A Cluster-Based Randomized Controlled Trial Promoting Community Participation in Arsenic Mitigation Efforts in Bangladesh

Millions of villagers in Bangladesh drink water which exceeds the Bangladesh arsenic (As) standard of 50 micrograms per liter. Exposure to elevated levels of inorganic As (As) is associated with cancers of the skin, bladder, and lung, developmental effects, cardiovascular disease, skin lesions, and decreased children's intellectual functioning. Arsenic mitigation typically involves an outsider coming into a village to test the well water for As. After the results of the As test are provided this person typically leaves the village without providing the resources to address health concerns or give advice on mitigation options. In this dissertation, in an effort to provide ongoing resources on the health implications of As and to reduce As exposure, we sought to evaluate community level intervention strategies that could be used for successful As mitigation in Bangladesh. In Singair, Bangladesh, we conducted a household drinking water survey of 6649 households. The results of our survey indicated that 80% of wells were untested for As. Furthermore, we demonstrated that testing all of these untested wells would increase the number of households that lived with fifty meters of an As safe drinking water source by nearly 2.5 fold. In a cluster based randomized control trial (RCT) of 1000 households, we evaluated the effectiveness of having community members, compared to outside representatives, disseminate As education and conduct water As (WAs) testing. In 10 villages, a community member disseminated As education and provided WAs testing. In a second set of 10 villages an outside representative performed these tasks. Overall, fifty three percent of respondents with unsafe wells at baseline switched after receiving the As education and WAs testing intervention. There was no significant association observed between the type of As tester and well switching (Odds ratio (OR) =0.77; 95% confidence interval (CI) (0.37-1.61)). At follow-up, the average UAs concentrations for those with unsafe wells at baseline who switched to safe wells significantly decreased. In both intervention groups a significant increase in knowledge of As was observed at follow-up compared to baseline. The unavailability of As-safe drinking water sources in some villages was the most substantial barrier to well switching identified. The Hach EZ As field test kit measurements conducted by the As testers were highly correlated with laboratory results. This finding indicates that the As testers were able to accurately measure the WAs concentration of wells. Furthermore in our pilot study, the performance of the Econo-Quick (EC) kit, a new field WAs testing kit, was comparable to that of the commonly used EZ kit and the Wagtech Arsenator kit. The EC kit has the advantage of a substantially shorter reaction time of only 12 minutes in comparison to the 40 minutes required by these other kits. Through this dissertation, we have demonstrated that As education and WAs testing programs can be used as an effective method to reduce As exposure and increase As awareness in many As affected areas of Bangladesh. Furthermore, our findings indicated that many households are using tubewells that are untested for As therefore demonstrating the urgent need for access to water As testing services.