Health Policy and Planning Advance Access published online on June 21, 2007
Health Policy and Planning, doi:10.1093/heapol/czm018
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Determinants of drinking arsenic-contaminated tubewell water in Bangladesh
1Department of Public Health, Sapporo Medical University School of Medicine, Japan.
2Department of Statistics, Jahangirnagar University, Savar, Dhaka, Bangladesh.
3Department of Public Health Medicine, Bielefeld University School of Public Health, Germany.
*Corresponding author. Department of Public Health Medicine, Bielefeld University School of Public Health, Postfach 100131, D-33501 Bielefeld, Germany. Email: mobarak.khan{at}uni-bielefeld.de or mmhkhan70{at}yahoo.com
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Abstract |
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Bangladesh has already experienced the biggest catastrophe in the world due to arsenic contamination of drinking water. This study investigates the association of drinking arsenic-contaminated water (DACW) with both personal and household characteristics of 9116 household respondents using the household data of the Bangladesh Demographic and Health Survey (BDHS) 2004. Here DACW means that arsenic level in the drinking water is greater than the permissible limit (50 µg/l) of Bangladesh. The overall rate of DACW was 7.9%. It was found to be significantly associated with education, currently working, and division of Bangladesh, either by cross tabulation or multivariate logistic regression analyses or both. Similarly, household characteristics—namely television, bicycle, materials of the wall and floor, total family members, number of sleeping rooms, and availability of foods—were significantly associated in bivariate analyses. Many household characteristics—namely electricity, television, wall and floor materials, and number of sleeping rooms—revealed significant association in the logistic regression analysis when adjusted for age, education and division. This study indicates that respondents from Chittagong division and lower socio-economic groups (indicated by household characteristics) are at significantly higher risk of DACW. These findings should be taken into account during the planning of future intervention activities in Bangladesh.
Key Words: Determinants, arsenic contamination, drinking water, Bangladesh
KEY MESSAGES
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Introduction |
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Bangladesh is a developing country overburdened with an enormous population (about 140 million living in 147 570 km2), severe poverty (rank 72nd among 94 developing countries according to the Human Poverty Index), common illiteracy and frequent natural disasters such as floods, cyclones, tidal bores and droughts. Another significant feature is its location at one of the largest river deltas in the world. The extensive networks of large (The Ganges, Brahmaputra and Meghna) and small rivers are of primary importance to the socio-economic life of the nation. It is an agricultural country with the vast majority of its people involved in food production (Frisbie et al. 2002
; NIPORT et al. 2005).
Unfortunately, arsenic contamination of groundwater (ACG) has emerged as an additional burden and further worsened the overall situation of the country. ACG in Bangladesh, which was first identified in 1993, is the biggest arsenic catastrophe in the world (Smith et al. 2000; Watanabe et al. 2001; Khan et al. 2003). This contamination of groundwater is reported as the unfortunate result of a programme designed to prevent water-borne diseases such as cholera and typhoid (McLellan 2002). Until the early 1970s, most of the people of Bangladesh drank water from shallow hand-dug wells, rivers and ponds. But those sources were highly polluted, which caused epidemics of many gastrointestinal diseases namely diarrhoea, amoebiasis, polio, typhoid and other water-borne diseases (Frisbie et al. 2002; Caldwell et al. 2003; Mahmood and Ball 2004). Consequently, both infant and child mortality rates were very high (Caldwell et al. 2003; Rahman 2003; Mahmood and Ball 2004). This situation persuaded several aid agencies (e.g. UNICEF) and the Bangladesh government to spend tens of millions of pounds on sinking tubewells for bacteria-free water. Due to easy availability, good microbiological quality and cheap technologies (Ahmed 2003), the rural population also sank many tubewells privately (Frisbie et al. 2002; Caldwell et al. 2003; Mahmood and Ball 2004). As a result, more than 97% of the rural population now drink mainly underground water (Caldwell et al. 2003; Khan et al. 2003), collected through several (8 to 12) million hand-pumped shallow tubewells (BGS and DPHE 2001; Frisbie et al. 2002).
Although the shift to groundwater helped in controlling waterborne diseases (Mahmood and Ball 2004), presently around 50% of the Bangladeshi population, living in 61 out of 64 districts, is at risk of arsenic poisoning (Fazal et al. 2001; Khan et al. 2003; Mahmood and Ball 2004). Surveying 411 Upzilas (a sub-division of a district with a police station), 270 were found to be arsenic contaminated according to the Bangladesh standard (0.05 mg/l). The most severe problem is found in the southern (coastal area) and northeastern parts of the country (Fazal et al. 2001). Recently, the Bangladesh Arsenic Mitigation Water Supply Project (BAMWSP) reported that 29% of the 4.9 million tubewells, located in 270 Upzilas, are arsenic contaminated. The number of Upzilas with contaminated tubewells of 
20%, 40%, 60%, 80% and 90% were 137 (50.7%), 88 (32.6%), 61 (22.6%), 23 (8.5%) and 11 (4.1%), respectively. The Project also identified 38 430 arsenicosis patients in the surveyed areas from 66 million people (BAMWSP 2005). A similar percentage of contaminated tubewells has been reported by other studies (BGS and DPHE 2001; Chowdhury 2004).
Initially, several hypotheses were proposed to explain the presence of arsenic in groundwater in Bangladesh, but many did not get wider support in the absence of adequate evidence (Ahmed 2003). Presently, two hypotheses—namely (a) pyrite oxidation (oxidation hypothesis) and (b) iron oxy-hydroxide reduction (reduction hypothesis)—prevail in Bangladesh (Fazal et al. 2001). The latter of these two hypotheses, iron oxy-hydroxide reduction, serves as a generic model for arsenic contamination of aquifers where waters are anoxic, particularly where organic matter is abundant (McArthur et al. 2001; Ahmed 2003).
Arsenic-contaminated drinking water is highly toxic and hazardous for human health. Chronic exposure to high levels of arsenic for a long time is reported to be associated with a variety of adverse health effects (Smith et al. 2000; Rahman et al. 2001; Mandal and Suzuki 2002; Khan et al. 2003; Rahman 2003; Chowdhury 2004; Lokuge et al. 2004; Mahmood and Ball 2004; Yoshida et al. 2004; NIPORT et al. 2005; Rahman et al. 2006). A conservative estimate indicates that there would be in excess of 290 000 cancer cases in the present generation of Bangladesh due to arsenic exposure over the recommended level (Rahman 2003). Arsenic contamination may double the mortality risk from liver, bladder and lung cancers in Bangladesh (Chen and Ahsan 2004). Another study revealed that arsenic-related diseases currently result in 9136 deaths per year and 174 174 disability-adjusted life years lost per year in those exposed to arsenic concentrations >50 µg/l (Lokuge et al. 2004). Various studies have speculated that the situation of ACG could be more alarming in future and, as a consequence, a huge number of new arsenicosis patients would be added to the existing numbers if the people live for a long time and continue to drink arsenic-contaminated water (Smith et al. 2000; Safiuddin and Karim 2001; Rahman 2002; Khan et al. 2003).
Although many studies have been conducted in Bangladesh since 1993, to our knowledge none have explicitly addressed the association between drinking arsenic-contaminated water (DACW) and personal and household characteristics. Therefore, analysing the data from the Bangladesh Demographic and Health Survey (BDHS) 2004, the present study has identified some of the personal and household characteristics that are significantly associated with DACW by both bivariate and multivariate analyses. Here DACW means that the arsenic level in the drinking water is greater than the permissible limit (50 µg/l) of Bangladesh.
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Methods |
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The detailed methodology of the BDHS 2004 has been explained elsewhere (NIPORT et al. 2005
). Briefly, this survey is a nationwide, well-designed survey that collected a lot of information using four different questionnaires, including a household questionnaire. The draft household questionnaire, which was developed after a series of meetings among experts, was finally reviewed and approved by the BDHS technical Review Committee. This survey was implemented by Mitra and Associates, a well-known Bangladeshi research firm located in Dhaka, under the authority of the National Institute for Population Research and Training (NIPORT) of the Ministry of Health and Family Welfare. ORC Macro of Calverton, Maryland, USA, provided technical assistance to the project as part of its international Demographic and Health Survey programme, and financial assistance was provided by the U.S. Agency for International Development (USAID/Bangladesh). Sample design
The 2004 BDHS used a stratified and multistage cluster sample, which included 361 primary sampling units (PSUs) (122 from the urban area and 239 from the rural area) from the whole country (which consists of six divisions and 64 districts). The Bangladesh population census of 2001 created enumeration areas, based on a convenient number of dwelling units, for collecting data. Because these sketch maps of enumeration areas were accessible, the 2004 BDHS considered enumeration areas as the PSUs. In each division, the list of enumeration areas constituted the sampling frame for the 2004 BDHS.
For collecting data, Mitra and Associates first conducted a household listing operation in all the selected PSUs from 3 October 2003 to 15 December 2003. Then a systematic sample of 10 811 households (an average of 30 households per PSU) was selected from the selected PSUs. Among the 10 811 selected households, 10 523 households were occupied during the survey time, of which 10 500 households (99.8%) were interviewed successfully. The household questionnaire was used to list all the usual members and visitors in the selected households and the interviewer assigned a unique number (called a line number) to each listed member for identification purposes. From each household, only one respondent completed the household questionnaire. Using the line number of the respondent, we recorded some of their personal characteristics: age, sex, education, marital status and working status, including background characteristics, namely place of residence and division. Information about the dwelling itself was also collected. The variables collected included: the materials used to construct the roof, wall and floor of the house; types of toilets used in the household; sources of dishwashing and drinking water; duration of using the drinking water source; level of arsenic in the water tested by Hach's EZ Arsenic kit (hereafter Hach kit), marking of tubewell (by green or red) to indicate the safeness from arsenic contamination; number of sleeping rooms in the household; ownership of various consumer goods and amenities such as electricity, radio, television, bicycle, telephone; sufficiency of food in the household for consumption in the whole year.
As our dependent variable was related to arsenic concentration in drinking water, from 10 500 household respondents we excluded 35 for which information about arsenic concentration in drinking water was missing. Again, as it is mainly the tubewell water in Bangladesh that is contaminated by arsenic, we further excluded 1349 household respondents who were not drinking tubewell water. Thus we had a total of 9116 household respondents for final analysis.
Testing kit for determining arsenic level in the water
Trained interviewers tested the household drinking water using the Hach kit, which is widely used in Bangladesh (Jalil and Ahmed 2003; NIPORT et al. 2005). This kit has a detection limit of 0.0–0.50 mg/l (colour scale for 0.0, 0.01, 0.03, 0.05, 0.07, 0.30 and 0.50 mg/l), which is equivalent to 0.0–500.0 ppb in 50 millilitres (ml) or 0.0–500.0 µg/l of water. Respondents to the household questionnaire were asked to provide a glass of the water that the household uses for drinking. If tubewell was mentioned by the respondent as a source of drinking water, this was probed then by matching the answers of two related questions. Interviewers poured 50 millilitres of given water into a special testing vessel, added two reagents in the prescribed order, and quickly closed the vessel with a cap to which a testing strip was attached. Twenty minutes later, the testing strip was removed and matched with a colour chart to determine the level of arsenic in the water (Hach Company 2001; Jalil and Ahmed 2003; NIPORT et al. 2005).
Variables selected and statistical analysis
Covariates and their classifications are shown in Tables 2 to 4. We used a dichotomous dependent variable (DACW): whether the tested water contained arsenic at the level >50 µg/l (i.e. was arsenic contaminated) or not. At first, we performed simple (frequency) tests for each covariate variable to show the distribution of respondents, and then cross tabulations to show the percentage of DACW including P values, based on 
2 tests, to indicate the association of each variable with DACW. Later we analysed the covariate variables by binary logistic regression to examine their independent effects on DACW by using odds ratios (OR) and corresponding 95% confidence intervals (CI). SPSS version 10.0 was used for analysing the data.
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Results |
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Table 1 shows that 7.9%, 2.7% and 1.1% of respondents were drinking arsenic-contaminated water which contained arsenic concentrations of >50 µg/l, >100 µg/l and >250 µg/l, respectively. About 74% of households used tubewell water for dishwashing (not shown in Table 1). Table 2 presents the percentage distribution of respondents DACW, including their distribution by some selected personal and geographic variables. DACW was found to be significantly associated with current working status (P = 0.001) and division (P < 0.001). Respondents under the category of currently working and Barisal/Rajshahi division showed significantly lower rates of DACW compared with other categories of each variable.
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Distribution of respondents by household characteristics, and the association of DACW with these characteristics, is shown in Table 3. Respondents of households which possessed a television (P = 0.050) and a bicycle (P < 0.001) showed significantly lower rates of DACW. Similarly, respondents belonging to households for which wall (P < 0.001) and floor (P = 0.001) materials were brick/concrete and cement also showed significantly lower rates of DACW. Table 4 reveals that number of family members (P < 0.001) and sleeping rooms (P < 0.001) in the households were positively associated with DACW. Availability of food in the households during the whole year was found to be negatively associated with DACW (P = 0.010).
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Although education was insignificant in bivariate analysis (Table 2), ORs estimated by multivariate logistic regression analysis (Table 5) showed that risk of DACW was 23% lower (significantly) for those respondents who had 6 years or more education (OR = 0.77, 95% CI = 0.61–0.96) than for those with no education. Urban-rural place of residence and current working status revealed insignificant association. Divisional analysis indicates that the OR for DACW was highest in Chittagong (OR = 22.07, 95% CI = 9.66–50.45), followed by Sylhet (OR = 10.76, 95% CI = 4.56–25.37), Dhaka (OR = 5.75, 95% CI = 2.51–13.20) and Khulna (OR = 4.83, 95% CI = 2.05–11.36), respectively.
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Table 6 presents the multivariate adjusted (for age, education and division) ORs of DACW, including 95% CIs for all the covariate variables shown in Tables 3 and 4. According to this analysis, respondents from households with electricity and television showed significantly lower ORs of DACW compared with the reference category. Similarly, wall and floor materials of brick/concrete and cement were associated with significantly lower risk of DACW. Significantly higher ORs of DACW were found for respondents belonging to households having three (OR = 1.34, 95% CI = 1.05–1.71) and four or more sleeping rooms (OR = 1.36, 95% CI = 1.01–1.83) compared with the reference category. Three significantly associated variables revealed by bivariate analyses—namely bicycle, total family members and availability of food—became insignificant under the multivariate adjusted logistic regression analysis.
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Discussion |
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The present cross-sectional study revealed that about 7.9% of the total respondents were drinking water from sources which contained arsenic at a level of >50 µg/l. The situation seems to be encouraging because in comparison with arsenic-contaminated tubewells, which range from 20–52% in Bangladesh (BGS and DPHE 2001
; van Geen et al. 2002; Caldwell et al. 2003; Chowdhury 2004), the percentage of household respondents DACW is much less. This may be the result of increasing awareness, which is indicated by the fact that 85% of the tubewell owners were concerned enough to retest their water for arsenic within 1 year, and 90% of the owners gathered water from their neighbours if their own water was found to be contaminated by arsenic >10 µg/l (Frisbie et al. 2005).
In view of the magnitude and severity of the arsenic problem, the government of Bangladesh and national and international aid organizations have responded to this crisis and implemented various mitigation activities. One such activity was the marking of the tubewells with red (meaning arsenic contaminated) or green (meaning not contaminated) to indicate the safeness of the water from arsenic contamination (Ahmad 2002; Hanchett et al. 2002). Unfortunately, our data showed some inconsistencies when water from previously marked green and red tubewells was retested during the survey. For example, 4.2% of the previously green-marked (safe) tubewells provided arsenic-contaminated water and 50.2% of the red-marked tubewells provided arsenic-free water (not shown). Rahman et al. (2002) also reported such inconsistencies in Bangladesh. These findings suggest that all tubewells (irrespective of red or green colour) should be tested periodically. According to Rahman et al. (2001), a 3–6 month interval between two consecutive tests is necessary to track the new development. It is important as the mislabelling of safe tubewells has a major socio-economic impact in the situation of a scarcity of uncontaminated water (Ahmad 2002).
These inconsistent findings may also be related to the quality of field kits used for arsenic testing. Field kits are not precise because the users estimate the concentration from a colour chart (Frisbie et al. 2005) and the accuracy depends on reaction time (van Geen et al. 2005a). Although laboratory tests provide higher accuracy, it is not realistic to expect such an approach to allow testing on demand; it would be nearly impossible to perform several millions of laboratory analyses in a few centralized locations and to communicate these results back to individual households in Bangladesh (van Geen et al. 2005b). Perhaps for this reason, BAMWSP assessed the performances of five different field kits in Bangladesh during 2001 and selected the Hach kit for testing tubewells as it provided the best score (Khaliquzzaman and Khan 2003). Two recent studies reported the accuracy of the Hach kit (van Geen et al. 2005a; Steinmaus et al. 2006). Van Geen et al. (2005a) found that 88% of the results obtained by the Hach kit were accurate according to a laboratory method. Steinmaus et al. (2006) also suggest that the Hach test is highly capable of detecting arsenic concentration close to 10 µg/l. Based on experience, Polya et al. (2005) stated that data quality and the Hach kit's usefulness depend critically on the training and robust implementation of procedures by field operators. Finally, as the cost of laboratory testing is many times higher (Ahmad 2002) and laboratory facilities are less accessible to the vast majority of people, it is likely that field kits will continue to be used in the near future until a network of laboratories is established in the country for testing arsenic at a reasonable cost (Jalil and Ahmed 2003).
In the context of Bangladesh, people who are living in houses with brick/concrete and cement walls and floors are socio-economically better off than others. Similarly, possession of household amenities such as electricity and television are some of the indicators of high socio-economic status, as is food availability in the household. Food deficiency indicates that people are not well off. Many factors such as low income due to low education and having insufficient land may be related to the deficiency of food throughout the year. Our results revealed that relatively rich people (indicated by above-mentioned household characteristics) are at lower risk of DACW compared with poor people. It is expected that socio-economically wealthy people are better educated and more health conscious than poor people. These arguments are consistent with the findings of Hadi (2003). Wealthy people have a higher capability to replace their arsenic-contaminated tubewells with new, deeper ones, compared with poor people. It is reported that deeper tubewells produce less arsenic-contaminated water compared with shallower ones (Kamal and Parkpian 2002; van Geen et al. 2002; van Geen et al. 2003; Chowdhury 2004; Rahman et al. 2005).
Television has been disseminating the consequences of drinking arsenic-contaminated water over the last few years to motivate people to drink arsenic-free water in Bangladesh. Hadi (2003) reported that exposure to electric media significantly raised the knowledge level of people regarding arsenic issues, irrespective of their education. According to the present study, having a television in the household was significantly negatively associated with DACW, even after adjusting for age, education and division (Table 6). However, this relationship became weaker and insignificant (OR = 0.87; 95% CI = 0.69–1.10) when two more household variables, namely floor and wall materials, were adjusted (not shown). It is therefore not clear whether the effect of television should be interpreted in terms of its function as a source of information, or as another indicator of socio-economic status.
Our results revealed that households with higher numbers of members are positively associated with DACW. The reasons are not yet known. One of the possible explanations may be related to the underlying negative association between household wealth and household size. According to the report, wealth index is negatively associated with household size and DACW (NIPORT et al. 2005). Another possible explanation may be that larger households need more water for drinking and cooking purposes, and hence they pump more water from the same source, which may increase the arsenic level in the water.
The significant difference by division in DACW may be attributed to the sources of drinking water. Data indicated that the percentage of household respondents who were drinking water from red tubewells was highest for Chittagong division (14.0%), followed by Dhaka (8.8%), Khulna (8.7%), Sylhet (6.4%), Barisal (1.8%) and Rajshahi (0.5%) divisions, respectively (data not shown). These divisional differences may be due to large variations in arsenic contamination, even within the small geographical area of Bangladesh (Watanabe et al. 2001), in awareness about the meaning of red or green coloured tubewells, as well as variations in the availability of green tubewells in some areas (Hanchett et al. 2002). These findings indicate that more prevention activities are needed in Chittagong, Dhaka, Khulna and Sylhet divisions than in Barisal and Rajshahi divisions.
As ACG is a serious public health problem in Bangladesh (Khan et al. 2003), the combined forces of politicians, public health experts, epidemiologists, statisticians and scientists from many disciplines, including social sciences and geosciences, are needed (McLellan 2002) to reduce the arsenic-related consequences for several million people in Bangladesh (Rahman et al. 2001; Safiuddin and Karim 2001; McLellan 2002; Hadi 2003; Rahman et al. 2006). In particular, an integrated and comprehensive approach is required to supply and monitor safe, arsenic-free drinking water for the currently exposed population. Options already recommended by various studies are: (i) identification of a nearby tubewell with water of low arsenic concentration; (ii) installation of community wells where the proportion of safe wells is particularly low and the sharing of tubewells is consequently not a viable option; (iii) close down highly contaminated tubewells where an alternative water source is available; (iv) share nearby arsenic-free tubewells; (v) proper watershed management, treating surface and ground water; (vi) rain water harvesting; (vii) traditional water management, such as dug well and surface water, with controls of bacterial and other chemical contamination through filtration and chlorination; (viii) increasing public awareness of the arsenic calamity and assurance that it is not a curse of God; and (ix) informing people that there is no effective therapy (Smith et al. 2000; Rahman et al. 2001; Safiuddin and Karim 2001; Rahman 2002; Caldwell et al. 2003; van Geen et al. 2003; Mahmood and Ball 2004; Rahman et al. 2005). Community education, mobilization, motivation and proper monitoring may be essential for a sustainable solution to the problem (Smith et al. 2000; Rahman 2002).
Although water from deep aquifers was thought to be least or not contaminated, recent statistics show that it is no longer a safe option (Rahman et al. 2001; Ahmed 2003; BAMWSP 2005). Bangladesh depends heavily on groundwater for all major uses, both in urban and in rural areas. It is an agriculture-based country, where the agricultural system is almost groundwater dependent (Ahmed 2003). The massive extraction of groundwater for irrigation, which may alter the aquifer, is hypothesized as one of the causes of the arsenic problem in deep aquifers (Safiuddin and Karim 2001). Another reason may be leakage from shallow aquifers to deep aquifers (Hanchett et al. 2002; Ahmed 2003). These findings suggest that there should be no hydraulic connection between the upper and lower aquifers (Ahmed 2003), and the drilling process needs to be refined so that the deeper aquifers are not contaminated by arsenic-bearing water trickling down from the shallow aquifers through the boreholes themselves (Smith et al. 2000; Chowdhury 2004). It is also important to find ways to reduce the use of underground water. Unfortunately, there are no regulations on groundwater withdrawal in Bangladesh. Therefore, the withdrawal of underground water should be checked by local and national governments through drawing up and implementing regulations on the boring of new tubewells (Rahman et al. 2001) and on limiting the indiscriminate extraction of groundwater (Safiuddin and Karim 2001).
There may be other potential responses to the arsenic crisis. For instance, photos of individuals who have skin lesions caused by arsenic should be displayed in the arsenic-contaminated areas. As 95% of the population lives within 200 metres of a safe well, people should be motivated to shift from the unsafe to safe tubewells. But switching families to other tubewells is sometimes difficult, as most tubewells are privately owned and women are traditionally restricted from leaving their local communities unless accompanied by a man. Moreover, some people think that losing their own wells means losing their standard of living (Mahmood and Ball 2004). Increasing education seems to be another important strategy as higher educated people show significantly lower rates of DACW.
As arsenic toxicity is more pronounced among poor and malnourished groups of people (Kamal and Parkpian 2002; Mahmood and Ball 2004), health education programmes should be targeted to the lower socio-economic strata to encourage switching wells (Parvez et al. 2006). Moreover, mitigation/intervention activities should be targeted to those areas where exposure has been confirmed (e.g. Chittagong division). However, it must be ensured that these interventions will significantly reduce arsenic exposure without a concomitant substantial increase in other risks such as water-related infectious disease (Lokuge et al. 2004).
The main strength of the study is that it is the first national study, to our knowledge, to investigate the association of DACW with numerous household characteristics, in addition to personal characteristics. Therefore, the study findings should help in designing further studies and policies at the national level.
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Conclusion |
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Overall, 7.9% of respondents drank water from arsenic-contaminated tubewells, which seems to be very encouraging. The situation has certainly improved because previous studies reported that almost 50% of people were at risk of arsenic contamination. This improvement may be the result of various mitigation activities which have already taken place in Bangladesh, by both national and international experts and organizations. However, further research is still needed to minimize the divisional differences in arsenic-free water supply. More mitigation activities are needed in the more contaminated areas, particularly in Chittagong division where the prevalence of DACW is highest. Similarly, as DACW in poor socio-economic groups is significantly higher, and poor people suffer from more arsenic toxicity, more intervention activities may be useful for them. At the same time, some population-wide programmes, irrespective of socio-economic status, are needed, as the whole country is affected and most people in Bangladesh are poor by international standards. The findings of the present study should be taken into account during the planning of future intervention activities in Bangladesh.
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Acknowledgements |
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We thank Professor Alexander Kraemer, Department of Public Health Medicine, Bielefeld University School of Public Health, Germany, for his valuable suggestions and support in finalizing the paper.
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Accepted for publication 29 March 2007.
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