Flexible Bayesian hierarchical spatial modeling in disease mapping.

The Gaussian Intrinsic Conditional Autoregressive (ICAR) spatial model, which usually has two components, namely an ICAR for spatial smoothing and standard random effects for non-spatial heterogeneity, is used to estimate spatial distributions of disease risks. The normality assumption in this model may not always be correct and misspecification of the distribution of random effects could result in biased estimation of the spatial distribution of disease risk, which could lead to misleading conclusions and policy recommendations. Limited research studies have been done where the estimation of the spatial distributions of diseases under the ICAR-normal model were compared to those obtained from fitting ICAR-nonnormal model. The results from these studies indicated that the ICAR-nonnormal models performed better than the ICAR-normal in terms of accuracy, efficiency and predictive capacity. However, these efforts have not fully addressed the effect on the estimation of spatial distributions under flexible specification of ICAR models in disease mapping. The overall aim of this PhD thesis was to develop approaches that relax the normality assumption that is often used in modeling and fitting of ICAR models in the estimation of spatial patterns of diseases. In particular, the thesis considered the skewnormal and skew-Laplace distributions under the univariate, and skew-normal for the multivariate specifications to estimate the spatial distributions of either univariable or multivariable areal data. The thesis also considered non-parametric specification of the multivariate spatial effects in the ICAR model, which is a novel extension of an earlier work. The estimation of the models was done using Bayesian statistical approaches. The performances of our suggested alternatives to the ICAR-normal model were evaluated by simulating studies as well as with practical application to the estimation of district-level distribution of HIV prevalence and treatment coverage using health survey data in South Africa. Results from the simulation studies and analysis of real data demonstrated that our approaches performed better in the prediction of spatial distributions for univariable and multivariable areal data in disease mapping approaches. This PhD has shown the limitations of relying on the ICAR-normal model for the estimations of spatial distributions for all spatial analyses, even when the data could be asymmetric and non-normal. In such scenarios, skewed-ICAR and nonparametric ICAR approaches could provide better and unbiased estimation of the spatial pattern of diseases.