**Abstract**

This paper highlights some of the fundamentally geographical features of primary health care and introduces some motivations and questions for focused research. Although not mutually exclusive, the research agenda distinguishes quantitative inquiries on distributional features, and qualitative inquiries focused on place. Each involves its own theoretical assumptions, concepts and empirical foci. To assist scholars, we provide some leads into the broader geographical literature on health care.

**Key Words** geography, place, primary health care, space

# Geographies of Primary Health Care

GAVIN J. ANDREWS &
VALORIE A. CROOKS

**Introduction**

It has taken less than thirty years for primary health care (PHC) to progress from a conceptual discussion between policy makers and international agencies[1] to being a core component of health service delivery internationally. Although it has been interpreted broadly, as Crooks and Andrews illustrate, PHC is widely recognized to possess a number of core features.[2] First and foremost, PHC is a ‘system’ that is community-based and provides a first point of contact with health care for the public. The system incorporates a range of service types (including general practice, health promotion, chronic disease management, emergency

care, holistic medicine), a diverse mixture of professions, occupations and work types (including physicians, nurses, occupational therapists, pharmacists), and possesses certain qualities (such as being responsive, comprehensive, internally continuous between services, and linked ‘externally’ to other sectors such as social care, housing and education).[2] Ultimately, after three decades of development and refinement, many commentators now regard PHC to be a health sector unto itself, which is distinct from secondary health care (SHC).*

Accompanying the emergence of PHC, recent decades have witnessed the publication of a wide-range of dedicated PHC research across the health and social sciences. The considerable volume and scope of the empirical output to date makes describing and categorizing it in a limited space challenging. Nevertheless, it is fair to suggest that substantial attention has been paid in this literature to a wide-range of subjects including PHC funding, financing, policy, law and ethics, interprofessional collaboration, technology and other innovation, service forms and integration,
community and family participation, continuity of care and
care pathways.[2] Moreover, reflecting the maturing of this
research tradition, a growing volume of literature focuses
on the nature of research itself including methodological
innovation, theoretical development and empirical cover-
age. Providing some ideas on future research directions, this
paper argues for the extension of a geographical perspective.
Examining the conceptual basis for such inquiry, the first part
is focused the general arguments for studying all health care
geographically. The second part focuses on those features of
PHC which are fundamentally geographical in their orienta-
tion. Offering further insights, the third part introduces some
key themes and scales of potential research. To assist future
research, a final discussion provides some broader leads into
the geographical study of health care.

Why study health care geographically?

Why study health care spatially; PHC, SHC or otherwise?
Andrews and Evans argue that, beyond important, well-
rehearsed geographical arguments (such as distance and
location ‘matter’ in the planning of health care), the spatial
character of the emerging health care is an additional con-
temporary factor.[3]

They posit that, first, recent years have witnessed the increas-
ing spatial diffusion of health care provision. At one level,
smaller and more specialized settings – such as clinics -have
become commonplace.[3] At another level, health care is
increasingly provided in public and private places completely
new to the sector. Indeed, services now reach straight into
the places where people live, learn, work, shop, and spend
their leisure time.[3-4] Second, although communities were
once conveyed in policy and practice circles somewhat as
featureless spaces and/or basic population counts, they are
now recognized as diverse groups of people possessing both

health needs and the ability to partner in care.[3,5] Third,
recent structural reform of traditional institutional environ-
ments has changed both their function and character. Most
hospitals used to be bare and sterile places but many are now
being reinvented under a corporate ethos as commercial,
inviting and entertaining spaces.[3,6] Such change raises
questions concerning the demands on professionals working
on them, and the experiences of all others entering them.

Fourth, the new health care is very much dependent on
technology. Emerging forms include assistive devises, tele-
medicine, remote monitoring systems, digital health records
and information, and robotic surgery.[4] Technologies have
altered the form, structure and range of places used for
care, and the communication methods used in and between
them.[3-4,7] Technology also changes social relationships,
making professionals more physically and narratively distant
from each other and their patients.[3,8] At a micro-scale, this
can occur at the bedside, or at a macro scale in the context
of increasing distance work.

Fifth, connecting variously to all of the above changes is
the emergence of global health as a concept and specific
set of challenges. It is increasingly recognized that social,
disease, and service concerns cross the geopolitical bound-
aries of nation states, moral responsibility needs to be shared
between nations and systems need to be developed that tran-
scend them. Moreover, an emphasis is laid in global health
on the interconnectivity of health care at various scales rang-
ing from single facilities and neighborhoods to continents
and the world. Geography runs throughout most discussions
of global health.

The fundamentally geographical features of PHC

Despite the above observations, one notable criticism that
has been made of PHC research is that it is often approached

<table><caption>Table 1: Space-centered inquiry on PHC</caption>
  <caption>Questions</caption>
  <tbody>
    <tr>
      <td>What are the key distributional features of different PHC facilities and types of services at different scales (e.g. local, regional, national)?</td>
    </tr>
    <tr>
      <td>What are the relationships between distributions of PHC facilities and distributions of populations?</td>
    </tr>
    <tr>
      <td>What social, political and economic forces determine the above distributions and relationships?</td>
    </tr>
    <tr>
      <td>What are the relationships between distance to different kinds of PHC services, their use and population health across space?</td>
    </tr>
    <tr>
      <td>What cultural, social, economic and political factors combine to make distance more or less of a barrier to PHC provision and use?</td>
    </tr>
    <tr>
      <td>What are the optimal distributions of PHC resources and how might these be achieved?</td>
    </tr>
  </tbody>
</table>
as spatially.[2] In other words, lacking a strong geographical tradition, rarely does it consider the role of space, place, environment - and other geographical concepts - in shaping the production and consumption of PHC. This is despite the fact that PHC is based on a set of core principles that imply highly spatial qualities and relationships.[2,9] Below we briefly describe four of these: 'universal accessibility', 'embeddedness in community', 'sensitivity to local determinants of health' and an 'emphasis on settings'.

(i) As suggested above, at the heart of PHC is the principle for it to be first contact care which is 'universally accessible'.[1] Throughout the 1980s and 1990s this principle was translated into system priorities across many countries. In a strict definitional sense, universal accessibility means that every person has access. However beyond this, making accessibility morally 'fair' involves making sure that every person has equal access (what is known as 'equality of opportunity'). Even if it is never fully achieved, working towards equal access to PHC involves a priority that no particular social, economic, and demographic groups in society are overly advantaged or disadvantaged. At another level it involves a priority that where consumers live in relation to services poses neither as an extreme advantage or disadvantage. A spatial concern thus follows that PHC should be distributed across space in a way that makes such care accessible to the most people possible, the ultimate aim - even if practically unachievable - being 'distributive justice' whereby need is met equally across geographical areas.[10]

(ii) The emphasis on the 'community embeddedness' of PHC distinguishes it from other health care sectors and service delivery models.[2,9] Community, however, is a fundamentally spatial concept. At one level, communities are constructed from physical phenomena - such as roads, buildings, city quarters and urban neighbourhoods - where clients and workers live often in close spatial proximity to each other

(thus becoming familiar with the same local social, economic, political and cultural contexts). As suggested above, at a social level community is now being re-imagined in PHC practice as the interconnected social environment of care, possessing a differentiated mosaic of locally distinct vulnerabilities, needs and capacities.[3,5] It follows that PHC must recognize community character and need while also being part of the community.

(iii) Related to community is the requirement for PHC to recognize and be sensitive to 'local determinants of health'. Research tells us that health status in populations is affected by residential location. Localized determinants of health include social composition (including ethnicity, socio-economic status), social contexts (such as housing, shops, services) and social cohesion and capital (for example, through family, friendships, clubs, religious organizations and other groups). In addition to these social variables are local environmental influences on health such as air and water quality, the presence of chemical contaminants, and even the local impact of global climate change. Geography is thus important in terms of the local health need to be serviced by PHC services, and the character of those services.

(iv) At the micro-scale are the 'clinical settings' within which PHC is provided and consumed (buildings, rooms and even mobile vehicles). These settings tend to be much smaller in size and more frequent in number than settings for SHC. However, in terms of their character, they are typically less institutional, more intimate and, as suggested above, designed to be more integrated into local community life. As we shall see in the following section, this integration - and how it is constructed and experienced - connects closely to emerging attention in contemporary geographical inquiry to 'place'.[7]

<table><caption>Table 2: Place-centered geographical inquiry on PHC</caption><thead><tr><th>Questions. How are places/settings for PHC:</th></tr></thead><tbody><tr><td>Located in the social and cultural life of local communities and neighbourhoods?</td></tr><tr><td>Envisaged and designed by different health care systems, organizations and individuals?</td></tr><tr><td>Negotiated, used and/or manipulated on a daily basis by different user and professional groups?</td></tr><tr><td>Felt, experienced and remembered (as for example, therapeutic/anti-therapeutic, safe/unsafe, medicalized/holistic, welcoming/unwelcoming)?</td></tr><tr><td>Influential in the nature and delivery of clinician's practice, including clinical decisions and disease prevention strategies?</td></tr><tr><td>Represented (such as in the media, by providers, users, professionals and others)?</td></tr></tbody></table>
# The research agenda

## (i) Space-centered inquiry on PHC

Since the late 1950s the positivistic tradition of 'spatial science' in human geography has viewed space as a blank surface; a template on which human activity occurs and thus on which its geometry can be mathematically measured and mapped. Motivated by a belief that space is a fundamental factor in human behavior, and that there is a logical spatial order to the world, 'spatial science' thus concentrates analysis on locations and the distances, directions and times between them. Moving beyond description, however, spatial science also involves constructing spatial models with predictive power and applications to planning.[10]

Although often being far more theoretically reflective than the above descriptions depict, a few geographers have drawn on these underlying approaches when analyzing PHC. Considering, for example the spatial expression and impacts of PHC policies, and other spatial features of the sector and its use.[11-15] Far more remains to be done, however, to develop a more comprehensive coverage and understanding of spatial features of supply, demand and consumption. In terms of scale, this research might focus on policy and practice internationally, between countries, within countries, between regions, within regions and within cities, towns and neighbourhoods (table one). It would be particularly useful for informing planning, resourcing, staffing and formulating policy for PHC at various levels.

Research methods used to investigate these kinds of issues are typically quantitative, to highlight broad trends and support

potentially generalisable conclusions. They might include datasets on health services, user and local populations, and oftentimes dedicated surveys. Analysis and presentation might be assisted by computer technologies such as in Geographical Information Science (GIS).

## (ii) Place-centered geographical inquiry on PHC

The humanistic tradition in the discipline of geography has a conceptual emphasis on place. Being recognized as far more than points or containers of human activities, places are thought to be created, experienced, represented and recalled socially and culturally.[16-17] In terms of construction, individual and collective attitudes towards places might be attained through physical presence/experience or through their representation (e.g. in media or through how others talk to us about them). The result of these processes is that places have many qualities for people (who when in-situ experience a 'sense of place'), and evoke a range of emotions, from the personally very positive (e.g. happiness, therapeutic, nosalgic) to the personally very negative (e.g. fear, sadness). Moreover, places might provide a basis for social unity or struggle.[17] In terms of the social control, certain groups define the pro-social norms of places whilst other groups 'transgress' these norms by holding alternative ideas about, and having alternative uses of, them.[17] Equally, 'placelessness' is an important emerging concept. Referring to a lack of traditional attachments and identities to place, it helps explain human relations with and within the growing number of ubiquitous places in (post)modern life, through which people often pass in a transient fashion.[17]

<caption>Table 3: Key areas of inquiry on health care in medical and health geography</caption>

* Broad sub-disciplinary reviews.[3,31-38]
* Focused commentaries on the direction of specific empirical subfields/specialisms, or specific theoretical directions.[39-46]
* Sub-disciplinary controversies and debates, such as on place and qualitative inquiry.[47-52]
* Relationships between distributions of services, patterns of use and population health.[14, 53-57]
* Structural features that shape distributions of services on the ground, such as policy and administration initiatives.[12,58-61]
* The geographical dimensions to, or consequences of, decision making: specific financial, planning or clinical issues, downstream of policy change.[11,62]
* The geographical dimensions to, or consequences of, decision making: workers' preferences with respect to where they live and work, and the implications for towns, cities and regions.[63-67]
* Critical studies of economic, ideological and cultural changes that shape health care nationally, regionally and in settings.[68-69]
* The representational politics connected with the corporization of health care, including conflicts over institutional provision, purpose and identity.[70-74]
* The spatial features of interpersonal communication and everyday working life.[75-78]
With regard to theoretical underpinnings, as Crang has suggested, in the current post-modern era of geography, relationships with places are explained by three philosophical debates. Collectively these debates imply that places are a complex starting point for human knowledge, attitudes and actions.[18] First, debates on intentionality. Husserl argues that objects' intended uses are critical to their meaning (they are 'about' what we do with them). Extending such a perspective, it may also be argued that places' uses are critical to their meaning (they are 'about' what we do in them.[16-18] Second, debates on essences. 'Essences' are the characteristics that influence what we feel emotionally about objects. The argument follows that places also have essences that, for example, we might define or explore.[16-18] Third, debates on 'imbedded' knowledge. The idea of imbedded knowledge builds on Heidegger's view that humans can only relate through their physical situation, through their 'being-in-the-world'. As Crang describes, consciousness is always consciousness of 'something else' in the world. In relational terms 'something else' can be human-made objects, other life on earth (including people), and the places they are part of. Thus all knowledge is 'em-placed'.[18]

Notably, when embracing these ideas on place, space can be defined differently from the spatial science approach outlined above. The humanistic idea of 'social space' hence treats space not as a blank surface, void or distance, but as a complex human reality, existing through social processes.[17] Hence, in qualitative research, questions on space become centered around how the spaces (within places) are navigated, negotiated and 'owned' by different groups.[17]

The understandings of place introduced above can be applied to the study of PHC. Specifically, we need to understand how places for PHC are experienced and navigated through time-space routines and rituals, how they hold meanings, attach-

ments and identities, and how they affect clinical practice. For example, the dynamics between different professional groups could be investigated. Like any workplace, settings for PHC are often constituted of coexisting occupational/professional categories that are engaged in coalitions, rivalries and negotiations over boundary issues.[3,7] These relationships potentially create local PHC cultures of production and that intimately affect its consumption. A small number of studies have started to articulate these kinds of issues.[19-20] Beyond these initial inquires however, more geographical research needs to be conducted (table two). Non-clinical places also require attention as part of moving towards a greater understandings of how communities, neighbourhoods and homes play a role in PHC.

Research methods used here would typically be qualitative, in order to articulate the rich and complex nature of place and place-relations. They might involve, for example, ethnography, observation, interviews and focus groups, oftentimes combined to address specific issues and questions.

## Research leads: medical and health geography

For the relatively uninitiated, a range of books provide broad overviews of, and introductions to, the sub-discipline of medical and health geography,[21-22] or overviews of and introductions to key sub-disciplinary concepts or empirical subfields.[23-30] In terms of journals, Health and Place, and Social Science and Medicine are popular and prestigious interdisciplinary venues that publish a great deal of research in medical and health geography (the latter having a dedicated geography editor). Otherwise, a number of journals which span the 'parent discipline' of human geography also publish health-orientated research. These include general titles, such as Progress in Human Geography, GeoJournal, Area, The Professional Geographer, Social and Cultural

<caption>Table 4: Key areas of inquiry in geographical nursing research</caption>

* Broad review and theory articles.[81-85]
* The varied attachments and identities that nurses, doctors and patients develop with places, and how places come to symbolize different things to these groups.[86-89]
* Health care places as essential to the character and experience of particular nursing and medical specialties.[90-95]
* Place as a central feature in focused clinical initiatives [96, 97], and limits to their generalizability and transferability.[98]
* The impact of places on nurses' communications and relationships with other nurses.[99-101]
* The impact of places on nurses' communications and relationships with patients, and related ethical issues.[8, 102-107]
* The broader extra-institutional connections between nursing, local communities and local physical environments.[108-113]
* The globalization of nursing, nursing labormarkets, and global health.[114-119]
Geography, Geography Compass, and more theoretically and/or conceptually and/or empirically focused titles including Gender Place and Culture, Emotion, Space and Society, Population Space and Place, and Cultural Geographies. Many other journals exist in both the above categories. Entry points into the geographical study of health and health care are highlighted in table three.[also see 2-3]

## Research leads: geographical nursing research

Outside medical and health geography, nursing research has been very active in geographical explanations of health care. The impact of urban and clinical environments on health played a big part in Nightingale's original definitions and interpretations of nursing in the nineteenth century. Since the 1950s, alongside "person" and "health", the concept of "nursing environment" - thought of as the combined economic, social, and cultural contexts to professional activity- has acted as one of the central concepts underpinning models of nursing research and practice.[79,80] During the past decade, dedicated geographical studies by nurse researchers have provided some important insights into how many activities involved in practice, relate to space and place. Whilst the majority of these studies are 'explicitly geographical' (meaning that the authors in some way identify them as geography), a minority are 'implicitly geographical' (meaning that they are geographical in orientation but the authors have not identified specifically with the discipline). Unlike, medical and health geography, it is not possible to identify specific books and journals where this work is published, as it tends to be spread across a variety of venues. Themes and entry points are provided in table four [also see 3,81]. Overall, the emerging spatial or geographical 'turn' in nursing research has articulated many issues related to applied clinical practice that medical and health geography to date has not.[3,10,81] We therefore recommend it, alongside geography, as a reasonable place to start.

## Conclusion

A rapidly changing and increasingly complex health care requires inter-disciplinary research both to understand it, and provide evidence to support its development [3]. New disciplinary perspectives are encouraged particularly if they are well matched. Because many features of PHC are spatial, it follows that PHC research should have a strong geographical tradition.[2] If this is to occur, many questions remain with regard to theory, methods and empirical directions. Hopefully however, this paper might help nurse researchers and other scholars make progress along these lines.

## *Note

Secondary Health Care (SHC): It is worth noting that the 'secondary' descriptor originally arose in medical and policy terminology as an implication or 'bi-product' of the emerging emphasis on PHC, meaning simply every service that follows PHC - to which patients are referred by PHC providers (for example cardiology, dermatology, radiology and other focused hospital-based specialisms). In recent years however SHC has become a focus of dedicated attention and development itself. More sophisticated interpretations now lay greater emphasis on the collective nature of SHC, commonalities and cohesions across various forms of SHC, its needs, and place in whole health care systems. The emergence of PHC might well have assisted a split recognition of health care systems. Despite these origins however, PHC and SHC are very much connected and certainly not of 'primary' and 'secondary' importance.

## References

1. World Health Organization. The Alma-Ata Declaration: Geneva, 1978.

2. Crooks V, Andrews GJ. Thinking geographically about primary health care. In Crooks V, Andrews GJ. (eds) Primary Health Care: people, Practice, Place. Aldershot: Ashgate; 2009.

3. Andrews GJ, Evans J. Understanding the reproduction of health care: towards geographies in health care work. Progress in Human Geography 2008; 32(6):759-780.

4. HCTP – Health Care Technology and Place www.HCTP.utoronto.ca. Accessed January 10th 2009.

5. Prince R, Kearns RA, Craig D. Govermentality, discourse and space in the New Zealand health care system. Health and Place 2006; 12(3):253-266.

6. Kearns RA, Barnett JR. Happy meals in the Starship Enterprise: interpreting a moral geography of food and health care consumption. Health and Place 2000; 6(2):81-93

7. Poland B, Lehoux P, Holmes D, Andrews GJ. How place matters: unpacking technology and power in health and social care Health and Social Care in the Community 2005; 13(2):171-180.

8. Malone R. Distal nursing. Social Science and Medicine 2003; 56(11):2317-2326.

9. Crooks V, Andrews GJ. Community, equity, access: core geographic concepts in primary health care. Primary Health Care: Research and Development, 2009; 10(3):270-273.
10. Andrews GJ, Crooks V. Geographical perspectives on health care: ideas, disciplines, progress in Crooks V and Andrews G J (eds) Primary Health Care: people, Practice, Place. Aldershot: Ashgate; 2009.

11. Moon G, Mohan J, Twigg L, McGrath K, Pollock A. Catching waves: the historical geography of the general practice fundholding initiative in England and Wales, Social Science and Medicine 2002; 55(12):2201-2213.

12. Moon G, North N. Policy and place: general practice in the UK. Basingstoke: MacMillan, 2002.

13. Norris P. The state and the market: the impact of pharmacy licensing on the geographical distribution of pharmacies. Health & Place 2000; 3(4):259-269.

14. Pooley C, Briggs J, Gatrell T, Mansfield T, Cummings D, Deft J. Contacting your GP when the surgery is closed: issues of location and access. Health and Place 2003; 9(1):23-32.

15. Ricketts T, Randolph R, Howard A, Pathman D, Carey T. Hospitalization rates as indicators of access to primary care. Health and Place 2001; 7(1):27-38.

16. Andrews GJ. Locating a geography of nursing: space, place and the progress of geographical thought. Nursing Philosophy 2003; 4(3):231-248.

17. Andrews GJ. Place and space in qualitative research. In The SAGE Encyclopedia of Qualitative Research Methods. London: SAGE, 2008.

18. Crang M. Cultural geography. London: Routledge, 1998.

19. Rapport F, Doel M, Greaves D, Elwyn G. From manila to monitor: biographies of general practitioner workspaces Health 2006; 10(2):233-251.

20. Rapport F, Doel M, Greaves D, Elwyn G. Snapshots and snippets: general practitioners reflections on professional space. Health and Place 2007; 13(2):532-544.

21. Meade M, Earickson RJ. Medical Geography (second edition). New York: Guilford, 2000.

22. Gatrell AC, Elliott S. Geographies of health: an introduction. Oxford: Blackwell, 2009

23. Joseph A, Phillips. DR. Accessibility and utilization: geographical perspectives on health care delivery. London: Harper and Row, 1984.

24. Williams A. Therapeutic Landscapes. Aldershot: Ashgate, 2007.

25. Gatrell AC. GIS and health. London: Taylor and Francis, 1998.

26. Kearns RA, Gesler W. Putting health into place: landscape, identity and well-being. Syracuse: University Press, 1998.

27. Shaw M, Mitchell R, Dorling D. Health, place and society. London: Prentice Hall, 2002.

28. Gesler W, Kearns R. Culture/place/health London: Routledge, 2002.

29. Curtis S. Health and Inequality: geographical perspectives. London: SAGE, 2004.

30. Andrews GJ, Phillips DR. Ageing and place: perspectives, policy, practice. London: Routledge, 2005.

31. Rosenberg M. Medical or health geography? Populations, people and places. International. Journal of Population Geography 1998; 4:211-226.

32. Kearns RA. Medical geography: making space for difference. Progress in Human Geography. 1995; 19:251-259.

33. Kearns RA. AIDS and medical geography: embracing the other? Progress in Human Geography 1996; 20:123-131.

34. Kearns RA. Narrative and metaphor in health geographies. Progress in Human Geography 1997; 21:269-277.

35. Kearns RA, Moon G. From medical to health geography: novelty, place and theory after a decade of change. Progress in Human Geography 2002; 26:605-625.

36. Parr H. Medical geography: diagnosing the body in medical and health geography, 1999-2000. Progress in Human Geography 2002; 26(2):240-251.

37. Parr H. Medical geography: care and caring. Progress in Human Geography 2003; 27(2):212-221.

38. Parr H. Medical geography: critical health geography? Progress in Human Geography 2004; 28(2):246-257.

39. Eyles J. Environmental health research: setting an agenda by spinning our wheels or climbing the mountain? Health and Place 1997; 3(1):1-13.

40. Brown T, Duncan C. London's burning: recovering other geographies of health. Health and Place 2000; 6(4):363-375.

41. Brown T, Duncan C. Placing geographies of public health. Area 2002; 33(4):361-396.

42. Hall E. 'Blood, brains and bones': taking the body seriously in the geography of health and impairment. Area 2000; 31:21-30.
43.Philo C. Across the water: reviewing geographical studies of asylums and other mental health facilities. Health and Place 1997; 3(2):73-89.

44.Andrews, GJ, Cutchin M, McCracken K, Phillips DR, Wiles J. Geographical gerontology: the constitution of a discipline. Social Science and Medicine 2007; 65(1):151-168.

45.Andrews GJ. Ageing and Health in The International Encyclopedia of Human Geography. Oxford: Elsevier, 2009.

46.Andrews GJ, Milligan C, Phillips DR, Skinner M. Geographical gerontology: mapping a disciplinary intersection. Geography Compass 2009; 1-19.

47.Kearns RA. Place and health: towards a reformed medical geography. The Professional Geographer 1993; 46:67-72.

48.Kearns RA. Putting health and health care into place: an invitation accepted and declined. The Professional Geographer 1994; 46:111-115.

49.Kearns RA. To reform is not to discard: a reply to Paul. The Professional Geographer 1994; 46:505-507.

50.Paul BK. Commentary on Kearns' 'Place and health: toward a reformed medical geography'. The Professional Geographer 1994; 46:504-505.

51.Mayer JD, Meade MS. A reformed medical geography reconsidered. The Professional Geographer 1994; 46:103-106.

52.Dorn M, Laws G. Social theory, body politics and medical geography: extending Kearns' invitation. The Professional Geographer 1994; 46:106-110.

53.Lovett A, Haynes R, Sunnenberg G, Gale S. Car travel time and accessibility by bus to general practitioner services: a study using patient registers and GIS. Social Science and Medicine 2002; 55(1):97-111.

54.Mohan J. Explaining geographies of health care: A critique Health & Place 1998; 4(2):113-124.

55.Eyles J. How significant are the spatial configurations of health care systems? Social Science and Medicine 1990; 31(1):157-164.

56.Curtis S, Copeland A, Fagg J, Congdon P, Almog M, Fitzpatrick J. The ecological relationship between deprivation, social isolation and rates of hospital admission for acute psychiatric care: a comparison of London and New York City. Health and Place 2006; 12(1):19-37.

57.Foley R, Platzer H. Place and provision: mapping mental health advocacy services in London. Social Science and

Medicine 2007; 64:617-632.

58.Joseph A, Chalmers A. Restructuring long-term care and the geography of ageing: a view from rural New Zealand. Social Science and Medicine 1996; 42(6):887-896.

59.Moon G, Brown T. Governmentality and the spatialized discourse of policy: the consolidation of the Post-1989 NHS reforms. Transactions Institute British Geographers 2000; 25(1):65-76.

60.Cloutier-Fisher D, Skinner M. Levelling the playing field? Exploring the implications of managed competition for voluntary sector providers of long-term care in small town Ontario. Health and Place 2006; 12(1):97-109.

61.Williams A. Restructuring home care in the 1990s: geographical differentiation in Ontario, Canada Health and Place 2006; 12(2):222-238.

62.Iredale R, Jones L, Gray J, Deaville J. 'The edge effect': an explanatory study of some factors affecting referrals to cancer general services in rural Wales. Health and Place 2005; 11(3):197-204.

63.Cutchin M. Physician retention in rural communities: the perspectives of experiential place integration Health and Place 1997; 3(1):25-41.

64.Baer LD. A proposed framework for analyzing the potential replacement of international medical graduates. Health and Place 2003; 9(4):291-304.

65.Laditka JN. Physician supply, physician diversity and outcomes of primary health care for older persons in the United States. Health and Place 2004; 10(3):231-244.

66.Wei L. Using a GIS-floating catchment method to assess areas with shortage of physicians. Health and Place 2004; 10(1):1-11.

67.Guagliardo MF, Ronzio CR, Cheung I, Chacko E, Joseph JG, Physician accessibility: an urban case study of pediatric providers. Health and Place 2004; 10(3):273-283.

68.Kearns RA, Joseph AE. Restructuring health and rural communities in New Zealand. Progress in Human Geography, 1997; 21(1):18-32.

69.Prince R, Kearns RA, Craig D. Governmentality, discourse and space in the New Zealand health care system. Health and Place 2006; 12(3):253-266.

70.Kearns RA, Barnett JR. Consumerist ideology and the symbolic landscapes of private medicine. Health and Place 1997; 3(3):171-180.
71. Kearns RA, Barnett JR, Newman D. Placing private health care: reading Ascot hospital in the landscape of contemporary Auckland. Social Science and Medicine 2003; 56(11):2303-2315.

72. Kearns RA, Barnett JR. Auckland's Starship Enterprise: placing metaphor in a childrens' hospital. In Williams A. eds Therapeutic landscapes: the dynamic between place and wellness. Lanhan: University Press of America, 1999.

73. Kearns RA, Barnett JR. To boldly go? Place, metaphor and marketing of Auckland's Starship hospital, Environment and Planning D: Society and Space 1999; 17:201-226.

74. Kearns RA, Barnett JR. Happy meals in the Starship Enterprise: interpreting a moral geography of food and health care consumption. Health and Place 2000; 6(2):81-93.

75. Hanlon N, Sense of place, organizational context and the strategic management of publicly funded hospitals Health Policy 2001; 58:151-173.

76. Brown S, Middleton D. The baby as virtual object: agency and difference in a neonatal intensive care unit. Environment and Planning D: Society and Space 2005; 23:695-715.

77. Curtis S, Gesler W, Fabian K, Francis S, Priebe S. Therapeutic landscapes in hospital design: a qualitative assessment by staff and service users of the design of a new mental health inpatient unit. Environment and Planning C: Government and Policy 2007; 25:591-610.

78. Kearns RA. Creating a place for population health: interpreting the spaces of a new School in Auckland, New Zealand. Social Science and Medicine 2007; 65(1):125-137.

79. Andrews GJ, Moon G. Space, place and the evidence base, part two: rereading nursing environment through geographical research Worldviews on Evidence-Based Nursing 2005; 2(3):142-156.

80. Thorne S, Canam C, Dahinten S, Hall W, Henderson A, Kirkham S. Nursing's metaparadigm concepts: disimpacting the debates. Journal of Advanced Nursing 1998; 27(6):1257-1268.

81. Andrews GJ. Geographies of health in nursing. Health and Place 2006; 12(1):110-118.

82. Carolan, M Andrews GJ, Hodnett E. Writing place: a comparison of nursing research and health geography Nursing Inquiry 2006; 13(3):203-219.

83. Jonas-Simpson C. The possibility of changing meaning in light of space and place. Nursing Science Quarterly 2006; 19(2):89-94.

84. Solberg SM, Way C. The importance of geography and health in nursing research. Canadian Journal of Nursing Research 2007; 39(3):8-13.

85. Sandelowski M. Visible humans, vanishing bodies and virtual nursing: complications of life, presence, place and identity. Advances in Nursing Science 2002; 24(3):58-70.

86. Buchan J. Still attractive after all these years? Magnet hospitals in a changing health care environment. Journal of Advanced Nursing 1999; 30(1):100-108.

87. Halford S, Leonard P. Space and place in the construction and performance of gendered nursing identities. Journal of Advanced Nursing 2003; 42(2):201-208.

88. Cheek J. Older people and acute care: a matter of place. Illness, Crisis and Loss 2004; 12(1):52-62.

89. Gilmour JA. Hybrid space: constituting the hospital as a home for patients. Nursing Inquiry 2006; 13(1):16-22.

90. Roush CV, Cox JE. The meaning of home: how it shapes the practice of home and hospice care. Home Healthcare Nurse 2000; 19(6):388-94.

91. Montgomery P. Shifting meaning of asylum Journal of Advanced Nursing 2001; 33(4):425-431.

92. Lock LR, Gibb HJ. The power of place. Midwifery 2003; 19:132-139.

93. Duke M, Street AE. Hospital in the home: constructions of the nursing role: a literature review. Journal of Clinical Nursing 2003; 12:852-859.

94. Pryce A. Governmentality, the iconography of sexual disease and 'duties' of the STI clinic. Nursing Inquiry 2001; 8(3):151-163.

95. Andes M, Shattell MM. An exploration of the meanings of space and place in acute psychiatric care. Issues in Mental Health Nursing 2006; 27:699-707.

96. Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth (review). The Cochrane Database of Systematic Reviews 2005; 1:1-38.

97. McKeever P, Stevens B, Miller KL, Macdonnell J, Gibbins S, Guerriere, Dunn D, Coyte P. Home verses hospital lactation support for newborns. Birth 2002; 29(4)258-265.

98. Angus J, Hodnett E, O'Brien-Pallas, L. Implementing evidence-based nursing practice: a tale of two intrapartum nursing units. Nursing Inquiry, 2003; 10(4):218-228.
99. Andrews GJ, Brodie D, Andrews JP, Thomas G, Wong J. Place(ment) matters: the impacts of students' clinical placement experiences on their preference for first employer. *International Nursing Review* 2005; 52(2):142-154.

100. West E, Barron DN. Social and geographical boundaries around senior nurse and physician leaders: an application of social network analysis. *Canadian Journal of Nursing Research* 2005; 37(3):132-148.

101. Barnes L, Rudge T. Virtual reality or real virtuality: the space of flows and nursing practice. *Nursing Inquiry* 2005; 12(4):306-315.

102. Purkis ME. Nursing in quality space: technologies governing experiences of care. *Nursing Inquiry* 1996; 3:101-111.

103. Liaschenko J. The moral geography of home care. *Advances in Nursing Science* 1994; 17(2):16-25.

104. Liaschenko J. Ethics and the geography of the nurse-patient relationship: spatial vulnerable and gendered space. *Scholarly Inquiry for Nursing Practice*, 1997; 11(1):45-59.

105. Peter E. The history of nursing in the home: revealing the significance of place in the expression of moral agency. *Nursing Inquiry*, 2002; 9(2):65-72.

106. Peter E, Liaschenko J. Paradoxes of proximity: a spatio-temporal analysis of moral distress and moral ambiguity. *Nursing Inquiry* 2004; 11(4):218-225.

107. Andrews GJ, Shaw D. Clinical geography: nursing practice and the (re)making of institutional space. *Journal of Nursing Management* 2008; 16:463-473.

108. Skelly A, Arcury TA, Gesler W, Cravey A, Dougherty M, Washburn S, Nash S. Sociospatial knowledge networks: appraising community as place. *Research in Nursing and Health*, 2002; 25:159-170.

109. Affonso D, Andrews GJ, Jeffs L. The urban geography of SARS: paradoxes and dilemmas in Toronto's healthcare. *Journal of Advanced Nursing* 2004; 45(6):1-11.

110. Leipert B, Reutter L. Women's health and community health nursing practice in geographically isolated settings: a Canadian perspective. *Health Care for Women International*, 1998; 19:575-588.

111. Bender A, Clune L, Guruge S. Considering place in community health nursing. *Canadian Journal of Nursing Research*, 2007; 39(3):20-35.

112. Grady P, Harden JT, Mortiz P, Amende LM. Incorporating

environmental sciences and nursing research: an NINR initiative. *Nursing Outlook*, 1997; 45(2):73-75.

113. Lapum J, Chen S, Peterson J, Leung D, Andrews GJ. The place of nursing in primary health Care. In Crooks V and Andrews GJ (eds) Primary health care: people, practice, place. Aldershot: Ashgate, 2009.

114. Ketefian S, Redman RW. Nursing science in the global community. *Journal of Nursing Scholarship* 1997; 29(1):11-15.

115. Davis AJ. Global influence of American Nursing: some ethical issues. *Nursing Ethics* 1999; 6(2):118-125.

116. Buchan J. Global nursing shortages are often a symptom of wider health system or societal ailments. *British Medical Journal* 2002; 324:751-752.

117. Buchan J, Sochalski J. The migration of nurses: trends and policies. *Bulletin of the World Health Organization* 2004; 82:8.

118. Kingma M. Nurses on the move: migration and the global health care economy. *Ithaca: Cornell University Press*, 2006.

119. Andrews GJ. Global climate change: a framework for nursing action. *Aporia* 2009; 1(1):22-29.

Contact Information for Author:

Gavin J. Andrews Ph.D.
McMaster University
Department of Health, Aging and Society
1280 Main Street West
Hamilton, ON, M6J 2G4
Canada
andrews@mcmaster.ca

Valorie A Crooks Ph.D.
Simon Fraser University
Department of Geography