSLS), University of Pittsburgh, conducted a needs assessment and offered a series of workshops to 298 public librarians.
Brief Description: The National Library of Medicine–funded project “Access to Electronic Health Information” at the HSLS, University of Pittsburgh, provided Internet health information training to public libraries and librarians in sixteen counties in western Pennsylvania. Through this project, this academic medical center library identified the challenges for public librarians in providing health-related reference service, developed a training program to address those challenges, and evaluated the impact of this training on public librarians' ability to provide health information.
Results/Outcome: The HSLS experience indicates academic medical center libraries can have a positive impact on their communities by providing health information instruction to public librarians. The success of this project—demonstrated by the number of participants, positive course evaluations, increased comfort level with health-related reference questions, and increased use of MEDLINEplus and other quality information resources—has been a catalyst for continuation of this programming, not only for public librarians but also for the public in general.
Evaluation Method: A training needs assessment, course evaluation, and impact training survey were used in developing the curriculum and evaluating the impact of this training on public librarians' professional activities.
PMCID: PMC164399  PMID: 12883558
16.  Initiating informatics and GIS support for a field investigation of Bioterrorism: The New Jersey anthrax experience 
The investigation of potential exposure to anthrax spores in a Trenton, New Jersey, mail-processing facility required rapid assessment of informatics needs and adaptation of existing informatics tools to new physical and information-processing environments. Because the affected building and its computers were closed down, data to list potentially exposed persons and map building floor plans were unavailable from the primary source.
Controlling the effects of anthrax contamination required identification and follow-up of potentially exposed persons. Risk of exposure had to be estimated from the geographic relationship between work history and environmental sample sites within the contaminated facility. To assist in establishing geographic relationships, floor plan maps of the postal facility were constructed in ArcView Geographic Information System (GIS) software and linked to a database of personnel and visitors using Epi Info and Epi Map 2000. A repository for maintaining the latest versions of various documents was set up using Web page hyperlinks.
During public health emergencies, such as bioterrorist attacks and disease epidemics, computerized information systems for data management, analysis, and communication may be needed within hours of beginning the investigation. Available sources of data and output requirements of the system may be changed frequently during the course of the investigation. Integrating data from a variety of sources may require entering or importing data from a variety of digital and paper formats. Spatial representation of data is particularly valuable for assessing environmental exposure. Written documents, guidelines, and memos important to the epidemic were frequently revised. In this investigation, a database was operational on the second day and the GIS component during the second week of the investigation.
PMCID: PMC293473  PMID: 14617376
17.  Feasibility study of geospatial mapping of chronic disease risk to inform public health commissioning 
BMJ Open  2012;2(1):e000711.
To explore the feasibility of producing small-area geospatial maps of chronic disease risk for use by clinical commissioning groups and public health teams.
Study design
Cross-sectional geospatial analysis using routinely collected general practitioner electronic record data.
Sample and setting
Tower Hamlets, an inner-city district of London, UK, characterised by high socioeconomic and ethnic diversity and high prevalence of non-communicable diseases.
The authors used type 2 diabetes as an example. The data set was drawn from electronic general practice records on all non-diabetic individuals aged 25–79 years in the district (n=163 275). The authors used a validated instrument, QDScore, to calculate 10-year risk of developing type 2 diabetes. Using specialist mapping software (ArcGIS), the authors produced visualisations of how these data varied by lower and middle super output area across the district. The authors enhanced these maps with information on examples of locality-based social determinants of health (population density, fast food outlets and green spaces). Data were piloted as three types of geospatial map (basic, heat and ring). The authors noted practical, technical and information governance challenges involved in producing the maps.
Usable data were obtained on 96.2% of all records. One in 11 adults in our cohort was at ‘high risk’ of developing type 2 diabetes with a 20% or more 10-year risk. Small-area geospatial mapping illustrated ‘hot spots’ where up to 17.3% of all adults were at high risk of developing type 2 diabetes. Ring maps allowed visualisation of high risk for type 2 diabetes by locality alongside putative social determinants in the same locality. The task of downloading, cleaning and mapping data from electronic general practice records posed some technical challenges, and judgement was required to group data at an appropriate geographical level. Information governance issues were time consuming and required local and national consultation and agreement.
Producing small-area geospatial maps of diabetes risk calculated from general practice electronic record data across a district-wide population was feasible but not straightforward. Geovisualisation of epidemiological and environmental data, made possible by interdisciplinary links between public health clinicians and human geographers, allows presentation of findings in a way that is both accessible and engaging, hence potentially of value to commissioners and policymakers. Impact studies are needed of how maps of chronic disease risk might be used in public health and urban planning.
Article summary
Article focus
To explore the feasibility of producing small-area geospatial maps of chronic disease risk for use by clinical commissioning groups and public health teams.
Key messages
Creating small-area geospatial maps of risk of type 2 diabetes is feasible using routinely collected data from electronic general practice records.
Maps complement a traditional statistical approach to public health data, requiring different ways of processing and presenting information.
Such maps may be of use to commissioners and public health planners who seek to make sense of vast amounts of routine health information.
Strengths and limitations of this study
The study uses routinely collected local individual patient data to generate high-quality small-area maps of disease risk across an entire district.
Quality and completeness of the data set from which the geospatial maps were derived was high.
A potential limitation of our study is the uniqueness of the local IT context. In order for the method used here to be successfully reproduced by others, a number of conditions need to be met.
PMCID: PMC3282296  PMID: 22337817
18.  Public library consumer health information pilot project: results of a National Library of Medicine evaluation 
In October 1998, the National Library of Medicine (NLM) launched a pilot project to learn about the role of public libraries in providing health information to the public and to generate information that would assist NLM and the National Network of Libraries of Medicine (NN/LM) in learning how best to work with public libraries in the future. Three regional medical libraries (RMLs), eight resource libraries, and forty-one public libraries or library systems from nine states and the District of Columbia were selected for participation. The pilot project included an evaluation component that was carried out in parallel with project implementation. The evaluation ran through September 1999. The results of the evaluation indicated that participating public librarians were enthusiastic about the training and information materials provided as part of the project and that many public libraries used the materials and conducted their own outreach to local communities and groups. Most libraries applied the modest funds to purchase additional Internet-accessible computers and/or upgrade their health-reference materials. However, few of the participating public libraries had health information centers (although health information was perceived as a top-ten or top-five topic of interest to patrons). Also, the project generated only minimal usage of NLM's consumer health database, known as MEDLINEplus, from the premises of the monitored libraries (patron usage from home or office locations was not tracked). The evaluation results suggested a balanced follow-up by NLM and the NN/LM, with a few carefully selected national activities, complemented by a package of targeted activities that, as of January 2000, are being planned, developed, or implemented. The results also highlighted the importance of building an evaluation component into projects like this one from the outset, to assure that objectives were met and that evaluative information was available on a timely basis, as was the case here.
PMCID: PMC35252  PMID: 11055298
19.  Defining Neighborhood Boundaries for Urban Health Research 
American journal of preventive medicine  2007;32(6 Suppl):S154-S159.
The body of literature exploring neighborhood effects on health has increased rapidly in recent years, yet a number of methodological concerns remain, including preferred methods for identification and delineation of study neighborhoods. In research combining census or other publicly available data with surveys of residents and/or street-level observations, questions regarding neighborhood definition take on added significance. Neighborhoods must be identified and delineated in such a way as to optimize quality and availability of data from each of these sources.
IMPACT, a multi-level study examining associations between features of the urban environment and mental health, drug use, and sexual behavior, utilized a multi-step neighborhood definition process including development of census block group maps, review of land use and census tract data, and field visits and observation in each of the targeted communities. Field observations were guided by a pre-identified list of environmental features focused on the potential for recruitment (e.g. pedestrian volume); characteristics commonly used to define neighborhood boundaries (e.g. obstructions to pedestrian traffic, changes in land use), and characteristics that have been associated in the literature with health behaviors and health outcomes (such as housing type, maintenance and use of open spaces). This process, implemented in February through July 2005, proved feasible and offered the opportunity to identify neighborhoods appropriate to study objectives and to collect descriptive information that can be used as a context for understanding study results.
PMCID: PMC2467386  PMID: 17543706
20.  The Health Information Literacy Research Project* 
This research studied hospital administrators' and hospital-based health care providers' (collectively, the target group) perceived value of consumer health information resources and of librarians' roles in promoting health information literacy in their institutions.
A web-based needs survey was developed and administered to hospital administrators and health care providers. Multiple health information literacy curricula were developed. One was pilot-tested by nine hospital libraries in the United States and Canada. Quantitative and qualitative methods were used to evaluate the curriculum and its impact on the target group.
A majority of survey respondents believed that providing consumer health information resources was critically important to fulfilling their institutions' missions and that their hospitals could improve health information literacy by increasing awareness of its impact on patient care and by training staff to become more knowledgeable about health literacy barriers. The study showed that a librarian-taught health information literacy curriculum did raise awareness about the issue among the target group and increased both the use of National Library of Medicine consumer health resources and referrals to librarians for health information literacy support.
It is hoped that many hospital administrators and health care providers will take the health information literacy curricula and recognize that librarians can educate about the topic and that providers will use related consumer health services and resources.
PMCID: PMC2759165  PMID: 19851494
21.  Demarcation of local neighborhoods to study relations between contextual factors and health 
Several studies have highlighted the importance of collective social factors for population health. One of the major challenges is an adequate definition of the spatial units of analysis which present properties potentially related to the target outcomes. Political and administrative divisions of urban areas are the most commonly used definition, although they suffer limitations in their ability to fully express the neighborhoods as social and spatial units.
This study presents a proposal for defining the boundaries of local neighborhoods in Rio de Janeiro city. Local neighborhoods are constructed by means of aggregation of contiguous census tracts which are homogeneous regarding socioeconomic indicators.
Local neighborhoods were created using the SKATER method (TerraView software). Criteria used for socioeconomic homogeneity were based on four census tract indicators (income, education, persons per household, and percentage of population in the 0-4-year age bracket) considering a minimum population of 5,000 people living in each local neighborhood. The process took into account the geographic boundaries between administrative neighborhoods (a political-administrative division larger than a local neighborhood, but smaller than a borough) and natural geographic barriers.
The original 8,145 census tracts were collapsed into 794 local neighborhoods, distributed along 158 administrative neighborhoods. Local neighborhoods contained a mean of 10 census tracts, and there were an average of five local neighborhoods per administrative neighborhood.
The local neighborhood units demarcated in this study are less socioeconomically heterogeneous than the administrative neighborhoods and provide a means for decreasing the well-known statistical variability of indicators based on census tracts. The local neighborhoods were able to distinguish between different areas within administrative neighborhoods, particularly in relation to squatter settlements.
Although the literature on neighborhood and health is increasing, little attention has been paid to criteria for demarcating neighborhoods. The proposed method is well-structured, available in open-access software, and easily reproducible, so we expect that new experiments will be conducted to evaluate its potential use in other settings. The method is thus a potentially important contribution to research on intra-urban differentials, particularly concerning contextual factors and their implications for different health outcomes.
PMCID: PMC2915962  PMID: 20587046
22.  Connecting for Health Literacy: Health Information Partners 
Health promotion practice  2008;11(1):79-88.
This article describes a community-based health information partnership to address health literacy and health information inequalities in marginalized communities. Public health, medical, literacy, and library practitioners promote health literacy through outreach, training, and professional development activities in community settings. They create learning environments for people to develop the necessary knowledge and skills to better understand health information and health policy so they can make decisions concerning personal and community health. Outreach activities focus on visits to neighborhood health centers, health fairs, health exhibits at union meetings and conferences; training programs involve hands-on, peer-led computer classes for people living with HIV and for the general public; and professional development programs connect librarians, health providers, public health workers, and literacy teachers in joint planning and learning. Several learners currently participate in and lead community health education programs and HIV advocacy. The coalition's strength develops from strongly shared objectives, an absence of territoriality, and a core active leadership group.
PMCID: PMC2952395  PMID: 18544664
Internet; health literacy; health information outreach; coalitions
23.  Defining Neighborhood Boundaries for Urban Health Research in Developing Countries: A Case Study of Accra, Ghana 
Journal of maps  2013;9(1):36-42.
The neighborhood has been used as a sampling unit for exploring variations in health outcomes. In a variety of studies census tracts or ZIP codes have been used as proxies for neighborhoods because the boundaries are pre-defined units for which other data are readily available. However these spatial units can be arbitrary and do not account for social-cultural behaviors and identities that are significant to residents. In this study for the city of Accra, Ghana, our goal was to create a neighborhood map that represented the boundaries generally agreed upon by the residents of the city using the smallest available census unit, the enumeration area (EA), as the base unit. This neighborhood map was then used as the basis for mapping spatial variations in health within the city. The first step in demarcating the boundaries was to identify features that limit a person’s movement including the major roads, drainage features, and railroad tracks that people use to partially define their neighborhood boundaries. Once an initial set of boundaries were established, they were iteratively modified by walking the neighborhoods, talking to residents, public officials, and others. The resulting neighborhood map consolidated 1,723 EAs into 108 neighborhoods covering the entire Accra metropolitan area. Results indicated that the team achieved 71 percent accuracy in mapping neighborhoods when the neighborhood keyed to the survey EA was compared with the response given by the interviewees in the 2008–2009 Women’s Health Survey of Accra when asked which neighborhood they lived in.
PMCID: PMC3656474  PMID: 23690870
24.  Methods to Measure the Impact of Home, Social, and Sexual Neighborhoods of Urban Gay, Bisexual, and Other Men Who Have Sex with Men 
PLoS ONE  2013;8(10):e75878.
Men who have sex with men (MSM) accounted for 61% of new HIV diagnoses in the United States in 2010. Recent analyses indicate that socio-structural factors are important correlates of HIV infection. NYCM2M was a cross-sectional study designed to identify neighborhood-level characteristics within the urban environment that influence sexual risk behaviors, substance use and depression among MSM living in New York City. The sample was recruited using a modified venue-based time-space sampling methodology and through select websites and mobile applications.
This paper describes novel methodological approaches used to improve the quality of data collected for analysis of the impact of neighborhoods on MSM health. Previous research has focused predominately on residential neighborhoods and used pre-determined administrative boundaries (e.g., census tracts) that often do not reflect authentic and meaningful neighborhoods. This study included the definition and assessment of multiple neighborhoods of influence including where men live (home neighborhood), socialize (social neighborhood) and have sex (sexual neighborhood). Furthermore, making use of technological advances in mapping, we collected geo-points of reference for each type of neighborhood and identified and constructed self-identified neighborhood boundary definitions. Finally, this study collected both perceived neighborhood characteristics and objective neighborhood conditions to create a comprehensive, flexible and rich neighborhood-level set of covariates. This research revealed that men perceived their home, social and sexual neighborhoods in different ways. Few men (15%) had the same home, social and sexual neighborhoods; for 31%, none of the neighborhoods was the same. Of the three types of neighborhoods, the number of unique social neighborhoods was the lowest; the size of sexual neighborhoods was the smallest. The resultant dataset offers the opportunity to conduct analyses that will yield context-specific and nuanced understandings of the relations among neighborhood space, and the well-being and health of urban MSM.
PMCID: PMC3797712  PMID: 24146785
25.  Tobacco Company Efforts to Influence the Food and Drug Administration-Commissioned Institute of Medicine Report Clearing the Smoke: An Analysis of Documents Released through Litigation 
PLoS Medicine  2013;10(5):e1001450.
Stanton Glantz and colleagues investigate efforts by tobacco companies to influence Clearing the Smoke, a 2001 Institute of Medicine report on harm reduction tobacco products.
Please see later in the article for the Editors' Summary
Spurred by the creation of potential modified risk tobacco products, the US Food and Drug Administration (FDA) commissioned the Institute of Medicine (IOM) to assess the science base for tobacco “harm reduction,” leading to the 2001 IOM report Clearing the Smoke. The objective of this study was to determine how the tobacco industry organized to try to influence the IOM committee that prepared the report.
Methods and Findings
We analyzed previously secret tobacco industry documents in the University of California, San Francisco Legacy Tobacco Documents Library, and IOM public access files. (A limitation of this method includes the fact that the tobacco companies have withheld some possibly relevant documents.) Tobacco companies considered the IOM report to have high-stakes regulatory implications. They developed and implemented strategies with consulting and legal firms to access the IOM proceedings. When the IOM study staff invited the companies to provide information on exposure and disease markers, clinical trial design for safety and efficacy, and implications for initiation and cessation, tobacco company lawyers, consultants, and in-house regulatory staff shaped presentations from company scientists. Although the available evidence does not permit drawing cause-and-effect conclusions, and the IOM may have come to the same conclusions without the influence of the tobacco industry, the companies were pleased with the final report, particularly the recommendations for a tiered claims system (with separate tiers for exposure and risk, which they believed would ease the process of qualifying for a claim) and license to sell products comparable to existing conventional cigarettes (“substantial equivalence”) without prior regulatory approval. Some principles from the IOM report, including elements of the substantial equivalence recommendation, appear in the 2009 Family Smoking Prevention and Tobacco Control Act.
Tobacco companies strategically interacted with the IOM to win several favored scientific and regulatory recommendations.
Please see later in the article for the Editors' Summary
Editors' Summary
Up to half of tobacco users will die of cancer, lung disease, heart disease, stroke, or another tobacco-related disease. Cigarettes and other tobacco products cause disease because they expose their users to nicotine and numerous other toxic chemicals. Tobacco companies have been working to develop a “safe” cigarette for more than half a century. Initially, their attention focused on cigarettes that produced lower tar and nicotine yields in machine-smoking tests. These products were perceived as “safer” products by the public and scientists for many years, but it is now known that the use of low-yield cigarettes can actually expose smokers to higher levels of toxins than standard cigarettes. More recently, the tobacco companies have developed other products (for example, products that heat aerosols of nicotine, rather than burning the tobacco) that claim to reduce harm and the risk of tobacco-related disease, but they can only market these modified risk tobacco products in the US after obtaining Food and Drug Administration (FDA) approval. In 1999, the FDA commissioned the US Institute of Medicine (IOM, an influential source of independent expert advice on medical issues) to assess the science base for tobacco “harm reduction.” In 2001, the IOM published its report Clearing the Smoke: Assessing the Science Base for Tobacco Harm and Reduction, which, although controversial, set the tone for the development and regulation of tobacco products in the US, particularly those claiming to be less dangerous, in subsequent years.
Why Was This Study Done?
Tobacco companies have a long history of working to shape scientific discussions and agendas. For example, they have produced research results designed to “create controversy” about the dangers of smoking and secondhand smoke. In this study, the researchers investigate how tobacco companies organized to try to influence the IOM committee that prepared the Clearing the Smoke report on modified risk tobacco products by analyzing tobacco industry and IOM documents.
What Did the Researchers Do and Find?
The researchers searched the Legacy Tobacco Documents Library (a collection of internal tobacco industry documents released as a result of US litigation cases) for documents outlining how tobacco companies tried to influence the IOM Committee to Assess the Science Base for Tobacco Harm Reduction and created a timeline of events from the 1,000 or so documents they retrieved. They confirmed and supplemented this timeline using information in 80 files that detailed written interactions between the tobacco companies and the IOM committee, which they obtained through a public records access request. Analysis of these documents indicates that the tobacco companies considered the IOM report to have important regulatory implications, that they developed and implemented strategies with consulting and legal firms to access the IOM proceedings, and that tobacco company lawyers, consultants, and regulatory staff shaped presentations to the IOM committee by company scientists on various aspects of tobacco harm reduction products. The analysis also shows that tobacco companies were pleased with the final report, particularly its recommendation that tobacco products can be marketed with exposure or risk reduction claims provided the products substantially reduce exposure and provided the behavioral and health consequences of these products are determined in post-marketing surveillance and epidemiological studies (“tiered testing”) and its recommendation that, provided no claim of reduced exposure or risk is made, new products comparable to existing conventional cigarettes (“substantial equivalence”) can be marketed without prior regulatory approval.
What Do These Findings Mean?
These findings suggest that tobacco companies used their legal and regulatory staff to access the IOM committee that advised the FDA on modified risk tobacco products and that they used this access to deliver specific, carefully formulated messages designed to serve their business interests. Although these findings provide no evidence that the efforts of tobacco companies influenced the IOM committee in any way, they show that the companies were satisfied with the final IOM report and its recommendations, some of which have policy implications that continue to reverberate today. The researchers therefore call for the FDA and other regulatory bodies to remember that they are dealing with companies with a long history of intentionally misleading the public when assessing the information presented by tobacco companies as part of the regulatory process and to actively protect their public-health policies from the commercial interests of the tobacco industry.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Thomas Novotny
The World Health Organization provides information about the dangers of tobacco (in several languages); for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
A PLOS Medicine Research Article by Heide Weishaar and colleagues describes tobacco company efforts to undermine the Framework Convention on Tobacco Control, an international instrument for tobacco control
Wikipedia has a page on tobacco harm reduction (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The IOM report Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction is available to read online
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The University of California, San Francisco Center for Tobacco Control Research and Education is the focal point for University of California, San Francisco (UCSF) scientists in disciplines ranging from the molecular biology of nicotine addiction through political science who combine their efforts to eradicate the use of tobacco and tobacco-induced cancer and other diseases worldwide
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
PMCID: PMC3665841  PMID: 23723740

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