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Arsenic poisoning

A major case of arsenic contamination was witnessed in Bangladesh and India in the year 1983 with a majority of causalities from Bangladesh. As per the world report around 80% of the people in Bangladesh are affected by arsenic poisoning. It means around 19.3 million are currently effected. From amongst the several countries affected by arsenic pollution, Bangladesh is at the highest risk. The country has been reported to have the highest groundwater arsenic contamination (Rahman, Dong & Naidu, 2015). The issue is highly neglected despite its identification decades ago. It constitutes the rationale for the study. The aim of the proposal is to develop a hypothetical health promotion intervention to mitigate the arsenic poisoning in Bangladesh.

According to Rahman, Dong & Naidu (2015), arsenic poisoning refers to the condition wherein the levels of arsenic exceed in the body. Arsenic poisoning is that medical condition wherein symptoms such as vomiting, diarrhea and abdominal pain are witnessed in case of short- term exposures. On the other hand, in case of long- term exposure, symptoms such as thickening and darkening of skin, heart diseases and even cancer has been observed. The major reason behind the long- term exposure to arsenic poisoning has been contaminated drinking water. Arsenic is found in huge quantities inside the crust of Earth, which leads to contamination of underground water. Groundwater is usually most affected from arsenic poisoning. The arsenic level in water is considered to be between 10 and 50 parts per billion. Usually arsenic poisoning is usually caused accidentally.   

According to Sidhu et al., (2015), the major source of arsenic in the environment is from the minerals present in the crust of the Earth. Usually arsenic gets dissolved with the underground water through the use of fertilizers, insecticides, mining activities and herbicides. A major source of groundwater contamination is irrigation of crops especially rice. Mining activities highly impact the freshwaters as it increases the level of arsenic content in the freshwaters. The industrial effluents and the mining effluents affect the freshwaters, which when gets mixed with marine waters, leads to arsenic pollution. The excessive use of insecticides, fertilizers and pesticides has also led to soil contamination. The soil contamination becomes a source of arsenic contamination in food especially rice. Fruits, vegetables and meat are also affected by arsenic pollution and poses severe health hazards when humans consume those items.

According to Yunus et al., (2016), arsenic is considered to be one of the most poisonous elements that is extremely hazardous for the environment and the human health. Arsenic is highly toxic for the human body. Humans are subjective to arsenic pollution mainly from water, air and food with water being the major source of arsenic toxicity all over the world. Acute arsenic poisoning causes several chronic problems in humans. It has cancerous effects on skin, liver, lungs and kidney. Arsenic poisoning also affects cardiovascular, neurological, pulmonary, immunological and endocrine disorders. Arsenic pollution adversely affects the respiratory system of humans. Gastrointestinal irritation along with thirst, nausea and painful swallowing has been noticed in the patients suffering from arsenic pollution. Arsenic pollution has also caused anemia and leucopenia among humans. The dermal impact includes pigmentation on body. Several studies have found that children born to women exposed to arsenic pollution suffer from several malformations and disorders.  In Bangladesh, every one in ten people has the probability of developing cancer due to arsenic.

Sources of arsenic in the environment

According to Chakraborti et al., (2015), there are mainly two ways of minimizing the impact of arsenic pollution on human health. These two ways include prevention and cure. In case of prevention, it becomes necessary to screen the tube wells and the population contaminated with arsenic. It is also necessary to identify the level of arsenic contamination. The Governments of the countries usually screen the tube wells. Further, the level of concentration of arsenic is detected and compared with the acceptable limits. In accordance with the level of arsenic contamination, the tube wells with unsafe drinking water are marked red whereas the tube wells with safe drinking water are marked green. Several promotional campaigns are set up to make the people aware about arsenic pollution and are encouraged to consume only arsenic free water. Awareness is also spread to encourage use of water purifiers and filters that reduce the level of arsenic and makes the water safe for drinking.  Drinking water contaminated with arsenic one of the major threats to humans. Therefore, it becomes necessary to mitigate arsenic pollution to reduce the health hazards. There are several remediation techniques which include membrane technologies, oxidation, coagulation flocculation, ion exchange, phytoremediation, adsorption, and electro kinetics. All these techniques help in removing arsenic concentration from drinking water.

Arsenic pollution in Bangladesh has become a major health hazard in the recent years. The country has more than 10 million tube- wells, which supply ground water affected by arsenic pollution. The arsenic concentration in groundwater has been reported to be more than 50 micrograms/L, which makes the water unfit for consumption. Several reports have stated that more than two- third of the population in Bangladesh has been affected by arsenic pollution (Talbot & Verrinder, 2009). The major reason behind this has been late identification of the issues and neglecting the issue. The chances of developing cancer have been very high among the Bangladeshis along with the people of West Bengal. Contamination of arsenic in soil, drinking water and vegetables has been a common scenario in Bangladesh. Bangladesh has been facing severe threats from arsenic pollution and has become the worst case of arsenic pollution in the world. Usually arsenic gets dissolved with the underground water through the use of fertilizers, insecticides, mining activities and herbicides. A major source of groundwater contamination is irrigation of crops especially rice in Bangladesh. Mining activities highly impact the freshwaters as it increases the level of arsenic content in the freshwaters. The industrial effluents and the mining effluents affect the freshwaters, which when gets mixed with marine waters, leads to arsenic pollution. The excessive use of insecticides, fertilizers and pesticides has also led to soil contamination in Bangladesh, which has increased the level of arsenic contamination in food crops (Rahman, Dong & Naidu, 2015).   

Impact of Arsenic pollution on human health

The aim of the study is to collect high-level evidence of whether providing education and water purifiers can reduce arsenic poisoning in rural Bangladesh

The following are the objectives of the study:

  • To know the level of awareness about arsenic pollution in rural areas
  • Evaluate Behavioral change education for  farmers  in rural Bangladesh
  • To reduce arsenic poisoning by providing water purifiers

The following are the research questions:

  • Can education of  farmers in rural areas decrease arsenic poisoning
  • is the intervention education, awareness campaigns and supply of water purifiers to rural farmers cost effective?

The study shall involve quantitative research paradigm. The rural participants (farmers) will be directly surveyed regarding the impact of arsenic pollution on them and their nearby surroundings. The sample size will include 1000 members including  farmers. It will help to know the level of awareness among the people regarding arsenic pollution in Bangladesh. It is expected that more than 80% of the respondents shall provide appropriate answers. From the percentage of people demonstrating low awareness of arsenic poisoning, few will be selected for randomized control trial.

Based on the survey response, an effectiveness trial will be conducted among the rural population. For this trial the intervention includes increasing awareness by education, and provides them with water purifiers. Followed by interventions,  the goal is to assess the impact of the awareness and use of the water purifiers.

In the randomized pair, the farmers in the rural areas will be randomized in each pair. One of the pair will be allocated to the intervention group randomly and other to the control group.  A total of 500 farmers will be included in the trial.

For randomized trial, the participants in the trial groups will be provided with education and water purifiers to assess the impact of this method in reducing arsenic related health issues.

The intervention will be educational support and training of the farmers. Education of farmers through books, television and videos on –

  • On farming techniques that can prevent arsenic poisoning and
  • On cautious use of the pesticides and fertilizers.
  • Proper use of water poisoning
  • Regular health check up for arsenic poisoning

The participants in the control group of RCT group will receive no education or the purifiers.  

  • Farmers within age limit 25-30 years, unable to access safe water, lack awareness as identified from the survey
  • Those accessing safe water or using filters or boiled water are excluded
  • Farmers using green manure or biofertilisers will be excluded

The primary study outcome will be greater participation of the farmers in remedial measures such as health checkups or use of water purifiers followed this intervention. The primary outcomes will be depicted as binary elements: category 1 if the level of awareness increases and improves health in first year and category 2 if there is no increase in awareness and no improvement in health.

 The cost-effectiveness analysis will be based-

  • On costs and outcomes observed in the trials.

The costs of the intervention will include the-

  • Cost of the communication materials,
  • Cost of recruiting the retired health professional and
  • Organizational costs associated with service delivery
  • Analysis of financial records of the health care programs
  • Analysis of health service facilities involved in the trials

As per the literature search, the potential risk factors that would affect the results are-

 Proximate determinants- number of people correctly used purifiers, attends regular health checkups, was aware of causes of arsenic poisoning and adhered to guidelines given by researcher.

Arsenic pollution mitigating techniques

Social determinants- social disparities in terms of living, status,  educational attainment, accessibility to health care .

Economic determinants- difference of wealthy and poor households that effects the Social and Spatio-Temporal Patterns of arsenic exposure.

Health data- Staff will be trained on collecting health data prior to intervention

To ensure that the results are not manipulated, prior to randomized control trial the participant’s health data will be collected. It will help to know the level of arsenic exposure already present in them. Based on the intervention results, it will be easy to know the change in the arsenic poisoning before and after the intervention.

The following are the strategies that shall ascertain the positive impact of the action plan:

  • Linking the action plan with the long- term vision
  • Ensuring that the plan is realistic
  • Ensuring whether the plan is integrated or not
  • Ensuring whether the plan is balanced or not
  • Ensuring whether the plan is complete or not

In this study, both primary and secondary data collection methods shall be used to ensure that the objectives of the study are achieved. Further data collection method includes-

  • paper based checklists/ questionnaires
  • System of field data editing
  • Data entry screening checks
  • Web based data entry using open source software (called open clinical data entry)- applicable for trial group
  • System of error reporting           

Throughout the research study, it shall be ensured that the action plan shall be developed based upon the genuine data collected from the respondents. The information shall be kept confidential and the budget shall be appropriately utilized. Respect and dignity of the participants will be maintained. There is no advocacy of new drugs and participants will not be forced to participate. Informed consent will be taken prior to intervention. Ethical approval from local committee will be taken. Sincere efforts will be made to cause no harm to the participants.       

Developing educational plan in simple language and easy to understand format will ensure positive outcomes.

The following are the anticipated outcomes of the health promotion intervention:

  • Increase in the awareness related to arsenic poisoning in Bangladesh especially the rural areas.
  • Proper identification of the areas affected by arsenic poisoning
  • Increased knowledge of the farmers regarding their farming practices and their impact on the increase of arsenic poisoning
  • Increase in the use of water filters that help in eliminating arsenic from the drinking water
  • Proper identification of the patients affected by arsenic poisoning
  • Decrease in the number of people affected by arsenic poisoning especially economically backward people
  • Improvement in the health of the people in Bangladesh and reduction in the arsenic contamination in soil

The trial may run for period of 4 years

Work to be accomplished 

Year 1 

Quarters 

Year 2 

Quarters 

Year 3 

Quarters 

Year 4 

Quarters 

Ethics clearance

Formative research 

Develop intervention

Develop study instruments 

Enrolment of study subjects 

Implementation of intervention

Evaluation 

Follow up of participants

Data entry

Data analysis

 Figure 1: Proposed Timeline

(Source: Author’s work) 

Summary

              $ 

(a) 

Materials and consumables

240,521

(b) 

Staff salaries

1,659,612

(c) 

Equipment (stationery, data collection instruments etc)

180,923 

(d) 

Travel and communication

236,293

(e) 

Miscellaneous 

116,113 

Total direct costs

2,243,789 

Indirect costs (15% of subtotal) 

275,630

GRAND TOTAL

$ 49,552,881

References:

Chakraborti, D., Rahman, M. M., Mukherjee, A., Alauddin, M., Hassan, M., Dutta, R. N., ... & Rahman, M. (2015). Groundwater arsenic contamination in Bangladesh—21 Years of research. Journal of Trace Elements in Medicine and Biology, 31, 237-248.

Hoque, M. E., Karim, S., Jahan, N., & Aziz, M. T. (2017). Chronic Arsenic Poisoning with Skin Cancer. Anwer Khan Modern Medical College Journal, 7(2), 53-55.

New water filter to combat arsenic poisoning. (2017). IRIN. Retrieved 25 October 2017, from https://www.irinnews.org/report/76176/bangladesh-new-water-filter-combat-arsenic-poisoning

Rahman, M. M., Dong, Z., & Naidu, R. (2015). Concentrations of arsenic and other elements in groundwater of Bangladesh and West Bengal, India: potential cancer risk. Chemosphere, 139, 54-64.

Sidhu, M. S., Desai, K. P., Lynch, H. N., Rhomberg, L. R., Beck, B. D., & Venditti, F. J. (2015). Mechanisms of action for arsenic in cardiovascular toxicity and implications for risk assessment. Toxicology, 331, 78-99.

Talbot, L., & Verrinder, G. (2009). Promoting health: the primary health care approach. Elsevier Australia.

Tareq, S. M., Maruo, M., & Ohta, K. (2013). Characteristics and role of groundwater dissolved organic matter on arsenic mobilization and poisoning in Bangladesh. Physics and Chemistry of the Earth, Parts A/B/C, 58, 77-84.

Yunus, F. M., Khan, S., Chowdhury, P., Milton, A. H., Hussain, S., & Rahman, M. (2016). A review of groundwater arsenic contamination in Bangladesh: the millennium development goal era and beyond. International journal of environmental research and public health, 13(2), 215.

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