Arsenic Poisoning in Bangladesh: Health Promotion Intervention Report

This report addresses the critical public health issue of arsenic poisoning in Bangladesh. It begins with a comprehensive background, rationale, and literature review, detailing the sources of arsenic contamination, its impact on human health, and existing mitigating techniques. The report specifically focuses on the situation in Bangladesh, highlighting the severity of the problem and the need for intervention. It outlines the aims and research questions, proposing a quantitative study design with a sample size of 1000 participants to assess the effectiveness of a hypothetical health promotion intervention. The intervention involves educating farmers and providing water purifiers. The report details the study design, sampling methods, inclusion and exclusion criteria, analysis methods, and cost-effectiveness analysis, along with anticipated outcomes and a proposed timeline. The study aims to determine if education and access to water purifiers can reduce arsenic poisoning in rural Bangladesh, addressing the urgent need for solutions to this widespread health crisis.

Running head: THE ARSENIC POISONING IN BANGLADESH
The arsenic poisoning in Bangladesh
Name of the student:
Name of the University:
Author note:

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Abstract:
The report mentions the issues associated with arsenic poisoning in Bangladesh along with a
hypothetical heath promotion intervention. Bangladesh has been facing severe threats from
arsenic pollution and has become the worst case of arsenic pollution in the world. 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. The report states the aims and
objectives of the topic. The report includes the background and rationale of the topic along with
proposed hypothetical intervention. The report also mentions the budget
Table of Contents

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Background, rationale and brief literature review...........................................................................4
Background:.................................................................................................................................4
Literature review..........................................................................................................................4
Arsenic poisoning........................................................................................................................4
Sources of arsenic in the environment.........................................................................................5
Impact of Arsenic pollution on human health.............................................................................5
Arsenic pollution mitigating techniques......................................................................................6
Arsenic pollution in Bangladesh..................................................................................................7
Aims and research question:............................................................................................................8
Research questions:.........................................................................................................................8
Study design and Sample size..........................................................................................................8
Recruitment, intervention and assessment chart............................................................................10
Sampling methods, inclusion and exclusion criteria.....................................................................11
Analysis method and Cost-effectiveness analysis:........................................................................12
Measurements................................................................................................................................12
Data collection method:.................................................................................................................13
Ethical statement:...........................................................................................................................14
Anticipated outcomes and significance:........................................................................................14
Proposed timeline..........................................................................................................................15
References:....................................................................................................................................17

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Background, rationale and brief literature review
Background:
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.
Literature review
Arsenic poisoning:
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

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level in water is considered to be between 10 and 50 parts per billion. Usually arsenic poisoning
is usually caused accidentally.
Sources of arsenic in the environment:
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.
Impact of Arsenic pollution on human health:
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

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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.
Arsenic pollution mitigating techniques:
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.

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Arsenic pollution in Bangladesh:
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).

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Aims and research question:
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
Research questions:
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?
Study design and Sample size
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.

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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.

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Number of farmers recruited in survey N-1000 Included in RCT study-500
Randomization Control 250
Intervention-250 Recruitment of farmers
Consent Baseline assessment
Education and water purifiers for farmers in intervention group Control group will have no intervention except standard health care checkups
Assessment after 12 months
Recruitment, intervention and assessment chart

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Sampling methods, inclusion and exclusion criteria
Intervention
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
Control
The participants in the control group of RCT group will receive no education or the purifiers.
Inclusion and Exclusion criteria
 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


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Analysis method and Cost-effectiveness analysis:
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
Measurements
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.

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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
Data collection method:
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

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 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
Ethical statement:
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.
Anticipated outcomes and significance:
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

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 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
Proposed timeline
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
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
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)

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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

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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
http://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.

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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.