State government, university, and local health department (LHD) partners collaborated to build the geographic information system (GIS) capacity of 5 LHDs in North Carolina. Project elements included procuring hardware and software, conducting individualized and group training, developing data layers, guiding the project development process, coordinating participation in technical conferences, providing ongoing project consultation, and evaluating project milestones. The project provided health department personnel with the skills and resources required to use sophisticated information management systems, particularly those that address spatial dimensions of public health practice.

This capacity-building project helped LHDs incorporate GIS technology into daily operations, resulting in improved time and cost efficiency. Keys to success included (1) methods training rooted in problems specific to the LHD, (2) required project identification by LHD staff with associated timelines for development, (3) ongoing technical support as staff returned to home offices after training, (4) subgrants to LHDs to ease hardware and software resource constraints, (5) networks of relationships among LHDs and other professional GIS users, and (6) senior LHD leadership who supported the professional development activities being undertaken by staff.

PUBLIC HEALTH AGENCIES are responsible for disseminating information to and conducting analyses for decisionmakers and the general public. Understanding the spatial components that characterize public health and environmental issues allows policymakers to implement more realistic and more meaningful programs, with ensuing improvements in service delivery. Many geographic information system (GIS)–based projects have been successful in supporting public and environmental health practice, including those investigating toxic exposure,14 vector-borne disease,57 health information access,6,8 and the built environment.9,10

After significant hurricane-induced flooding in 1999, the North Carolina Division of Public Health organized a series of disaster response review meetings with the affected counties. It was determined that local health departments (LHDs) lacked the skills, resources, and infrastructure necessary to use sophisticated information management systems, particularly those that incorporated spatial dimensions of public health practice. Funding was sought and secured from the US Centers for Disease Control and Prevention (CDC) for a 2-year project to build GIS capacity in 5 LHDs.

This project relied on a team drawn from state government, academia, and LHDs, including the Occupational and Environmental Epidemiology Branch (OEEB) within the North Carolina Department of Health and Human Services; the North Carolina Center for Geographic Information and Analysis (NC CGIA); Albemarle Regional Health Services (an LHD serving Bertie, Camden, Chowan, Currituck, Paquotank, and Perquimans Counties); the Craven, New Hanover, Pamlico, and Wayne County Health Departments; and the Nicholas School of the Environment and Earth Sciences (NSEES) at Duke University.

Located within the Division of Public Health, OEEB staff provided fiscal coordination, managed communication with the CDC, and coordinated a conference to present results of the project. NC CGIA is a receipt-funded public agency for spatial and geographic analysis, situated within the North Carolina Department of Environment and Natural Resources. For this project, NC CGIA conducted equipment-needs assessments for the LHDs, designed and conducted individualized training sessions and assisted at group sessions, developed data layers, and provided ongoing technical consultation.

NSEES staff managed the overall coordination of the project, with specific responsibilities including organizing and assisting with hardware and software training sessions, designing and conducting individualized training sessions, developing data layers, guiding the project development process, coordinating participation in and attendance of technical conferences, providing ongoing project consultation, and evaluating project progress and success.

Because of the link between funding and the 1999 flooding events, all of the LHD partners had to be in North Carolina’s coastal plain. The 5 LHDs were selected primarily on the basis of the enthusiasm of LHD leadership and line personnel and, to a lesser extent, known data availability. In addition, LHDs were intentionally selected to encompass a relatively wide variety of sizes and technological sophistication. The initial focus on water quality issues eventually broadened to include a wider array of environmental and public health issues (Table 1). As project participants, the LHDs agreed to participate in training and discussions with other LHDs, NC CGIA, NSEES, and OEEB, to use GIS to analyze at least 1 county or regional concern by integrating GIS into daily operations, to use project funds to procure equipment required to support GIS-based analyses and operations, to cooperate with NC CGIA and NSEES in developing GIS applications and establishing a data management structure compatible with GIS, to provide staff supervision and office space for a summer intern, to complete written assessments of benefits from participation in the project and recommendations for improvements, and to present GIS-based applications in a series of in-house workshops as well as in public venues.

Needs Assessment and Upgrading Technological Infrastructure

NSEES and NC CGIA staff initiated the project by visiting each LHD to provide both leadership and line personnel with a sense of the capabilities of GIS, to identify appropriate line personnel for project development tasks and training opportunities, and to begin conversations about suitable environmental health issue(s) around which to focus each LHD project.

Subsequently, NC CGIA conducted needs assessments for each LHD. The LHDs had a variety of health department data available for the project, although there was little consistency in data structure or quality across LHDs. Each LHD was allocated $35000 for the purchase of hardware, software, and training that was both relevant to the project and not otherwise available. The GIS software chosen for the project was ArcView 8.1, a subset of the ArcGIS software, made by ESRI (Redlands, Calif). In addition to computer hardware and software, several health departments purchased mapping-grade global positioning system (GPS) units, a technology that is tightly coupled with GIS, because GPS provides a means of collecting spatial data in the field.

Project Development and Training

Project development work and technical training were accomplished through group workshops held at NSEES. The LHDs were guided through all steps of project design and implementation. This ensured that clear goals were articulated, known technical resources were identified, an action plan was developed, and the LHDs could replicate the GIS process.

During group workshops, NSEES and NC CGIA staff met individually with each LHD, as well as with the group as a whole, to discuss and advance project development. At the first individual meeting, NSEES and NC CGIA staff provided each LHD with a CD-ROM containing extensive baseline GIS data for their counties. The CD-ROMs included base mapping layers from CGIA’s BasinPro set of GIS themes, the US Federal Emergency Management Agency (FEMA) flood plain, United States Department of Agriculture (USDA) soil type, county tax assessor, US Census demographic, and US Census street data specific to each LHD’s service areas. NSEES personnel demonstrated use of these databases within the context of the GIS training that the LHD staff had received earlier in the workshop. As LHDs articulated the problems that they wished to resolve, NSEES, NC CGIA, and LHD personnel then identified and developed or acquired additional data relevant to the individual LHD projects.

The group workshops also served as the venue for formal technical training in ArcView 8.1, Microsoft Access 2000 (Microsoft Corporation, Redmond, Wash), and GPS. Each training session was attended by staff members from each LHD and was taught by a professional trainer, with additional one-on-one help provided by NSEES and NC CGIA staff. Microsoft Access was the data management software chosen because it interfaces seamlessly with ArcView 8.1, and its ubiquity in the LHDs made the best use of available resources. GPS units serve as the state-of-the-art tool for collecting spatial field data—spatially referencing databases is critical to many parts of the mission of LHDs. NSEES staff developed several tailored exercises using data and topics of concern from the North Carolina coastal plain.

On the final day of each training session, the LHD staff worked through an exercise written by Duke staff. The exercise required the students to recall several of the GIS and Access concepts covered in the courses and to apply them to a scenario that could occur in the health department. As one person put it, “I especially liked the way you pulled it together on the last day by applying real-life situations and making us THINK!” These exercises were written up and made available to LHD staff in their home offices as a way to review and refresh their training. Each participating LHD successfully constructed a functioning GIS tool and, as their knowledge and familiarity increased, began to apply GIS in novel ways in their home offices.

Ongoing planning was carried out via a series of meetings, both at Duke University and at the health departments. All group workshops included presentations by the LHD staff on their selected projects, including a technical demonstration of the current status of their project. Project participants also attended and presented at technical GIS conferences throughout the project period, which provided important professional development and networking opportunities.

Networking

Throughout the project, opportunities were sought for the LHD staff to network with each other and with other GIS professionals. Each training session included a group meeting featuring discussion of common areas of importance, such as database design, coastal data sources, or software interfaces. The meetings offered each LHD the opportunity to get feedback from personnel from other health departments, NSEES, NC CGIA, and OEEB.

The large group meetings also offered each LHD the chance to consider how projects from other LHDs might be replicated for their own region. These exchanges encouraged LHD staff to identify and accumulate data that they valued to inform public health decisions and encouraged project participants to rely on each other for mutual support, which was maintained even after the grant period ended. The LHD staff also began to identify GIS colleagues, within their home counties, outside of the capacity-building project, including staff in mapping departments and tax assessor’s offices.

Technical Support

Many training programs essentially end when participants return to their home offices. In contrast, throughout the project period, NSEES and NC CGIA provided ongoing technical support by e-mail, phone, and through periodic trips to the LHDs. Support included assistance with database design, data acquisition and development, spatial data creation, GIS programming, GPS operation, and data entry. Additional support came from summer interns hired and trained at both NSEES and NC CGIA.

Two groups of LHD personnel, from both the environmental health and the public health sides of the LHDs, participated in this project. The second group was added when additional funding was made available mid project. The 5 LHDs sent a total of 33 individuals for all or part of the training over a 2-year period. Both groups received introductory and advanced training in ESRI’s ArcView and in Microsoft Access software. About half of the participants, primarily from the environmental health side of the LHDs, also trained in using GPS units.

All training sessions were hosted by Duke University’s NSEES. Duke and NC CGIA staff held a group meeting during each training session to demonstrate how ArcView, Access, and GPS technologies could be applied to environmental health, public health, or both, during these group sessions. Training included both line personnel and leaders (including 2 health department directors).

The overarching project goal was to get LHDs to incorporate the use of GIS technology into daily operations in ways that improved service delivery. Underlying objectives included (1) assessing and then building hardware and software capacity, (2) training staff in GIS and companion technologies, (3) working with LHD staff to identify and then develop functional GIS projects that supported the service delivery mission of the LHDs, (4) developing spatial databases with widespread applicability, and (5) providing ongoing technical consulting.

Albemarle Regional Health Services

Albemarle Regional Health Services used hand-held GPS units to map the locations of wells in Currituck County and septic tanks that fall within the Albemarle management entity. New septic systems were mapped as they were permitted, and existing systems were mapped as time allowed. Locating installed management-entity septic tanks and wells in Currituck County by field staff is an ongoing project. In the absence of a well ordinance, Albemarle was particularly interested in the locations of private wells for emergency response purposes during flooding events.

Albemarle has integrated GIS into several other applications. One such use was creating a new bus route for the Inter County Public Transportation Authority. Another involved using GIS to map and measure the distance between solid waste collecting sites and the regional landfill in consideration of new solid waste transportation contracts. Yet another application allowed Albemarle to georeference an image of a surveyor’s preliminary subdivision evaluation for a large undeveloped parcel of land.

Furthermore, Albemarle partners with 18 different counties on various epidemiology programs and has created GIS maps with layers that cover the entire service area, including major roads, population density, wetland locations, and cancer clusters. The collaborating agencies have mapped the locations of eastern equine encephalitis and West Nile virus cases, as well as wetlands and population density, to help determine areas that could potentially become problems for mosquitoes if not managed properly. The locations of home-bound patients were mapped in order to better manage the home-health nurses program. Also, in conjunction with the North Carolina Underground Storage Tank section of the Department of Environmental Health and Natural Resources, GIS was used to determine wells that needed testing for lead around an abandoned hazardous waste site managed under EPA’s Superfund Program.

Craven County Health Department

Craven County Health Department staff designed a GIS tool to manage permitted septic systems. Craven mapped the existing septic systems at the tax parcel level. Craven is particularly interested in why innovative septic systems are failing at unexpectedly high rates. Craven staff can now display the septic systems that have been repaired, denied, or failed on top of a USDA soil layer and examine the relationship. They also use the soil layer to determine the length of time that they should expect to spend in the field when inspecting a property for placement of a septic tank.

Craven also has developed a multistep process in GIS for creating septic permits, shown in Figure 1. The process includes (1) locating the parcel for which a septic permit has been submitted and noting its dimensions, (2) viewing the subsection of the USDA soil layer around the parcel to find the best areas to support a septic system, (3) using aerial photographs to consider parcel landscaping, and (4) sketching the construction authorization permits in GIS. When creating septic permits for newly proposed subdivisions, Craven staff added the additional steps of importing and georeferencing the proposed subdivision survey map, which includes areas that the surveyor has identified as best for supporting septic systems. GIS maps of soil types also are used in education sessions for county commissioners and members of communities frustrated by permit denials on the basis of poor soil conditions.

GIS is being used for vector-control applications. Maps of sentinel chicken flocks and mosquito traps have been created. A rabies control map has been made, showing the locations of reported sick foxes and raccoons, and data from Craven’s disease report card have been mapped.

Craven has subsequently mapped new cases of sexually transmitted diseases in order to make decisions on targeting limited resources for education programs and outreach for HIV testing. In setting up a public health emergency operations center as part of the bioterrorism preparedness plan, the computer designated for use in the center is equipped with GIS capability. At least 2 members of the staff assigned to the epidemiology team have been trained in its use.

New Hanover County Health Department

The New Hanover County Health Department designed a project to give the on-site waste-water group greater access to information about potential threats to groundwater quality. Although high-quality groundwater can generally be secured from a properly developed and safely located well, some identified areas produce drinking water containing known carcinogens in concentrations posing health risks. A GIS project was constructed to include pollution incident reporting from events, toxic release inventory facilities, registered underground storage tanks, and closed landfills. Gauging the proximity of a proposed well to known aquifer pollution gives the permitting authority the ability and duty, in appropriate cases, to require additional construction methodology. Enhanced construction parameters may lessen the potential for introducing pollutants into preexisting drinking-water wells.

Furthermore, New Hanover staff completed a high-resolution pilot project to map the county’s septic systems, wells, and residential structures. The pilot study was completed in a subdivision of the county and included layers of house footprints, the locations and important buffers of wells and septic tanks, and the location and footprint of the septic tank drain fields. This GIS project makes permitting on-site waste water systems and private wells on small land parcels more systematic.

New Hanover staff also integrated GIS into their mosquito control program. That project consisted of a spray zone layer overlaid with a map of special spray considerations, made up of residents who want to be notified before spraying, houses where residents have requested no spraying, and the locations of beekeepers (Figure 2). The contact information for the residents who have made special spray requests is available by clicking on their location. New Hanover also has mapped the locations of larvacide and light-trap sites. All of these layers have been overlaid on high-resolution aerial photographs of the county. The photos provide additional functionality by showing the mosquito control team color images of the houses to avoid while spraying and aiding the response to citizen complaints by revealing low-lying areas that may be mosquito breeding grounds. When the spread of West Nile virus escalated across the nation, New Hanover staff were able to demonstrate to the media and residents a structured plan to control mosquito populations in the community. This level of science and technology brought reassurance that adequate and validated control measures were being implemented to optimize safety and reduce the risk of disease.

Pamlico County Health Department

Pamlico County Health Department staff developed a project to map the buffers along surface waters that must be observed when permitting and installing septic systems. The buffers are based on a combination of the use designations of the different surface water bodies and the buffer radius required by different septic systems. The buffers are displayed on top of the tax parcel layer, allowing the environmental health staff to draw property-specific conclusions about septic system placement. The environmental health staff use this information to plan and implement their field visits.

Pamlico also created an Access database to store septic system information, transferring historical data into that system, starting with the systems that require the most management. The data were then geocoded. The Access database allows Pamlico staff to migrate the management of their installed septic systems to GIS from what was previously a hard file system.

Pamlico staff members are using GIS for other applications, such as mapping clinical data, including cases of Vibrio vulnificus, La Crosse encephalitis, and teen pregnancy. They also mapped areas flooded by Hurricane Isabel in 2003. Within 24 hours, maps were available to identify flood depths, number of homes affected, and number of people displaced. This information enabled the county to receive faster reimbursement from FEMA and to educate politicians about the extent of the disaster with a single picture.

Wayne County Health Department

The Wayne County Health Department undertook a project to manage its permitted septic systems in GIS, requiring the migration of more than 13000 records from an antiquated system, for which it can no longer receive technical support, to a new database. This is part of a long-term plan to integrate GIS with Wayne County’s new central permitting system. This system ties together the Planning, Inspections, and Environmental Health Departments, offering county property owners a 1-stop venue in developing their property or building a new structure. The system came into use in early 2003; a planned update of the system will include the geocoding of new septic systems. Wayne County environmental health staff use the resulting layer of permitted septic tanks to inform new property owners about their septic systems.

In an effort to increase GIS use and familiarity in the environmental health group, Wayne County staff installed ArcReader on all computers, a free package from ESRI that allows users to view maps created in ArcGIS. Wayne County is also undertaking an effort to make GIS data available to the public via its Web site, including inspected facilities (i.e., restaurants and other kitchens), restaurant grades, Superfund sites, septic tanks, hazardous waste sites, toxic releases, air emissions, and septic tank disposal sites.

At the end of the project period, NSEES organized separate focus groups with LHD staff and the LHD directors and received formal, anonymous written evaluations of the project. Both groups stated clearly that GIS technology had been incorporated into daily operations. Staff and directors alike viewed improved service delivery, as well as time and cost efficiency, as significant outcomes. The focus groups identified several keys to success:

Providing methods training that was rooted in the specific problems that LHD staff dealt with on a daily basis.

This approach ensured, from the beginning, that GIS would be a tool to help the LHD staff members do their jobs more efficiently, rather than being a source of more work. It also improved retention of classroom learning, because recently acquired skills were immediately useful and directly applicable in LHD offices.

Requiring LHD staff to identify and develop a project incorporating a GIS application with an associated timeline for development.

This approach encouraged the LHD staff to begin considering how they could apply GIS and then provided a project on which they could immediately begin. This was a key to solidifying the LHD participants’ understanding of GIS concepts. It also committed participants to a time-line for changing standard operating procedures.

Providing ongoing technical support as staff returned to their home offices after training meetings.

This measure offered the LHD staff an opportunity to work one-on-one with a GIS technician in a familiar computing environment based on each LHD’s specific database and equipment resources. Moreover, as NSEES and NC CGIA worked with LHD staff, it became clear which GIS concepts were well retained and applied by LHD staff. These concepts need to be reinforced with additional technical support and training, and additional topics should be taught in training sessions.

Providing subgrants to allow the LHDs to get past the initial hardware and software resource constraints.

The needs assessments conducted by NC CGIA determined that all of the LHDs needed additional hardware and software capability to run GIS. The cost of this equipment would have been an impediment to the participating LHDs without the subgrants. Having surmounted the initial infrastructure obstacles, improvements in time and cost efficiency allowed the LHDs to commit to maintaining appropriate technological capacity.

Developing a network of relationships among LHDs and other professional GIS users.

LHD staff participants learned from each other how best to apply the available data to public health issues and created a network of GIS users with common concerns. Moreover, the LHD employees created working relationships with GIS professionals in their county tax offices and mapping departments that will continue to connect them with useful data and resources in their regions.

Having senior leadership at the LHDs who were supportive of the professional development activities being undertaken by their staff.

The LHDs were required to contribute significant resources to the project, primarily in the form of personnel time. LHDs also had to adopt new data management practices and integrate new technology into their operations. The belief of senior LHD leadership that this investment in GIS would pay off in the improved delivery of LHD services made real and significant change possible.

This capacity-building project greatly enhanced the ability of LHDs to fulfill public health service delivery missions. Although this project focused on building GIS capacity in particular, it can serve as a general model for transferring critical technologies to LHDs, regardless of LHD size, technological sophistication, or distance from state and federal resources. As such, it provides a model for how state, university, and local partners can collaborate to augment the public health infrastructure, both in North Carolina and nationally.

Table
TABLE 1— Characteristics of Regions Supported by Participating Local Health Departments (LHDs): 2000
TABLE 1— Characteristics of Regions Supported by Participating Local Health Departments (LHDs): 2000
 Albemarle Regional Health ServicesCraven County Health Dept.New Hanover County Health Dept.Pamlico County Health Dept.Wayne County Health Dept.
Population11105 63991 436160 30712 934113 329
Population growth 1990–2000,%11,12111233148
Land area, square miles111842.26708.43198.93336.94552.57
LHD employees, n35114618619144
Technological sophisticationMediumMediumMediumLowLow

This project was supported by the US Centers for Disease Control and Prevention through the North Carolina Department of Health and Human Services, Division of Public Health, Occupational and Environmental Epidemiology Branch.

We recognize the important work of J. Tysmans, T. Morris, S. Cline, S. Edwards, C. Kiley, and N. Guthrie on this project. Special thanks to the following local health department staff for the time and effort they contributed: M. Burkett, R. Evans, G. Hodges, D. Jenkins, G. Midgett, M. Murosky, W. Nixon, R. Silverthorne, C. Timpy, and K. Whitley. Additional thanks to summer interns A. Bauer, J. Chen, G. Dail, S. Edwards, K. Ferrara, F. Hanson, B. McGinnis, B. Parker, U. Patel, and K. Stansell. We also recognize the many staff members from Albemarle Regional Health Services, and the Craven, New Hanover, Pamlico, and Wayne County health departments who participated in or supported this project. We are grateful for the thoughtful guidance provided by 2 anonymous reviewers.

Human Participant Protection No protocol approval was needed for this study.

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Marie Lynn Miranda, PhD, Jennifer M. Silva, MS, M. Alicia Overstreet Galeano, BS, Jeffrey P. Brown, MCRP, Douglas S. Campbell, MD, MPH, Evelyn Coley, RN, MSA, Christopher S. Cowan, BS, Dianne Harvell, REHS, RS, Jenny Lassiter, RN, MSN, Jerry L. Parks, MPH, and Wanda Sandelé, MBA Marie Lynn Miranda and M. Alicia Overstreet Galeano are with the Nicholas School of the Environment and Earth Sciences, Duke University, Durham, NC. Jeffrey P. Brown is with the North Carolina Center for Geographic Information and Analysis, Raleigh. Douglas S. Campbell is with the Occupational and Environmental Epidemiology Branch of the Division of Public Health, North Carolina Department of Health and Human Services, Raleigh. Evelyn Coley and Christopher S. Cowan are with the Wayne County Health Department, Goldsboro, NC. Dianne Harvell is with the New Hanover County Health Department, Wilmington, NC. Jenny Lassiter is with the Pamlico County Health Department, Bayboro, NC. Jerry L. Parks is with Albemarle Regional Health Services, Elizabeth City. NC. Wanda Sandelé is with the Craven County Health Department, New Bern, NC. At the time of the project, Jennifer M. Silva was with the Nicholas School of the Environment and Earth Sciences, Duke University, Durham. “Building Geographic Information System Capacity in Local Health Departments: Lessons From a North Carolina Project”, American Journal of Public Health 95, no. 12 (December 1, 2005): pp. 2180-2185.

https://doi.org/10.2105/AJPH.2004.048785

PMID: 16257950