Facilitators and barriers to safely managed water and sanitation: A spatio-temporal investigation of the association between socioeconomic factors and shigellosis incidence by Sabrina Li A thesis presented to the University of Waterloo in fulfillment of the thesis requirement for the degree of Master of Science in Geography Waterloo, Ontario, Canada, 2017 © Sabrina Li 2017 1 AUTHOR’S DECLARATION I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii ABSTRACT The lack of access to safe drinking water and sanitation worldwide has contributed to the occurrence of shigellosis, a waterborne infectious disease. Previous research has shown that shigellosis can be prevented by access to safe drinking water and adequate sanitation, however access is facilitated or hindered by socioeconomic conditions. The effects of socioeconomic conditions on shigellosis incidence are unclear in the context of rural China. This thesis explored the spatial patterns of shigellosis over time and the spatio-temporal association between shigellosis incidence and socioeconomic conditions of the rural population in Jiangsu province. Choropleth maps were created to understand the geographic distribution of shigellosis incidence at the county level. Spatial analysis methods such as spatial autocorrelation, Local Moran’s I, and the Getis Ord Gi were used to identify disease clusters, outliers, and hotspots. Based on the findings from the hot spot analysis and evidence from literature, a field visit to the northwestern county of Suining was conducted to further investigate the relationships between water and sanitation access and shigellosis incidence in the rural context. The temporal variability of the association between socioeconomic factors and shigellosis at the county level was investigated using negative binomial and quasi-Poisson regression models. The spatial relationship between socioeconomic factors and shigellosis at the county level was explored using a Bayesian spatial model. Results showed that shigellosis morbidity was characterized by significant declines in most regions from 2011 to 2015; however, high morbidity rates were still evident in the northwestern region of Jiangsu. At the county level, the factors such as the number of hospital beds per capita and the percentage of rural households has shown to be significantly associated with shigellosis incidence for years 2011, 2012, and 2014, respectively. The percentage of rural households was negatively correlated with shigellosis incidence; this relationship was further confirmed by results from the Bayesian spatial model. In addition, results showed that rural employment and the number of hospital beds per capita, respectively, were correlated with a decrease in shigellosis incidence. In contrast, the number of hospitals per capita was positively correlated with an increase in shigellosis incidence. Underreporting of shigellosis in rural areas was suspected to be the cause of the low rate of shigellosis in rural areas. The quality of the rural healthcare system and living conditions may have influenced this underreporting. Thus, a more active surveillance method should be adopted to gauge the real occurrence of shigellosis amongst the rural population. iii ACKNOWLEDGEMENTS I’d like to acknowledge and thank the funding I’ve received from the MITACS Globalink Award for supporting my thesis research in China. This thesis was completed with the support of many individuals. I would like to extend my sincerest thanks to all of them. Firstly, I would like to thank my supervisor Dr. Susan Elliott for supporting my interests and for dedicating her time to this thesis since the conception of my research topic. I feel like I became a more experienced researcher under your invaluable mentorship. Next, I’d like to thank my thesis committee members, Dr. Peter Deadman, Dr. Peter Johnson, and Dr. Lisa Guppy. Thanks for dedicating your time to reviewing and sharing your feedback on the content of this thesis. I would also like to extend my thanks to Jiang Han (Department of Geography and Environmental Management) for helping to translate data collected from China, Dr. Derek Robinson (Geography and Environmental Management) for suggesting tools in ArcGIS for spatial analysis, and Dr. Changbao Wu (Department of Statistics and Actuarial Science) and Dr. Jane Law (School of Planning) for verifying the procedure taken for the generalized linear regression analysis. This thesis would not have been possible without the support I have received in China. Thanks to Dr. Jinhe Zhang from Nanjing University for giving me the opportunity to connect with students and obtain the resources I needed for this thesis, and Dr. Yongyue Wei from Nanjing Medical University for his suggestions on epidemiological data analysis. A special thanks goes out to Victor Xu Qi, and Kang Jing Yao for helping me with finding GIS data, and Hu Huan for helping me to coordinate the paper work needed for my field visits. Furthermore, a BIG thank you goes to Di Meng and her friends at Suining County for connecting me to all the resources in Suining County. Thank you for showing me your hometown and providing me incredible support throughout. Lastly, thanks to my friends and family for their endless support. To my grad school friends, thanks for all the (much-needed) social outings, potlucks, zumba hangouts, fun side projects (Polygone and WAMS), and board game nights that have made grad school enjoyable. A special shout out to Sabrina Bedjera, Hongjing Chen, Sarah Irvine, Kelvin Liew, and Sabrina Touchette for all your kind words and hugs, especially when I needed them the most. To my friends Elaine Wong and Mark Vaz, thanks for always being there for me from the start to finish. To Francis Li, thanks for your optimism and supporting me in all my interests and endeavors. Finally, thanks to my parents for all your love and encouragement during this journey. Many hugs and kisses. iv DEDICATION This thesis is dedicated to my loving grandparents, lao lao and lao ye. Thank you both for fostering my creativity and always believing in me. v TABLE OF CONTENTS AUTHOR’S DECLARATION ..................................................................................................... ii ABSTRACT .................................................................................................................................. iii ACKNOWLEDGEMENTS ......................................................................................................... iv DEDICATION ............................................................................................................................... v LIST OF FIGURES .................................................................................................................... viii LIST OF TABLES ........................................................................................................................ ix CHAPTER 1: INTRODUCTION ................................................................................................ 1 1.1 Research Context .............................................................................................................................. 4 1.2 Research Objectives ......................................................................................................................... 6 1.3 Research Contributions .................................................................................................................... 8 1.4 Chapter Outline ................................................................................................................................ 9 CHAPTER 2: LITERATURE REVIEW .................................................................................. 10 2.1 Introduction .....................................................................................................................................10 2.2 Shigellosis: Causes, transmission pathways, and prevention ..........................................................10 2.3 Water and Sanitation in Rural China ...............................................................................................16 2.4 Theoretical Framework ...................................................................................................................19 2.5 Conceptual Framework ...................................................................................................................22 2.6 Methodological Literature ...............................................................................................................27 2.6.1 Spatial Data Visualization ........................................................................................................27 2.6.2 Spatial Analysis of Infectious Disease .....................................................................................28 2.6.3 Multivariate Regression Models for Small area Incidence ......................................................31 2.7 Chapter Summary ............................................................................................................................41 CHAPTER 3: METHODOLOGY ............................................................................................. 42 3.1 Introduction .....................................................................................................................................42