Brian Altonen, MPH, MS

Note: this page and neighboring pages are from older teaching materials used for a lab on GIS and the corresponding lecture/discussion series developed on ‘GIS, population health surveillance, epidemiology and public health’.

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The Perfect Test of “Space” and its Role in Public Health

The idea of combining regional health and demographic features in order to search for commonalities has a number of ways to be carried out. The definition of “region” by social geographers plays an important role in this process. Using the common sense approach, regions typically have physical geographic features to help differentiate them from one another. When we look at a map and try to define regions, there is a certain way we avoid merging thm together, like by combining the one side of a large mountain range with everything on the other side (i.e. the Rockies, Appalachia), unless the mountains themselves form an isolated island like setting, in which case the entire mountains and their mountainbottom places constitute a region (i.e. Adirondacks, NY, the Smokies, TN-NC, or Blue Mountains, OR).

But there is something about a region that has more to it than just its physiographical uniqueness. Oregon and California are right next to each other, yet most people know that the the region of Oregon close to the Columbia River cannot be effectively combined easily with that part of Oregon close to California, much less lining all of Oregon to parts of California close to Mexico. Oregon and Washington for the center of their own unique regions, to which is usually added Idaho and sometimes Montana. As for their northernmost edge of this Pacific Northwest region, there are some cultural resemblances as well existing across the national borders in the lower western parts of Canada, where Vancouver, B.C. and Vancouver, WA have important cultural resemblance, more historically than presently however.

Taking this even further, we can safely say that there are some distinct neighbor differences between Canada and the United States politically that keep us from merging too much of Canada with any United States sociological research. Therefore, it seems reasonable to allow political and governmental boundaries to prevail at times when it comes to reviewing the ways in whiuch we can define regions. Regarding corporate, political and government matters, region may be defined by the official documents themselves. If you are living in the Dakotas, or example, but your health insurance company serves primarily the northwest sector of the states, then you are considered outside your area of coverage. If you are on some form of governmentally sponsored program, governmentally defined boundaries prevail in defining the region you are allowed to reside in. This program may even describe where within its political boundaries you should be residing, such as on a Reservation or off, or within city or county limits or not.

With regard to public health, physiographic features like climate and weather, physiography and topography, animal ecology and vegetation zone types, all play a role in how our health impacts our manner of living in that region. How willing and how much we are able to recreate in the outdoors defines where we chose to stay often, should we be fortunate enough to have a choice. The local vegetation dictates whether or not we like where we are living whenever we have bad allergies, although this has become more unpredictable than it was in the past due to man’s ability to change the allergens natural to a region by changing its terrain ecology. Whether or not to live in a region with very cold winters, or very hot summers, very dry regional weather patterns, versus very humid year round maritime conditions, are all factors that come into play regarding how where we live has the potential of impacting our health. For this reason, regional health patterns is often viewed as being related mostly to the physical features of all land masses and their natural behaviors, and the impacts of these behavior upon our health.

Every region has its disasters, its unique climatic features, its unique animal ecology and vegetation patterns, and its most outstanding physiographic features that we try to deal with when residing in that region. For the most part, these natural features to a region are fairly unstable and unchanging, with the exception of man’s impact on each one of them. So when it comes to regional change and health, it is the people and cultural geography that have the opportunity to change the quickest, before the consequences of population change turn a place into some new all or partially manmade ecological setting. It is this cultural geography that has the greatest impact on the overall health of a region in terms of public health and health care related costs.

With health care costs in mind, these numbers can change overnight due to in-migration and out-migration related changes. Only occasionally does the natural history of a region change as quickly, thereby impacting regional health costs (i.e. natural disasters and natural ecology generated epidemic or endemic disease patterns). The health of people in general relies as much upon cultural ways to define the kinds of acute and chronic diseases or medical problems that will develop and recur within a given human ecological setting. Cultural geography, therefore, is what makes these regions so different from each other, when it comes to health care wants and needs.

Culture has a long history of teaching and practice in this country to which we attach certain meaning to human population settings, and if we review such topics even further, begin to assign behavioral patterns and ultimately health related features to the lifestyles attached to such regions. But populations alone do not rely upon culture to define their health. They also rely upon certain spatial aspects of there they reside to determine the relationships that exist healthwise between region and people. These relationships in the human ecological sense related to occupation types available, foodways and food content availability and use, certain environmental exposure linked consequences generated by the region, and certain travel related temporal changes that can occur. For this reason, in order to define a public health region, with culture playing a role as much as natural environment, we need to define distinct regions by focusing on the spaciousness and disconnect that exists between areas both physically an in terms of travel and transportation. This allows us to define regions that make sense in terms of public health related analyses.

Examples of well developed, growing, isolated communities with a substantial amount of social and economic growth include such regions as the Pacific Northwest, the climatically and topographically isolated states Hawaii and Alaska, the intracontinental topographically defined isolated regions and communities of the Billings, Montana settings and nearby urban centers, the isolated borderland region of northern California combined with southern Oregon, the climatically separated sections of Nevada and eastern California, the culturally defined edge cities and towns located near Canada, such as the Dakotas and possibly Minnesota, and the same for the Tex-Mex and Cal-Mex regions. These places which have historically been culturally-distinct regions are distinct due to their different lifestyle patterns, different climatic concerns and stressors, different intracultural and intercultural sociological factors impacting their human behaviors, disease patterns and healthcare needs, and the different medical and sociological expectations that exist for each of these regions when it comes to meeting the very basic needs such as employment, income generation, culturally defined community support habits linked to religion, church, food sources, health care provisions, or needs for establishing effective physical and mental health programs.

The following is a review of “regions” as they related to public health, presented from the smallest in size to largest in size. These different types of regions are meant to represent how public health settings can be subdivided and then studied with specific research purposes and goals in mind. In some cases, the very small community style regions play important roles in health analysis, especially with regard to culturally-defined medical conditions, services needs, costs, and kinds of care provided. The much larger regions define the more environmentally related problems that are dependent mostly upon large scale topographic and climatic events. Each of these different size regions also has different businesses and political or governmental services linked to them. The degree of involvement in health care administration and related intervention work varies between each of these region definition in terms of how improvements to be made in public health are decided upon, and how we go about making such changes.

We can apply this way of viewing regional health to defining what kinds of disease patterns may need to be evaluated for given population health research settings. The smaller the research area, the more fine-tuned and targeted the research programs can be. This enables for more effective, targeted interventions to be developed, and more effective measurements to be performed for any outcomes generated by these activities. The kinds of data quality and potential use vary for each of the datasets generated by these different levels of monitoring regional health care. Like in any public health research project, the smallest populations offer the best opportunities for well targeted intervention programs to be developed, and the larger populations more general, less personal forms of review to be developed. In terms of qualitative-quantitative research methodologies, the small area, small community studies allow for focus group and case studies to be incorporated into a study and report on local community-specific public health programs, unlike the large area studies which are too time consuming when such activities are engaged in.

Ethnically-defined. Ethnically defined subregions are areas within a well established community setting that have unique cultural or ethnic features to them. In some cases we see areas that are much larger and have a similar uniqueness such as Chinatown, Little India, and such, but typically this way of interpreting culture spatially is that the cultural setting is seen as a fairly small entity with its own community, sets of families and even forms of occupations that are for the most part culturally derived. These ethnically-defined reqions are evaluated in respect to the larger area around them, and can be considered pockets within the much larger community setting. What we know about these regions can be applied to neighboring places, and sometimes to larger ethnic settings of similar origins found in more urban settings. It is the nature of the relationships that exist and the degree of interactions that take place between these smaller areas and the local surrounding communities that perhaps differentiate this kind of setting from well defined, self-sustining, long lasting community-define ethnic settings.

We can consider, for a moment, three different types of ethnic settings:

1. the small “pockets” of ethnic communities such as several family low income settings, a hispanic center or block in the heart of a small town or city, and season farmworker establishments,
2. larger, almost completely socially engaged ethnic settings taking on a town and its borderlands
3. extremely large, heavily populated, urban like or urban related ethnic communities like Chinatown

Each of these has a different level and amount of social and cultural engagement. For the smallest settings this sociocultural pattern defines the region. For the middle-size setting, we see occupations, service industries and even some governmental activities focused on this social pattern, perhaps with a little bit of transient tourism and drive through consumer activities on the side. In the third situation we see people fully engaged at all levels in the cultural setting, with cultural subgroups formed as well, and involvement with the tourism industry in the form of products develop specifically for this market, be they restaurant types and foods, giftshops, outdoor recreation opportunities, local culturally-focused ed community events, etc. The last of these three examples best fits the next scenario regarding socially-defined regions. The first two provide examples of how small area, ethnicity-derived public health population health analyses can be developed.

Community-defined. A region in the public health world has to be defined as a space where human and environmental patterns and behaviors are so unique as to make one region very different from the other. The most important regions for these differences rely first upon physical barriers that exist between two areas, followed by the impacts of cultural differences that exist between regions with their edges defined by their physical barriers. In general, there are certain distance and transportation requirements that help to further this regionalization that is developed socially. Few connections between two regions, due to either topographic or economic regions help to maintain a successful separation between these two areas, like the mid-Rocky Mountain ranges serving as a combined transportation and economically related barrier between the eastern and western mountain faces, each having a unique cultural setting and health care behaviors, practices, and findings as a result. The same differences exist between the Willamette Valley setting in Oregon and its Eastern and Western edges, one a rangeland to desert like living setting with just a few isolated towns and cities and more connections the nearby Idaho, Wyoming and even Utah social settings than expected, and the other a maritime habitat settings with a completely different population types and completely set of environmentally linked disease problems.

Service-defined. The next area up from regions in the public health perspective of regionalism is the service defined regions defined by health care organizations and insurance providers. Health care organizations tend to follow the culturally defined way of regionally defining the different parts of its care, but also allow for multi-culturalism, and so, result in providing services to larger regions. involving different subgroups of people with different medical and health care requirements. Most health programs have high and low income community settings for example, which even if within the same culturally defined setting, have their own unique sets of health related differences. Health care organization programs which involve relationships between different health care providers, facilities, hospital bases, etc., have a more complex set of problems they are usually dealing with, meaning that a better understanding of the sociocultural and economic differences between groups may need to be understood to provide better health care services. One part of this differentiation already exists in the standard HEDIS-NCQA evaluations made of larger health care systems. Medicaid, Medicare, and employee health groups are analyzed separately from each other due to these inherent systems related health care availability, affordability, and coverage-related differences.

Insurer-Defined. The next higher up form of grouping health care populations together deals with regional health care insurance providers. An insurance company that provides care in multiple states, generally is going to be servicing multiple cultural types and groups, and represent one of the first regional forms that is large enough to begin to resemble some of the patterns that exist in this country on a much larger scale. Typically, because commercial activities and economics help to define where an insurer provides it services, there are some distance and transportation factors that help to define the outermost edges of these regions, and so long as they do not merge with nearby competitors, these regions are very representative of the health of large part of the country, but not the country as a whole. For example, a Company1 coverage area of all of the lower two thirds of California, including regions eastward into the westernmost portions of neighboring states, is going to service people residing in single and varied cultural settings, with very different environmental and urban/social linked pressures related to job type, income status, and even forms of care made available to them. Company2, which services the Oregon-California border communities, will be very different from the needs and demands of members serviced by Company1. Company3, located in upper Oregon, all of Washington and parts of Idaho, will have distinctly different medical ecological and climatic features to consider, different in- and out-migration related medical conditions, and different inland versus ocean edge community health related issues and disease patterns.

Major Corporation-defined. The next larger community for health care evaluations is the large insurance company or multiple-subsidiary area, in which related companies service a very large part of the country. Most of these types of companies will service more than three states but less than seven to ten, depending upon the part of the country we are looking at. These companies have medical distributions that mimic some parts of the regional definitions used for national disease surveillance programs and nationally run health care quality assurance measures. In general, the census defined tracts tend to fit into this type of regionalization, to some extent, as well as the HEDIS-NCQA defined regions, although the latter is mostly useful and applicable to the eastern half of this country.

Physiographically-defined. A much better example of this regional concept related to some definitions drawn up several years ago as part of the national dataset work I was engaged in. With this method, the NCQA areas served as the initial regions, each of which was broken down into smaller groups, defined by north-south and/or east west factors, transportation and economic routes of travel, and a combination of environmental, climate and physiographic (topographic) concerns due to the impacts of these features on human exposure, behavior, lifestyle and recreational habits. This method takes the NCQA method and allows a certain amount of demographic and sociocultural features to be linked to its definition and the means by which regional health will be evaluated.

This latter method is the largest regional pattern type of analysis useful to local research. Even though nearly all reports generated about service industry results as part of the national evaluation processes, the larger scale comparisons made between exceptionally large regions is of most value with regard to exceptionally large area geographic features, such as cost-related differences or major environmentally-linked medical differences. Yet even with the latter, as some preliminary evidence shows with ICDs, conditions we consider to be regionally linked like medical problems brought on by environmental exposure, tend to be driven more socially in their patterns. A high elevation sickness is not brought on by living in high elevation areas, but rather by living close to airports that bring one to such regions. Hypothermia and heat stroke are not necessarily elevation and latitude linked respectively. Seafood poisoning is not mostly a maritime community problem like we’d expect.

Census and NCQA-defined. The large areas defined by census and NCQA research serve a purpose in the evaluation of overall behaviors of large scale programs. Large census regions in this country are mostly demographically defined. NCQA regions are mostly defined by regional service and financial differences, and are designed to focus on treatment or therapeutic systems related costs, not individual ICDs and manners of care for specific illnesses. The sub-NCQA regions I defined serve to provide smaller NCQA-derived regions based on well defined barriers to interrelationships, such as latitude-longitude, topographic and transportation limits to economic interactions. Within these sub-NCQA regions we should be able to define small area cultural pockets, and large area population density defined rural to urban regions. These allow for large area small group analysis that can be related to large area outcomes, without loss of a local sense of our ability to develop effective intervention activities design to meet the goals set by such analyses.

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