- Email: [email protected]
Facilitators and Barriers to Effective Water and Sanitation Interventions for Characterizing Shigellosis Incidence in Jiangsu, China
Available online at www.sciencedirect.com
ScienceDirect Procedia Environmental Sciences 36 (2016) 65 – 69
International Conference on Geographies of Health and Living in Cities: Making Cities Healthy for All, Healthy Cities 2016
Facilitators and barriers to effective water and sanitation interventions for characterizing shigellosis incidence in Jiangsu, China Sabrina Lia, Susan J. Elliotta,* a
Department of Geography and Environmental Management, University of Waterloo, 200 University Avenue West, Waterloo, N2L 3G1, Canada
Abstract Effective water and sanitation interventions can help to reduce the prevalence of waterborne diseases such as shigellosis, which is a diarrheal disease prevalent in rural areas of China. Water and sanitation interventions can be strengthened or undermined by facilitators and barriers, which are factors that assist or hinder access to safe water and adequate sanitation. Facilitators and barriers can be assessed using a conceptual framework of socioeconomic and water and sanitation determinants to understand the prevalence of shigellosis. Insight into facilitators and barriers can help various stakeholders to strategize with communities to implement a sensible solution to the rural water crisis in China. © Published by Elsevier B.V. B.V. This is an open access article under the CC BY-NC-ND license © 2016 2016The TheAuthors. Authors. Published by Elsevier (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016. Peer-review under responsibility of the organizing committee of Healthy Cities 2016 Keywords: healthy geography; water and sanitation; shigellosis; diarrhea; GIS
1. Introduction In 2000, the United Nations established eight measurable goals - the Millennium Development Goals (MDGs) that focused on reducing poverty through improving health and development. The target for water and sanitation is MDG Target 7c, which aimed to reduce “the proportion of the population without sustainable access to safe
* Corresponding author. Tel.: +1-519-888-4567 ext. 31107 E-mail address: [email protected]
1878-0296 © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016 doi:10.1016/j.proenv.2016.09.013
66
Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69
drinking water and basic sanitation” by half by 20151. The water goal was reached; the sanitation goal was not. Despite reaching the water goal, close to 1 billion people in the world continue to lack access to safe water. The MDGs successors – the Sustainable Development Goals (SDGs), include Goal 6: to “ensure availability and sustainable management of water and sanitation for all”. Currently, 20% of the world’s population resides in China, which has 7% of the world’s freshwater supply2. Lakes and major rivers in China are severely polluted and water from reservoirs is unsuitable for drinking even after wastewater treatment3. Due to clean water scarcity, weak water infrastructure, and large urban-rural disparities, 96.6 million people in China still lack access to safe drinking water while 455.5 million people still lack access to adequate sanitation4. Poor water quality can be a major threat to human health. Exposure to water contaminated with human fecal matter as a result of open defecation or the lack of a toilet facility can cause severe diarrheal diseases. It is estimated that diarrhea caused by waterborne diseases accounts for 3.6% of the global disease burden, killing 1.5 million people every year5. Over 90% of diarrheal diseases are associated with children under the age of five6. China has implemented a five-year plan worth 410 billion RMB (66 billion USD) to provide safe drinking water through the expansion of its public water system to 54% of the population living in cities and towns by 20157. Access to water still varies greatly due to regional disparities; the rural population is more vulnerable to water-related diseases than the urban population. Accounting for 60% of the total population8, 70% of the rural population still lacks access to safe drinking water. 2. Burden of diarrhea due to unsafe water and poor sanitation: A case study of shigellosis in Jiangsu, China It is estimated that 700, 000 deaths each year are caused by a single type of bacteria called Shigella, which causes bacillary dysentery, or shigellosis9. Symptoms include watery diarrhea (that may contain mucus and blood), painful bowel movements, abdominal pain, nausea and vomiting, rapid dehydration, and weight loss. In rural areas, the lack of vaccines and access to antibiotics to cure shigellosis can be overcome by improving water sanitation, and hygiene (WASH) interventions. This infectious diarrheal disease accounts for 5% of all diarrheal episodes in China10. In China, shigellosis infections require legal notification from all clinical and hospital doctors to the local Center for Disease Control and Prevention (CDC). Shigellosis is a growing diarrheal disease among children in the eastern province of Jiangsu, China11. Jiangsu is the most densely populated province in China, with most of the population concentrated in its capital, Nanjing. Shigellosis is driven by geographical elements such as temperature and relative humidity. The majority of shigellosis incidents occur during the summer and autumn months (July - October)10,11. Tang et al.11 analyzed the spatial and temporal trends of Shigella incidence trends from 2001 to 2011 in Jiangsu and found that shigellosis incidence rates followed a decreasing trend over time, but peaked in 2004, 2006, and 2011. Maps illustrating incidence rates were created, and indicated that the southeastern region of Suzhou and Wuxi were identified as the two most prominent hotspots for Shigella transmissions. The disease burden associated with shigellosis can be effectively prevented by well-implemented WASH interventions, which can reduce diarrhea prevalence by one third12. Currently, no studies have evaluated the effectiveness of current water and sanitation interventions in shigellosis hotspots and rural towns in Jiangsu. By exploring the relationship between water and sanitation interventions and the prevalence of shigellosis in recent years, one can better understand the WASH conditions leading up to the end of the MDGs, and the conditions that follow into the time frame of the SDGs. 3. A Conceptual Framework using Facilitators and Barriers A conceptual framework is a system of concepts that supports, verifies, and outlines the process of the study. As shown in Figure 1, a conceptual framework can be built on the relationships between facilitators and barriers, and the state of water and sanitation interventions. The facilitators and barriers to effective water and sanitation interventions will be used as factors for understanding access to safe water and adequate sanitation, and how they can be used to gauge the prevalence of shigellosis. Facilitators and barriers can be further categorized into the following themes: socioeconomic determinants and water and sanitation interventions, as shown in Table 1.
Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69
Fig. 1. Conceptual framework of facilitators and barriers
An individual who has high socioeconomic status (SES), which is measured by income, employment, and education, will have a higher quality of life and standard of living. This leads to better access to safe water and adequate sanitation. In addition, someone with access to an improved drinking water source such as a public tap, borehole, or a protected spring, will have access to safe water. A household point-of-use (POU) treatment unit will help treat the water so it is safe for consumption. Access to an improved sanitation facility such as a private toilet (supported by a piped sewer system, septic tank, pit latrine, composting toilet, etc.) constitutes as having access to adequate sanitation. Table 1. Facilitators and barriers to water and sanitation interventions Socioeconomic Determinants x
High SES ¾ High income ¾ High education
x
Low SES ¾ Low income ¾ Low education ¾ Poverty
Facilitators
Barriers x
Weak social support network ¾ Left-over children phenomenon ¾ Children is responsible for fetching water
Water and Sanitation Interventions x x x x x
Access to improved drinking water sources Household Point-of-Use Treatment Access to improved sanitation facility Improved sanitation facility Regulated waste disposal
x x x x x x
Lack of water access Lack of access to improved water sources Prevalence of waterborne diseases Open defecation Shared sanitation facility Poor/lack of waste disposal regulations
On the other hand, an individual’s low socioeconomic status can hinder access to safe water and adequate sanitation. A person who has a low income, low education, or lacks stable employment, may not develop awareness of unsafe water and inadequate sanitation. Traveling long distances to fetch water is also a barrier as it is a time consuming process that prevents the porter from doing other socially valuable tasks such as working and going to school. Having access to a shared sanitation facility is not considered the same as having access to an improved sanitation facility. According to the WHO & UNICEF13, a shared facility is known to be “shared between two or more households…which include public toilets.” Moreover, the lack of a separate toilet facility can lead to open defecation. Inappropriate disposal of fecal matter can cause the contamination of water and create a breeding ground for waterborne diseases such as shigellosis. Additionally, the prevalence of waterborne disease outbreaks as a result of ineffective water and sanitation interventions can also act as a barrier to achieving safe water and adequate sanitation. Likewise, unregulated waste disposal is also identified as a barrier. Tang et al.11 claims that unregulated waste disposal is a factor that exacerbates Shigella transmissions in Jiangsu. Rego et al.14 also found that children exposed to garbage in their surrounding environment were four times more likely to contract and develop diarrhea. Children playing with garbage may contract diarrhea through oral contact due the lack of hygiene awareness and practices.
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Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69
Children fending for themselves may struggle with obtaining clean water and developing awareness of adequate sanitation due to the lack of a social support network. In rural China, “left-over children” are a cultural phenomenon where children are left behind in rural areas to live with their relatives, which are mainly grandparents with little to no education, financial support, or the physical ability to look after themselves and the child15. In addition, the child of a family may be responsible for fetching water. This hinders the child’s social development and education, which is another barrier to developing awareness for safe water and adequate sanitation practices. In order to study the spatial distribution of shigellosis incidence rates and analyze the attributes of facilitators and barriers, a mapping system using Geographic Information Systems (GIS) can play a critical role16. Mapping shigellosis incidence rates across regions in Jiangsu can provide a clear visualization of disease incidence per area and across regions of the province. Before the analysis of facilitators and barriers, it is critical to understand how a location is susceptible to shigellosis. Due to the variance in socioeconomic conditions and water and sanitation interventions, certain locations are more susceptible to shigellosis while others are not. Therefore, creating an incidence map can help to identify those locations and illustrate how geography and other social factors can affect the incidence of shigellosis in an area. 4. Conclusions In China, finding a sustainable solution to the water/sanitation problem is a major challenge due to the growing population and the large urban/rural divide. In the eastern province of Jiangsu, shigellosis incidence results from inadequate water and sanitation facilities. Investigating facilitators and barriers to access can be useful for understanding the underlying socioeconomic factors and current interventions that are assisting or hindering access to improved water and sanitation facilities, which is not possible through aggregated data reports. Based on this information, policy makers can implement more suitably effective monitoring and mitigation measures thus reducing the burden of illness and enhancing quality of life. Acknowledgements This project is supported by a Canadian MITACS Globalink Award. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
WHO & UNICEF. (2000). Progress on Sanitation and Drinking Water. Joint Monitoring Programme for Water Supply and Sanitation. United Nations. (2014). Water and Sustainability. Retrieved March 8, 2016 from UN Water: International Decade for Action "WATER FOR LIFE" 2005-2015: http://www.un.org/waterforlifedecade/pdf/01_2014_sustainability_eng.pdf Zhang, J., Mauzerall, D. L., Zhu, T., Liang, S., Ezzati, M., & Remais, J. V. (2010). Environmental health in China: progress towards clean air and safe water. The lancet, 375(9720), 1110-1119. JMP. (2015). JMP WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation . Retrieved December 18, 2015, from Improved and unimproved water sources and sanitation facilities: http://www.wssinfo.org/definitions- methods/watsan-categories/ WHO. (2012). Mortality and global health estimates: Causes of death. Retrieved March 8, 2016 from Global Health Observatory data repository: http://apps.who.int/gho/ Boschi-Pinto, C., Velebit, L., & Shibuya, K. (2008). Estimating child mortality due to diarrhoea in developing countries. Bulletin of the World Health Organization, 86(9), 710-717. Tao, T., & Xin, K. (2014, July 31). A sustainable plan for China's drinking water. Nature: Comment , 527-528. Yu, X., Geng, Y., Heck, P., & Xue, B. (2015). A Review of China’s Rural Water Management. Sustainability , 7 (5), 5773-5792. WHO. (2005). Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1. Geneva: WHO. Xu, Z., Hu, W., Zhang, Y., Wang, X., Tong, S., & Zhou, M. (2014). Spatiotemporal pattern of bacillary dysentery in china from 1990 to 2009: what is the driver behind?. Tang, F., Cheng, Y., Bao, C., Hu, J., Liu, W., Liang, Q., ... & Chen, F. (2014). Spatio-Temporal Trends and Risk Factors for Shigella from 2001 to 2011 in Jiangsu Province, People's Republic of China. PloS one, 9(1), e83487. Bartram, J., & Cairncross, S. (2010). Hygiene, sanitation, and water: forgotten foundations of health. PLoS Med, 7(11), e1000367. WHO & UNICEF. (2012). WHO/UNICEF joint monitoring report 2012: Key Terms. Retrieved March 8, 2016 from Water Sanitation Health: http://www.who.int/water_sanitation_health/monitoring/jmp2012/key_terms/en/ Rego, R. F., Moraes, L. R. S., & Dourado, I. (2005). Diarrhoea and garbage disposal in Salvador, Brazil. Transactions of the Royal Society of Tropical Medicine and Hygiene, 99(1), 48-54. Lu, S., Lin, Y. T., Vikse, J. H., & Huang, C. C. (2016). Well-being of migrant and left-behind children in China: Education, health, parenting, and personal values. International Journal of Social Welfare, 25(1), 58-68.
Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69 16. Fradelos, E. C., Papathanasiou, I. V., Mitsi, D., Tsaras, K., Kleisiaris, C. F., & Kourkouta, L. (2014). Health Based Geographic Information Systems (GIS) and their Applications. Acta Informatica Medica, 22(6), 402.
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ScienceDirect Procedia Environmental Sciences 36 (2016) 65 – 69
International Conference on Geographies of Health and Living in Cities: Making Cities Healthy for All, Healthy Cities 2016
Facilitators and barriers to effective water and sanitation interventions for characterizing shigellosis incidence in Jiangsu, China Sabrina Lia, Susan J. Elliotta,* a
Department of Geography and Environmental Management, University of Waterloo, 200 University Avenue West, Waterloo, N2L 3G1, Canada
Abstract Effective water and sanitation interventions can help to reduce the prevalence of waterborne diseases such as shigellosis, which is a diarrheal disease prevalent in rural areas of China. Water and sanitation interventions can be strengthened or undermined by facilitators and barriers, which are factors that assist or hinder access to safe water and adequate sanitation. Facilitators and barriers can be assessed using a conceptual framework of socioeconomic and water and sanitation determinants to understand the prevalence of shigellosis. Insight into facilitators and barriers can help various stakeholders to strategize with communities to implement a sensible solution to the rural water crisis in China. © Published by Elsevier B.V. B.V. This is an open access article under the CC BY-NC-ND license © 2016 2016The TheAuthors. Authors. Published by Elsevier (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016. Peer-review under responsibility of the organizing committee of Healthy Cities 2016 Keywords: healthy geography; water and sanitation; shigellosis; diarrhea; GIS
1. Introduction In 2000, the United Nations established eight measurable goals - the Millennium Development Goals (MDGs) that focused on reducing poverty through improving health and development. The target for water and sanitation is MDG Target 7c, which aimed to reduce “the proportion of the population without sustainable access to safe
* Corresponding author. Tel.: +1-519-888-4567 ext. 31107 E-mail address: [email protected]
1878-0296 © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of Healthy Cities 2016 doi:10.1016/j.proenv.2016.09.013
66
Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69
drinking water and basic sanitation” by half by 20151. The water goal was reached; the sanitation goal was not. Despite reaching the water goal, close to 1 billion people in the world continue to lack access to safe water. The MDGs successors – the Sustainable Development Goals (SDGs), include Goal 6: to “ensure availability and sustainable management of water and sanitation for all”. Currently, 20% of the world’s population resides in China, which has 7% of the world’s freshwater supply2. Lakes and major rivers in China are severely polluted and water from reservoirs is unsuitable for drinking even after wastewater treatment3. Due to clean water scarcity, weak water infrastructure, and large urban-rural disparities, 96.6 million people in China still lack access to safe drinking water while 455.5 million people still lack access to adequate sanitation4. Poor water quality can be a major threat to human health. Exposure to water contaminated with human fecal matter as a result of open defecation or the lack of a toilet facility can cause severe diarrheal diseases. It is estimated that diarrhea caused by waterborne diseases accounts for 3.6% of the global disease burden, killing 1.5 million people every year5. Over 90% of diarrheal diseases are associated with children under the age of five6. China has implemented a five-year plan worth 410 billion RMB (66 billion USD) to provide safe drinking water through the expansion of its public water system to 54% of the population living in cities and towns by 20157. Access to water still varies greatly due to regional disparities; the rural population is more vulnerable to water-related diseases than the urban population. Accounting for 60% of the total population8, 70% of the rural population still lacks access to safe drinking water. 2. Burden of diarrhea due to unsafe water and poor sanitation: A case study of shigellosis in Jiangsu, China It is estimated that 700, 000 deaths each year are caused by a single type of bacteria called Shigella, which causes bacillary dysentery, or shigellosis9. Symptoms include watery diarrhea (that may contain mucus and blood), painful bowel movements, abdominal pain, nausea and vomiting, rapid dehydration, and weight loss. In rural areas, the lack of vaccines and access to antibiotics to cure shigellosis can be overcome by improving water sanitation, and hygiene (WASH) interventions. This infectious diarrheal disease accounts for 5% of all diarrheal episodes in China10. In China, shigellosis infections require legal notification from all clinical and hospital doctors to the local Center for Disease Control and Prevention (CDC). Shigellosis is a growing diarrheal disease among children in the eastern province of Jiangsu, China11. Jiangsu is the most densely populated province in China, with most of the population concentrated in its capital, Nanjing. Shigellosis is driven by geographical elements such as temperature and relative humidity. The majority of shigellosis incidents occur during the summer and autumn months (July - October)10,11. Tang et al.11 analyzed the spatial and temporal trends of Shigella incidence trends from 2001 to 2011 in Jiangsu and found that shigellosis incidence rates followed a decreasing trend over time, but peaked in 2004, 2006, and 2011. Maps illustrating incidence rates were created, and indicated that the southeastern region of Suzhou and Wuxi were identified as the two most prominent hotspots for Shigella transmissions. The disease burden associated with shigellosis can be effectively prevented by well-implemented WASH interventions, which can reduce diarrhea prevalence by one third12. Currently, no studies have evaluated the effectiveness of current water and sanitation interventions in shigellosis hotspots and rural towns in Jiangsu. By exploring the relationship between water and sanitation interventions and the prevalence of shigellosis in recent years, one can better understand the WASH conditions leading up to the end of the MDGs, and the conditions that follow into the time frame of the SDGs. 3. A Conceptual Framework using Facilitators and Barriers A conceptual framework is a system of concepts that supports, verifies, and outlines the process of the study. As shown in Figure 1, a conceptual framework can be built on the relationships between facilitators and barriers, and the state of water and sanitation interventions. The facilitators and barriers to effective water and sanitation interventions will be used as factors for understanding access to safe water and adequate sanitation, and how they can be used to gauge the prevalence of shigellosis. Facilitators and barriers can be further categorized into the following themes: socioeconomic determinants and water and sanitation interventions, as shown in Table 1.
Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69
Fig. 1. Conceptual framework of facilitators and barriers
An individual who has high socioeconomic status (SES), which is measured by income, employment, and education, will have a higher quality of life and standard of living. This leads to better access to safe water and adequate sanitation. In addition, someone with access to an improved drinking water source such as a public tap, borehole, or a protected spring, will have access to safe water. A household point-of-use (POU) treatment unit will help treat the water so it is safe for consumption. Access to an improved sanitation facility such as a private toilet (supported by a piped sewer system, septic tank, pit latrine, composting toilet, etc.) constitutes as having access to adequate sanitation. Table 1. Facilitators and barriers to water and sanitation interventions Socioeconomic Determinants x
High SES ¾ High income ¾ High education
x
Low SES ¾ Low income ¾ Low education ¾ Poverty
Facilitators
Barriers x
Weak social support network ¾ Left-over children phenomenon ¾ Children is responsible for fetching water
Water and Sanitation Interventions x x x x x
Access to improved drinking water sources Household Point-of-Use Treatment Access to improved sanitation facility Improved sanitation facility Regulated waste disposal
x x x x x x
Lack of water access Lack of access to improved water sources Prevalence of waterborne diseases Open defecation Shared sanitation facility Poor/lack of waste disposal regulations
On the other hand, an individual’s low socioeconomic status can hinder access to safe water and adequate sanitation. A person who has a low income, low education, or lacks stable employment, may not develop awareness of unsafe water and inadequate sanitation. Traveling long distances to fetch water is also a barrier as it is a time consuming process that prevents the porter from doing other socially valuable tasks such as working and going to school. Having access to a shared sanitation facility is not considered the same as having access to an improved sanitation facility. According to the WHO & UNICEF13, a shared facility is known to be “shared between two or more households…which include public toilets.” Moreover, the lack of a separate toilet facility can lead to open defecation. Inappropriate disposal of fecal matter can cause the contamination of water and create a breeding ground for waterborne diseases such as shigellosis. Additionally, the prevalence of waterborne disease outbreaks as a result of ineffective water and sanitation interventions can also act as a barrier to achieving safe water and adequate sanitation. Likewise, unregulated waste disposal is also identified as a barrier. Tang et al.11 claims that unregulated waste disposal is a factor that exacerbates Shigella transmissions in Jiangsu. Rego et al.14 also found that children exposed to garbage in their surrounding environment were four times more likely to contract and develop diarrhea. Children playing with garbage may contract diarrhea through oral contact due the lack of hygiene awareness and practices.
67
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Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69
Children fending for themselves may struggle with obtaining clean water and developing awareness of adequate sanitation due to the lack of a social support network. In rural China, “left-over children” are a cultural phenomenon where children are left behind in rural areas to live with their relatives, which are mainly grandparents with little to no education, financial support, or the physical ability to look after themselves and the child15. In addition, the child of a family may be responsible for fetching water. This hinders the child’s social development and education, which is another barrier to developing awareness for safe water and adequate sanitation practices. In order to study the spatial distribution of shigellosis incidence rates and analyze the attributes of facilitators and barriers, a mapping system using Geographic Information Systems (GIS) can play a critical role16. Mapping shigellosis incidence rates across regions in Jiangsu can provide a clear visualization of disease incidence per area and across regions of the province. Before the analysis of facilitators and barriers, it is critical to understand how a location is susceptible to shigellosis. Due to the variance in socioeconomic conditions and water and sanitation interventions, certain locations are more susceptible to shigellosis while others are not. Therefore, creating an incidence map can help to identify those locations and illustrate how geography and other social factors can affect the incidence of shigellosis in an area. 4. Conclusions In China, finding a sustainable solution to the water/sanitation problem is a major challenge due to the growing population and the large urban/rural divide. In the eastern province of Jiangsu, shigellosis incidence results from inadequate water and sanitation facilities. Investigating facilitators and barriers to access can be useful for understanding the underlying socioeconomic factors and current interventions that are assisting or hindering access to improved water and sanitation facilities, which is not possible through aggregated data reports. Based on this information, policy makers can implement more suitably effective monitoring and mitigation measures thus reducing the burden of illness and enhancing quality of life. Acknowledgements This project is supported by a Canadian MITACS Globalink Award. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
WHO & UNICEF. (2000). Progress on Sanitation and Drinking Water. Joint Monitoring Programme for Water Supply and Sanitation. United Nations. (2014). Water and Sustainability. Retrieved March 8, 2016 from UN Water: International Decade for Action "WATER FOR LIFE" 2005-2015: http://www.un.org/waterforlifedecade/pdf/01_2014_sustainability_eng.pdf Zhang, J., Mauzerall, D. L., Zhu, T., Liang, S., Ezzati, M., & Remais, J. V. (2010). Environmental health in China: progress towards clean air and safe water. The lancet, 375(9720), 1110-1119. JMP. (2015). JMP WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation . Retrieved December 18, 2015, from Improved and unimproved water sources and sanitation facilities: http://www.wssinfo.org/definitions- methods/watsan-categories/ WHO. (2012). Mortality and global health estimates: Causes of death. Retrieved March 8, 2016 from Global Health Observatory data repository: http://apps.who.int/gho/ Boschi-Pinto, C., Velebit, L., & Shibuya, K. (2008). Estimating child mortality due to diarrhoea in developing countries. Bulletin of the World Health Organization, 86(9), 710-717. Tao, T., & Xin, K. (2014, July 31). A sustainable plan for China's drinking water. Nature: Comment , 527-528. Yu, X., Geng, Y., Heck, P., & Xue, B. (2015). A Review of China’s Rural Water Management. Sustainability , 7 (5), 5773-5792. WHO. (2005). Guidelines for the control of shigellosis, including epidemics due to Shigella dysenteriae type 1. Geneva: WHO. Xu, Z., Hu, W., Zhang, Y., Wang, X., Tong, S., & Zhou, M. (2014). Spatiotemporal pattern of bacillary dysentery in china from 1990 to 2009: what is the driver behind?. Tang, F., Cheng, Y., Bao, C., Hu, J., Liu, W., Liang, Q., ... & Chen, F. (2014). Spatio-Temporal Trends and Risk Factors for Shigella from 2001 to 2011 in Jiangsu Province, People's Republic of China. PloS one, 9(1), e83487. Bartram, J., & Cairncross, S. (2010). Hygiene, sanitation, and water: forgotten foundations of health. PLoS Med, 7(11), e1000367. WHO & UNICEF. (2012). WHO/UNICEF joint monitoring report 2012: Key Terms. Retrieved March 8, 2016 from Water Sanitation Health: http://www.who.int/water_sanitation_health/monitoring/jmp2012/key_terms/en/ Rego, R. F., Moraes, L. R. S., & Dourado, I. (2005). Diarrhoea and garbage disposal in Salvador, Brazil. Transactions of the Royal Society of Tropical Medicine and Hygiene, 99(1), 48-54. Lu, S., Lin, Y. T., Vikse, J. H., & Huang, C. C. (2016). Well-being of migrant and left-behind children in China: Education, health, parenting, and personal values. International Journal of Social Welfare, 25(1), 58-68.
Sabrina Li and Susan J. Elliott / Procedia Environmental Sciences 36 (2016) 65 – 69 16. Fradelos, E. C., Papathanasiou, I. V., Mitsi, D., Tsaras, K., Kleisiaris, C. F., & Kourkouta, L. (2014). Health Based Geographic Information Systems (GIS) and their Applications. Acta Informatica Medica, 22(6), 402.
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