Discussion
This study investigated behavioral determinants associated with exclusive use of arsenic-safe water and changing ones arsenic filter cartridge for households receiving the community-led SHWS arsenic mitigation program. The SHWS program significantly increased perceived vulnerability to arsenic exposure, and self-efficacy, descriptive norms, and injunctive norms related to the use of arsenic-safe water. Increased perceived vulnerability, self-efficacy, and commitment strength to using the POU arsenic filter faucet after SHWS program delivery was associated with higher exclusive use of arsenic-safe water at follow-up. Perceived vulnerability and self-efficacy were also associated with changing one’s arsenic filter cartridge during the follow-up period. These results suggest that the community-led SHWS program was effective in changing the targeted behavioral determinants of the use of arsenic-safe water and changing ones arsenic filter cartridge, and thereby increased these behaviors. This study demonstrates the effectiveness of theory driven community-led intervention approaches to reduce arsenic exposure. These findings complement those from George et al. and Zacher et al., which found that delivery of the SHWS intervention significantly reduced arsenic exposure (George et al., submitted; [Commitment strength to only drink and cook using water from the POU arsenic filter faucet was the behavioral determinant most strongly associated with the exclusive use of arsenic-safe water for both cooking and drinking. Numerous studies have highlighted the connection between commitment strength and behaviors to protect against water arsenic exposure, both in the United States and internationally [Perceived vulnerability to the health effects of arsenic exposure increased with SHWS delivery and was associated with exclusive use of arsenic-safe water for both cooking and drinking. This finding is consistent with previous studies conducted both in the United States and in Bangladesh that assessed arsenic mitigation [Self-efficacy at baseline was strongly associated with exclusive use of arsenic-safe water for both cooking and drinking at follow-up. Our findings suggest that those who are confident in their ability to use local resources to resolve an arsenic-related problem with their private well are more likely to perform protective behaviors to reduce their arsenic exposure. This is consistent with results of previous studies that have highlighted the importance of self-efficacy in water arsenic protective behaviors [The SHWS did not significantly increase arsenic knowledge between baseline and follow-up. However, baseline knowledge of how to remove arsenic from drinking water was associated with higher exclusive use of arsenic-safe water. One potential explanation for this finding is that because well water arsenic testing occurred prior to study enrollment, participants had already received some information regarding water arsenic levels, how to remove arsenic, and the possible health related effects of arsenic exposure. A few participants may have also been exposed to the intervention prior to their baseline questionnaire if they were not available when the initial household enrollment occurred. Even after the SHWS program was delivered, 18% of participants at follow-up still reported boiling could remove arsenic, and 17% did not know which household tasks could be safely performed with arsenic-safe water. Future SHWS health communication should work to further improve understanding of how to remove elevated arsenic from water and which tasks are safe to perform with contaminated water.Participants who were less worried about their POU arsenic filter compared to other concerns at baseline were more likely to report exclusive use of arsenic-safe water at follow-up. While initially unexpected, it is possible that these individuals placed higher trust in the POU arsenic filter faucet to provide arsenic-safe water, and thus devoted less time worrying about their filters. Many individuals in our study face numerous challenges in their daily lives apart from arsenic contamination of well water [None of the demographic factors assessed (age, sex, and education) predicted exclusive use of arsenic-safe water. Results from previous studies on the influence of demographic factors on arsenic treatment and mitigation and well testing for arsenic have yielded varying results [Changing the POU arsenic filter cartridge over the study period was associated with higher baseline self-efficacy in the ability to obtain arsenic-safe water for drinking and cooking and higher perceived vulnerability in the health effects from arsenic at both the personal and household levels. Changing one’s arsenic filter cartridge is an integral aspect of the SHWS program. If the POU arsenic filter is not changed as recommended, it may not reduce arsenic concentrations below 10 μg/L. Participants may therefore be unknowingly consuming arsenic-unsafe water despite using the arsenic faucet for drinking and cooking. To the authors knowledge, no study has specifically assessed prospectively behavioral determinants associated with changing or maintaining a POU arsenic filter. In one cross-sectional survey conducted in New Jersey among those treating water for arsenic, level of commitment and signing a service agreement were associated with treatment maintenance in all models tested [This study has some strengths and limitations. The first strength is that this study reports findings from the first RCT evaluating an arsenic mitigation program to reduce water arsenic exposure in North America. Second, this study presented the unique opportunitie to prospectively assess behavioral determinants of the use of arsenic-safe water and changing ones POU arsenic filter cartridge and the impact of the community-led SHWS program on these behavioral determinants. Another strength of this study is information on both exclusive use of arsenic-safe water for drinking and cooking, and changing one’s filter cartridge for arsenic. Previous intervention studies only focused on behavioral determinants of arsenic-safe water. The first limitation is the small sample size due to study enrollment being halted because of the COVID-19 pandemic which limited the ability to assess differences between study arms. Second, COVID-19 impacted study visit timelines and in-person visits.