Arsenic in private well water part 1 of 3: Impact of the New Jersey Private Well Testing Act on household testing and mitigation behavior

A Mixed Methods Approach to Understanding the Public Health Impact of a School-Based Citizen Science Program to Reduce Arsenic in Private Well Water

BACKGROUND

Exposure to arsenic (As) in well water is a well-documented public health issue for Maine and New Hampshire, as well as for other states in the United States and abroad. Arsenic contamination of well water in these locations is primarily attributed to metasedimentary bedrock that leaches As into groundwater. However, As can also enter groundwater reserves from soils contaminated by the historical use of arsenical pesticides. Approximately half of the households in Maine and New Hampshire rely on private wells, many of which have elevated As. Arsenic exposure has been associated with an increased risk of cancer, cardiovascular disease, reduced infection resistance, and lower intelligence quotient in children. Despite these known health impacts, well water testing and treatment are not universal.

OBJECTIVES

We have approached the problem of low well water testing rates in Maine and New Hampshire communities by developing the All About Arsenic (AAA) project, which engages secondary school teachers and students as citizen scientists in collecting well water samples for analysis of As and other toxic metals and supports their outreach efforts to their communities.

METHODS

We assessed this project's public health impact by analyzing student data relative to existing well water quality datasets in both states. In addition, we surveyed private well owners who contributed well water samples to the project to determine the actions taken to mitigate As in well water.

RESULTS

Students collected 3,070 drinking water samples for metals testing, and 752 exceeded New Hampshire's As standard of 5  ppb . The AAA data has more than doubled the amount of information available to public health agencies about well water quality in multiple municipalities across both states. Students also collected information about well types and treatment systems. Their data reveal that some homeowners did not know what type of wells they had or whether they had filtration systems. Those with filtration systems were often unaware of the type of system, what the system was filtering for, or whether the system was designed to remove As. Through interviews with pilot survey participants, we learned that some had begun mitigating their exposure to As and other toxic metals in response to test results from the AAA project.

DISCUSSION

A school-based approach to collecting and analyzing private well water samples can successfully reach communities with low testing rates for toxic elements, such as As and other metals. Importantly, information generated through the program can impact household decision-making, and students can influence local and state policymaking by sharing information in their communities. https://doi.org/10.1289/EHP13421.

An overview of the Be Well Home Health Navigator Program to reduce contaminants in well water: Design and methods

BACKGROUND

The Be Well Home Health Navigator Program is a prospective, randomized controlled trial (RCT) implemented to compare a community health navigator program to usual care program to reduce contaminants in drinking water.

DESIGN AND SETTING

This 4-year two-armed RCT will involve well owners in Oregon that have private drinking water wells that contain arsenic, nitrate, or lead above maximum contaminant levels.

INTERVENTION

The intervention leverages the trusted relationship between Cooperative Extension Service (CES) Community Educators and rural well owners to educate, assist and motivate to make decisions and set actionable steps to mitigate water contamination. In this study, CES will serve as home health navigators to deliver: 1) individualized feedback, 2) positive reinforcement, 3) teach-back moments, 4) decision-making skills, 5) navigation to resources, 6) self-management, and 7) repeated contact for shaping and maintenance of behaviors. Usual care includes information only with no access to individual meetings with CES.

MEASURABLE OUTCOMES

Pre-specified primary outcomes include 1) adoption of treatment to reduce exposure to arsenic, nitrate, or lead in water which may include switching to bottled water and 2) engagement with well stewardship behaviors assessed at baseline, and post-6 and 12 months follow-up. Water quality will be measured at baseline and 12-month through household water tests. Secondary outcomes include increased health literacy scores and risk perception assessed at baseline and 6-month surveys.

IMPLICATIONS

The results will demonstrate the efficacy of a domestic well water safety program to disseminate to other CES organizations.

TRIAL REGISTRATION NUMBER

NCT05395663.

Effect of an Arsenic Mitigation Program on Arsenic Exposure in American Indian Communities: A Cluster Randomized Controlled Trial of the Community-Led Strong Heart Water Study Program

BACKGROUND

Chronic arsenic exposure has been associated with an increased risk of cardiovascular disease; diabetes; cancers of the lung, pancreas and prostate; and all-cause mortality in American Indian communities in the Strong Heart Study.

OBJECTIVE

The Strong Heart Water Study (SHWS) designed and evaluated a multilevel, community-led arsenic mitigation program to reduce arsenic exposure among private well users in partnership with Northern Great Plains American Indian Nations.

METHODS

A cluster randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the SHWS arsenic mitigation program over a 2-y period on a) urinary arsenic, and b) reported use of arsenic-safe water for drinking and cooking. The cRCT compared the installation of a point-of-use arsenic filter and a mobile Health (mHealth) program (3 phone calls; SHWS mHealth and Filter arm) to a more intensive program, which included this same program plus three home visits (3 phone calls and 3 home visits; SHWS Intensive arm).

RESULTS

A 47% reduction in urinary arsenic [geometric mean  ( GM ) = 13.2  to  7.0 μ g / g creatinine] was observed from baseline to the final follow-up when both study arms were combined. By treatment arm, the reduction in urinary arsenic from baseline to the final follow-up visit was 55% in the mHealth and Filter arm (GM = 14.6  to  6.55 μ g / g creatinine) and 30% in the Intensive arm (GM = 11.2  to  7.82 μ g / g creatinine). There was no significant difference in urinary arsenic levels by treatment arm at the final follow-up visit comparing the Intensive vs. mHealth and Filter arms: GM ratio of 1.21 (95% confidence interval: 0.77, 1.90). In both arms combined, exclusive use of arsenic-safe water from baseline to the final follow-up visit significantly increased for water used for cooking (17% to 53%) and drinking (12% to 46%).

DISCUSSION

Delivery of the interventions for the community-led SHWS arsenic mitigation program, including the installation of a point-of-use arsenic filter and a mHealth program on the use of arsenic-safe water (calls only, no home visits), resulted in a significant reduction in urinary arsenic and increases in reported use of arsenic-safe water for drinking and cooking during the 2-y study period. These results demonstrate that the installation of an arsenic filter and phone calls from a mHealth program presents a promising approach to reduce water arsenic exposure among private well users. https://doi.org/10.1289/EHP12548.

Faucet-mounted point-of-use drinking water filters to improve water quality in households served by private wells

Approximately 13 % of Americans rely on private wells for household potable water. As private wells are not regulated beyond initial construction and often employ limited or no treatment, source water from wells can be vulnerable to contamination. While several studies have assessed applications of point-of-use (POU) filters in improving municipal tap water quality, few have investigated their use with private well water. This effort aims to build on previous examinations of POU treatment as a strategy to reduce adverse household drinking water exposures by: 1) assessing the effectiveness of commercially available faucet-mounted POU filters for improving microbial and chemical water quality in homes with private wells; and 2) documenting household ease of use and satisfaction with the filters. Faucet-mounted POU filters were distributed to 21 homes reliant on private wells in southern West Virginia and southwestern Virginia. Study participants were asked to collect water samples from two taps in their homes pre-filter installation, and again two-weeks and four-weeks post-installation. Participants filled out surveys about perceptions of their drinking water and the filter. Concentrations of Total Coliform, Ba, Cd, Cr, U, Cu, Pb, Al, Fe, Mn, Zn, and Sr were significantly lower (p < 0.05, Wilcoxon Rank Sum) in filtered water samples compared to paired unfiltered samples (n = 42) for the study period. However, concentrations of certain contaminants in filtered samples from homes with high levels of source water contamination still exceeded drinking water standards. Less than half of study participants reported that they intended to keep using the filters, citing issues of flowrate. Our findings suggest that faucet-mounted POU filters, while effective in reducing contaminants, might not be an appropriate intervention to improve water quality for all homes on private well water. Future investigation is required to improve filter user satisfaction and better assess appropriate source water chemistries for implementation.

Arsenic Exposure in Well Water From the Perspective of Patients and Providers

BACKGROUND

Arsenic is a well-known toxin which may contaminate household water. It is harmful when ingested over prolonged periods of time. As a result, public health experts recommend that water should be screened and treated to prevent arsenic ingestion. In the United States, the responsibility of testing and treatment of private wells falls on homeowners. Despite recommendations for routine screening, this is rarely done.

OBJECTIVES

To assess the prevalence of well water use in a Midwestern patient population, how patients and clinicians perceive the risks of arsenic in well water, and whether additional resources on well water testing are desired. These findings will be used to influence tools for clinicians regarding symptom and examination findings of chronic arsenic exposure and potentiate the distribution of informational resources on well water testing.

METHODS

Surveys were sent via email to all actively practicing primary care clinicians at the Mayo Clinic in the United States Midwest, and all active adult patients at the Mayo Clinic in the same region. Our team analyzed survey data to determine whether both patients and clinicians are aware of the health effects of chronic arsenic toxicity from well water, the need for routine well water testing and whether each group wants more information on the associated risks.

RESULTS

Both patients and primary care clinicians worry about arsenic exposure. Patients with well water are concerned about their water safety yet feel uninformed about testing options. Clinicians do not know how prevalent well water use is among their patients, feel uninformed about the chronic risks of arsenic exposure and the physical examination associated with it. Both groups unanimously want more information on testing options.

CONCLUSIONS

Our findings show a significant reliance on well water use in the American Midwest, and unanimous support for the need for further well water testing information and resources for patients and their clinicians.

Mechanistic Study of Arsenate Adsorption onto Different Amorphous Grades of Titanium (Hydr)Oxides Impregnated into a Point-of-Use Activated Carbon Block

Millions of households still rely on drinking water from private wells or municipal systems with arsenic levels approaching or exceeding regulatory limits. Arsenic is a potent carcinogen, and there is no safe level of it in drinking water. Point-of-use (POU) treatment systems are a promising option to mitigate arsenic exposure. However, the most commonly used POU technology, an activated carbon block filter, is ineffective at removing arsenic. Our study aimed to explore the potential of impregnating carbon blocks with amorphous titanium (hydr)oxide (THO) to improve arsenic removal without introducing titanium (Ti) into the treated water. Four synthesis methods achieved 8-16 wt.% Ti loading within the carbon block with 58-97% amorphous THO content. The THO-modified carbon block could adsorb both oxidation states of arsenic (arsenate and arsenite) in batch or column tests. Modified carbon block with higher Ti and amorphous content always led to better arsenate removal, achieving arsenic loadings up to 31 mg As/mg Ti after 70,000 bed volumes in continuous flow tests. Impregnating carbon block with amorphous THO consistently outperformed impregnation using crystalline TiO2. The best-performing system (TTIP-EtOH carbon block) was an amorphous THO derived using titanium isopropoxide, ethanol, and acetic acid via sol-gel technique, aged at 80° for 18 hours and dried overnight at 60°. Comparable pore size distribution and surface area of the impregnated carbon blocks suggested that chemical properties play a more crucial role than physical and textural properties in removing arsenate via amorphous Ti-impregnated carbon block. Freundlich isotherms indicated energetically favorable adsorption for amorphous chemically synthesized adsorbents. The mass transport coefficients for the amorphous TTIP-EtOH carbon block were fitted using a pore surface diffusion model, resulting in Dsurface = 3.1×10-12 cm2/s and Dpore = 3.2×10-6 cm2/s. Impregnating the carbon block with THO enabled effective arsenic removal from water without adversely affecting the pressure drop across the unit or the carbon block's ability to remove polar organic chemical pollutants efficiently.

Behavioral determinants of arsenic-safe water use among Great Plains Indian Nation private well users: results from the Community-Led Strong Heart Water Study Arsenic Mitigation Program

BACKGROUND

The objective of this study was to evaluate the behavioral determinants associated with exclusive use of arsenic-safe water in the community-led Strong Heart Water Study (SHWS) arsenic mitigation program.

METHODS

The SHWS is a randomized controlled trial of a community-led arsenic mitigation program designed to reduce arsenic exposure among private well users in American Indian Great Plains communities. All households received point-of-use (POU) arsenic filters installed at baseline and were followed for 2 years. Behavioral determinants selected were those targeted during the development of the SHWS program, and were assessed at baseline and follow-up.

RESULTS

Among participants, exclusive use of arsenic-safe water for drinking and cooking at follow-up was associated with higher self-efficacy for accessing local resources to learn about arsenic (OR: 5.19, 95% CI: 1.48-18.21) and higher self-efficacy to resolve challenges related to arsenic in water using local resources (OR: 3.11, 95% CI: 1.11-8.71). Higher commitment to use the POU arsenic filter faucet at baseline was also a significant predictor of exclusive arsenic-safe water use for drinking (OR: 32.57, 95% CI: 1.42-746.70) and cooking (OR: 15.90, 95% CI: 1.33-189.52) at follow-up. From baseline to follow-up, the SHWS program significantly increased perceived vulnerability to arsenic exposure, self-efficacy, descriptive norms, and injunctive norms. Changing one's arsenic filter cartridge after installation was associated with higher self-efficacy to obtain arsenic-safe water for drinking (OR: 6.22, 95% CI: 1.33-29.07) and cooking (OR: 10.65, 95% CI: 2.48-45.68) and higher perceived vulnerability of personal health effects (OR: 7.79, 95% CI: 1.17-51.98) from drinking arsenic-unsafe water.

CONCLUSIONS

The community-led SHWS program conducted a theory-driven approach for intervention development and evaluation that allowed for behavioral determinants to be identified that were associated with the use of arsenic safe water and changing one's arsenic filter cartridge. These results demonstrate that theory-driven, context-specific formative research can influence behavior change interventions to reduce water arsenic exposure. The SHWS can serve as a model for the design of theory-driven intervention approaches that engage communities to reduce arsenic exposure.

TRIAL REGISTRATION

The SHWS is registered with ClinicalTrials.gov (Identifier: NCT03725592).

Evaluation of a water arsenic filter in a participatory intervention to reduce arsenic exposure in American Indian communities: The Strong Heart Water Study

Many rural populations, including American Indian communities, that use private wells from groundwater for their source of drinking and cooking water are disproportionately exposed to elevated levels of arsenic. However, programs aimed at reducing arsenic in American Indian communities are limited. The Strong Heart Water Study (SHWS) is a randomized controlled trial aimed at reducing arsenic exposure among private well users in American Indian Northern Great Plains communities. The community-led SHWS program installed point-of-use (POU) arsenic filters in the kitchen sink of households, and health promoters delivered arsenic health communication programs. In this study we evaluated the efficacy of these POU arsenic filters in removing arsenic during the two-year installation period. Participants were randomized into two arms. In the first arm households received a POU arsenic filter, and 3 calls promoting filter use (SHWS mobile health (mHealth) & filter arm). The second arm received the same filter and phone calls, and 3 in-person home visits and 3 Facebook messages (SHWS intensive arm) for program delivery. Temporal variability in water arsenic concentrations from the main kitchen faucet was also evaluated. A total of 283 water samples were collected from 50 households with private wells from groundwater (139 filter and 144 kitchen faucet samples). Ninety-three percent of households followed after baseline had filter faucet water arsenic concentrations below the arsenic maximum contaminant level of 10 μg/L at the final visit during our 2 year study period with no difference between study arms (98 % in the intensive arm vs. 94 % in the mHealth & filter arm). No significant temporal variation in kitchen arsenic concentration was observed over the study period (intraclass correlation coefficient = 0.99). This study demonstrates that POU arsenic filters installed for the community participatory SHWS program were effective in reducing water arsenic concentration in study households in both arms, even with delivery of the POU arsenic filter and mHealth program only. Furthermore, we observed limited temporal variability of water arsenic concentrations from kitchen faucet samples collected over time from private wells in our study setting.

Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program

Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.

Revealing the sources of arsenic in private well water using Random Forest Classification and Regression

Exposure to arsenic through private drinking water wells causes serious human health risks throughout the globe. Water testing data indicates there is arsenic contamination in private drinking water wells across New Jersey. To reduce the adverse health risk due to exposure to arsenic in drinking water, it is necessary to identify arsenic sources affecting private wells. Private wells are not regulated by any federal or state agencies through the Safe Drinking Water Act and therefore information is often lacking. To this end, we have developed machine learning algorithms including Random Forest Classification and Regression to decipher the factors contributing to higher arsenic concentration in private drinking water wells in west-central New Jersey. Arsenic concentration in private drinking water wells served as a response variable while explanatory variables were geological bedrock type, soil type, drainage class, land use/cover, and presence of orchards, contaminated sites, and abandoned mines within the 152.4-meter (500 ft) radius of each well. Random Forest Classification and Regression achieved 66 % and 55 % prediction accuracies for arsenic concentration in private drinking water wells, respectively. Overall, both models identify that bedrock, soil, land use/cover, and drainage type (in descending order) are the most important variables contributing to higher arsenic concentration in well water. These models further identify bedrock subgroups at a finer scale including Passaic Formation, Lockatong Formation, Stockton Formation contributing significantly to arsenic concentration in well water. Identification of sources of arsenic contamination in private drinking water wells at such a fine scale facilitates development of more targeted outreach as well as mitigation strategies to improve water quality and safeguard human health.

Targeted Private Well Outreach Following a Change in Drinking Water Standard: Arsenic and the New Jersey Private Well Testing Act

CONTEXT

When the New Jersey Private Well Testing Act (PWTA) became effective in 2002, the maximum contaminant level (MCL) for arsenic in the United States was 50 μg/L. In 2006, the federal and New Jersey MCLs were lowered to 10 μg/L and 5 μg/L, respectively.

OBJECTIVE

To notify and provide free arsenic water testing for homeowners who had a PWTA arsenic result that passed for the MCL in 2006 or earlier but would exceed under the more health protective MCL enacted in 2006, which is still in effect as of this publication date.

DESIGN

About 1200 homeowners with PWTA arsenic results between 5 μg/L and 50 μg/L were offered free arsenic water testing. More than 400 homeowners requested tests and 292 returned samples.

SETTING

New Jersey, United States.

PARTICIPANTS

Homeowners with a passing PWTA arsenic result before 2006 that would have failed under the New Jersey arsenic MCL enacted in 2006.

MAIN OUTCOME MEASURES

Return rate of testing kits; number of tests exceeding arsenic MCL; and participant survey results.

RESULTS

Untreated well water samples (n = 279) were collected and 62.4% exceeded the New Jersey MCL. Treated well water samples (n = 102) were collected and 11.8% exceeded the current New Jersey MCL. In all, about 40% of drinking water samples from the tap, including those with or with no arsenic treatment, exceeded the New Jersey MCL. A survey of participants (n = 69) found that although many (67%) respondents reported that they at least had some idea that wells in their area are vulnerable to naturally occurring contaminants, such as arsenic, many (68%) reported that they had little or no idea that the New Jersey arsenic MCL had been lowered from 50 μg/L to 5 μg/L in 2006.

CONCLUSIONS

This effort further illuminates the necessity and significance of public health outreach for private well water users, especially after drinking water standards change.

Naturally occurring metals in unregulated domestic wells in Nevada, USA

The dominant source of drinking water in rural Nevada, United States, is privately-owned domestic wells. Because the water from these wells is unregulated with respect to government guidelines, it is the owner's responsibility to test their groundwater for heavy metals and other contaminants. Arsenic, lead, cadmium, and uranium have been previously measured at concentrations above Environmental Protection Agency (EPA) guidelines in Nevada groundwater. This is a public health concern because elevated levels of these metals are known to have negative health effects. We recruited individuals through a population health study, the Healthy Nevada Project, to submit drinking water samples from domestic wells for testing. Water samples were returned from 174 households with private wells. We found 22 % had arsenic concentrations exceeding the EPA maximum contaminant level (MCL) of 10 μg/L. Additionally, federal, state, or health-based guidelines were exceeded for 8 % of the households for uranium and iron, 6 % for lithium and manganese, 4 % for molybdenum, and 1 % for lead. The maximum observed concentrations of arsenic, uranium, and lead were ∼80, ∼5, and ∼1.5 times the EPA guideline values, respectively. 41 % of households had a treatment system and submitted both pre- and post-treatment water samples from their well. The household treatments were shown to reduce metal concentrations, but concentrations above guideline values were still observed. Many treatment systems cannot reduce the concentration below guideline values because of water chemistry, treatment failure, or improper treatment techniques. These results show the pressing need for continued education and outreach on regular testing of domestic well waters, proper treatment types, and health effects of metal contamination. These findings are potentially applicable to other arid areas where groundwater contamination of naturally occurring heavy metals occurs.

Human-induced arsenic pollution modeling in surface waters - An integrated approach using machine learning algorithms and environmental factors

In recent years, assessment of sediment contamination by heavy metals, i.e., arsenic, has attracted the interest of scientists worldwide. The present study provides a new methodology to better understand the factors influencing surface water vulnerability to arsenic pollution by two advanced machine learning algorithms including boosted regression trees (BRT) and random forest (RF). Based on the sediment quality guidelines (Effects range low) polluted and non-polluted arsenic sediment samples were defined with concentrations >8 ppm and <8 ppm, respectively. Different conditioning factors such as topographical, lithology, erosion, hydrological, and anthropogenic factors were acquired to model surface waters' vulnerability to arsenic. We trained and validated the models using 70 and 30% of both polluted and non-polluted samples, respectively, and generated surface vulnerability maps. To verify the maps to arsenic pollution, the receiver operating characteristics (ROC) curve was implemented. The results approved the acceptable performance of the RF and BRT algorithms with an area under ROC values of 85% and 75.6%, respectively. Further, the findings showed higher importance of precipitation, slope aspect, distance from residential areas, and slope length in arsenic pollution in the modeling process. Erosion, lithology, and land use maps were introduced as the least important factors. The introduced methodology can be used to define the most vulnerable areas to arsenic pollution in advance and implement proper remediation actions to reduce the damages.

User experience of point-of-use water treatment for private wells in North Carolina: Implications for outreach and well stewardship

Private well users are potentially exposed to a range of chemical contaminants through their drinking water. Point-of-use (POU) water treatment represents one potential solution to reduce harmful exposures through well water, but well users frequently do not adopt household treatment even if they learn their water is contaminated. This study elucidates the experiences, perceptions, and beliefs of 17 households on private wells in North Carolina that participated in a pilot-scale POU water treatment intervention to better understand the drivers and barriers of POU treatment adoption among well users. The intervention consisted of an under-sink activated carbon block POU filter designed to remove lead and two long-chain perfluoroalkyl acids. Filter effluents and influents were tested monthly for eight months. Questionnaires administered before and after the intervention showed a significant decrease in participants' perceived vulnerability to well water contamination, with 77% feeling vulnerable to poor well water quality before, compared to 23% after the filter was installed. However, the POU filters did not fully eliminate feelings of water insecurity (for example, concerns about exposure to contaminants when bathing remained). Lack of knowledge and skills associated with installing and maintaining POU treatment were important barriers to adoption for some well users. Perceptions of POU treatment were also significantly correlated with the intent to implement other well stewardship behaviors such as well water testing. The results highlight the need for strengthened outreach and support programs that provide technical assistance, education, and financial support for households relying on private wells.

Evaluating the impact of free private well testing outreach on participants' private well stewardship in New Jersey

Over 1 million people in New Jersey (NJ) are estimated to receive drinking water from private wells. The most commonly detected contaminants in NJ private well water are naturally occurring arsenic and gross alpha (8.3 and 10.9%, respectively). Between 2015 and 2018, three free and voluntary private well testing events tested a total of 571 at-risk wells and 226 (40%) were identified as having one or more contaminants exceeding drinking water standards. Participants were invited to complete a survey to evaluate household characteristics, participant experience, and private well stewardship behavior patterns. Of 529 delivered surveys, 211 (40%) participants completed surveys. Among respondents, 63% reported plans to test their private wells in the future. Among failed wells, 45% of households reported performing mitigative action in response to the event, either through the installation of water treatment system or switching to bottled water. The survey evaluation identified previous knowledge of well contamination risks and discussing test results with a third party as important factors for promoting self-reported stewardship behavior. The evaluation provides guidance for outreach organizers to develop effective testing events and further considers the private well owners' experience of the outreach events to identify information for 'best practices' and improvements of future programs.

Predictors of Water Lead Levels in Drinking Water of Homes With Domestic Wells in 3 Illinois Counties

CONTEXT

Millions of US homes receive water from private wells, which are not required to be tested for lead (Pb). An approach to prioritizing high-risk homes for water lead level (WLL) testing may help focus outreach and screening efforts, while reducing the testing of homes at low risk.

OBJECTIVE

To (1) characterize distribution of WLLs and corrosivity in tap water of homes with private residential wells, and (2) develop and evaluate a screening strategy for predicting Pb detection within a home.

DESIGN

Cross-sectional.

SETTING

Three Illinois counties: Kane (northern), Peoria (central), and Jackson (southern).

PARTICIPANTS

151 private well users from 3 Illinois counties.

INTERVENTION

Water samples were analyzed for WLL and corrosivity.

MAIN OUTCOME MEASURES

(1) WLL and corrosivity, and (2) the sensitivity, specificity, and predictive value of a strategy for prioritizing homes for WLL testing.

RESULTS

Pb was detected (>0.76 ppb) in tap water of 48.3% homes, and 3.3% exceeded 15 ppb, the US Environmental Protection Agency action level for community water systems. Compared with homes built in/after 1987 with relatively low corrosivity, older homes with more corrosive water were far more likely to contain measurable Pb (odds ratio = 11.07; 95% confidence interval, 3.47-35.31). The strategy for screening homes with private wells for WLL had a sensitivity of 88%, specificity of 42%, positive predictive value of 58%, and negative predictive value of 80%.

CONCLUSIONS

Pb in residential well water is widespread. The screening strategy for prioritizing homes with private wells for WLL testing is greater than 85% sensitive.

Leveraging Health Care Communication Channels for Environmental Health Outreach in New Jersey

Households with pregnancies and young children are a priority group for outreach on private well water screening due to the widespread occurrence and toxicity of common groundwater contaminants such as arsenic. Given the trusted role of health care providers as communicators of health risk, Columbia University investigators and New Jersey government partners collaborated with Hunterdon Healthcare to offer free well testing to residents of Hunterdon County, a hot spot for naturally occurring arsenic in New Jersey. Through practice-based test kit distribution and online patient portal messages, supported by a public multimedia campaign, we tested 433 private wells and alerted 50 families about elevated arsenic found in their drinking water. These health care-facilitated outreach strategies allowed for targeting based on geographic and demographic risk and suggested opportunities to better leverage communication channels, such as incorporating questions on home water source into the electronic medical record.

Methods for Estimating Locations of Housing Units Served by Private Domestic Wells in the United States Applied to 2010

In 1990, the last time the decennial census included a question on domestic drinking water source, it was estimated that private domestic water wells (PDWs) supplied household water to about 15.1 million housing units (15% of the population) in the United States (U.S.). PDWs are not regulated by the Safe Drinking Water Act, and with few exceptions, are not subject to the water quality testing required of public water suppliers. We expanded two methods in estimating housing units reliant on PDWs from an Oklahoma pilot study (Weaver et al. 2017), nationally. Both use 1990 census data on drinking water sources as a baseline. The first method uses housing unit change and private well drilling logs for 20 states. This allows for the rate of well use to change between 1990 and 2010 in these states. The second, based solely on housing unit change, assumes a constant rate of well use. Ordinary least squares regression demonstrated (R ² = 0.78) that the methods yield similar estimates for nationwide well use. Using the housing unit change method, it is estimated that in 2010, 23 million housing units were reliant on PDWs (17% of the population). We provide these estimates at the census block group and census block resolution. This dataset will assist in a better understanding of the reliance on PDWs in the U.S., and position local, tribal, state, and national groups to better protect this water resource from contaminant sources.

RESEARCH IMPACT STATEMENT

The work provides improved estimates of the spatial distribution of housing units reliant on private domestic wells in the United States and a foundation to protect this water supply at all levels of government.

Drinking Water Consumption Patterns among Private Well Users in Ontario: Implications for Exposure Assessment of Waterborne Infection

Understanding the water consumption patterns within a specific population informs development of increasingly accurate, spatially specific exposure and/or risk assessment of waterborne infection. The current study examined the consumption patterns of private well users in Ontario while considering potentially influential underlying sociodemographics, household characteristics, and experiential factors. A province-wide online survey was circulated between May and August 2018 (n = 1,162). Overall, 81.5% of respondents reported daily well water consumption (i.e., tap water). Results indicate a mean daily well water consumption rate of 1,132 mL/day (SD = 649 mL/day) among well water consumers. Gender was significantly associated with well water consumption, with higher consumption rates found among female respondents. The experience of acute gastrointestinal illness (AGI) symptoms or diagnosis in the past 12 months did not impact the volume of water consumed, suggesting that experiencing previous AGI does not decrease consumption volumes, and therefore exposure over time. Significantly higher rates of well water consumption were found among respondents who reported previous testing or ongoing water treatment. Approximately 45.5% of survey respondents who stated that they do not consume well water selected bottled water as their primary household drinking water supply. Bottled water consumption was also not associated with previous AGI experiences. Findings will inform future quantitative microbial risk assessments associated with private well water use by providing spatially and demographically specific estimates of well water consumption.

Knowledge and Beliefs Associated with Environmental Health Literacy: A Case Study Focused on Toxic Metals Contamination of Well Water

Environmental health literacy (EHL) is developing as a framework that can inform educational interventions designed to facilitate individual and collective action to protect health, yet EHL measurement poses several challenges. While some studies have measured environmental health knowledge resulting from interventions, few have incorporated skills and self-efficacy. In this study, a process-focused EHL instrument was developed, using the Newest Vital Sign (NVS) health literacy instrument as a model and tailoring it for the context of private well contamination with toxic metals. Forty-seven (47) participants, including undergraduate students and residents of communities with contaminated well water, piloted a prototype EHL instrument alongside NVS. Results suggested a moderate degree of correlation between NVS and the EHL prototype, and significant differences in scores were observed between students and residents. Responses to a self-efficacy survey, tailored for drinking water contaminated with arsenic, revealed significant differences between students and residents on items related to cost and distance. In response to open-ended questions, participants identified a range of potential environmental contaminants in drinking water and deemed varied information sources as reliable. This study highlights differences in knowledge and self-efficacy among students and residents and raises questions about the adequacy of EHL assessments that mimic formal education approaches.

Public and private tapwater: Comparative analysis of contaminant exposure and potential risk, Cape Cod, Massachusetts, USA

BACKGROUND

Humans are primary drivers of environmental contamination worldwide, including in drinking-water resources. In the United States (US), federal and state agencies regulate and monitor public-supply drinking water while private-supply monitoring is rare; the current lack of directly comparable information on contaminant-mixture exposures and risks between private- and public-supplies undermines tapwater (TW) consumer decision-making.

METHODS

We compared private- and public-supply residential point-of-use TW at Cape Cod, Massachusetts, where both supplies share the same groundwater source. TW from 10 private- and 10 public-supply homes was analyzed for 487 organic, 38 inorganic, 8 microbial indicators, and 3 in vitro bioactivities. Concentrations were compared to existing protective health-based benchmarks, and aggregated Hazard Indices (HI) of regulated and unregulated TW contaminants were calculated along with ratios of in vitro exposure-activity cutoffs.

RESULTS

Seventy organic and 28 inorganic constituents were detected in TW. Median detections were comparable, but median cumulative concentrations were substantially higher in public supply due to 6 chlorine-disinfected samples characterized by disinfection byproducts and corresponding lower heterotrophic plate counts. Public-supply applicable maximum contaminant (nitrate) and treatment action (lead and copper) levels were exceeded in private-supply TW samples only. Exceedances of health-based HI screening levels of concern were common to both TW supplies.

DISCUSSION

These Cape Cod results indicate comparable cumulative human-health concerns from contaminant exposures in private- and public-supply TW in a shared source-water setting. Importantly, although this study's analytical coverage exceeds that currently feasible for water purveyors or homeowners, it nevertheless is a substantial underestimation of the full breadth of contaminant mixtures documented in the environment and potentially present in drinking water.

CONCLUSION

Regardless of the supply, increased public engagement in source-water protection and drinking-water treatment, including consumer point-of-use treatment, is warranted to reduce risks associated with long-term TW contaminant exposures, especially in vulnerable populations.

Drinking Water Criteria for Arsenic in High-Income, Low-Dose Countries: The Effect of Legislation on Public Health

Due to the potential health risks at very low concentrations, the criterion for arsenic in drinking water has been debated. High-income, low-dose countries are uniquely positioned to follow WHO's recommendation of keeping concentrations "as low as reasonably possible." In this policy analysis, 47646 arsenic analyses from Denmark are used to follow the effect of lowering the national criterion from 50 to 5 μg/L. The first 3 years (2002-2004) following the criterion change, 106 waterworks were identified as noncompliant. An additional 64 waterworks were identified as noncompliant in the next 12 years (2005-2016). Of the 106 waterworks initially (2002-2004) aware of the violation, an average concentration drop from 6 to 3 μg/L was observed during a 6 year period following a lag time of 1 year. After this point, no further improvements were observed. Thirteen years after regulation was imposed, 25 of 170 waterworks were still in violation. The results suggest that legislation alone is insufficient to ensure better drinking water quality at some waterworks and that stakeholders' drivers and barriers to change also play an important role. In an exploration of five legislation scenarios, this study showed that a criterion of 1 μg/L would require action by more than 500 Danish waterworks, with treatment costs from 0.06 to 0.70 €/m³. These scenarios illustrate that it can be technically feasible and affordable to lower the arsenic criterion below 5 μg/L in low-dose, high-income countries. However, more information is needed to apply a cost-benefit model, and comparative studies from other counties are warranted.

Planning for the health impacts of climate change: Flooding, private groundwater contamination and waterborne infection - A cross-sectional study of risk perception, experience and behaviours in the Republic of Ireland

The frequency and severity of flooding events will increase over the coming decades due to global climate change. While close attention has typically been paid to infrastructural and environmental outcomes of flood events, the potential adverse human health consequences associated with post-event consumption from private groundwater sources have received minimal attention, leading to a poor understanding of private well users' preparedness and the drivers of positive behavioural adoption. The current study sought to quantify the capacity of private well users to cope with flood-triggered contamination risks and identify the social psychological determinants of proactive attitudes in the Republic of Ireland, using a cross-sectional questionnaire incorporating two distinct models of health behaviour, the Health Belief Model and Risk-Attitude-Norms-Ability-Self Regulation model. Adoption of healthy behaviours prior to flooding was evaluated with respect to respondents' risk exposure, risk experience and risk perception, in addition to systematic supply stewardship under normal conditions. Associations between adoption of protective behaviours and perception, experience and socio-demographic factors were evaluated through multinomial and multiple logistic regressions, while a multi-model inferential approach was employed with the predictors of health behaviour models. Findings suggest that floods are not considered likely to occur, nor were respondents worried about their occurrence, with 72.5% of respondents who reported previous flooding experience failing to adopt protective actions. Prior experience of well water contamination increased adoption of proactive attitudes when flooding occurred (+47%), with a failure to adopt healthy behaviours higher among rural non-agricultural residents (136%). Low levels of preparedness to deal with flood-related contamination risks are a side-effect of the general lack of appropriate well stewardship under normal conditions; just 10.1% of respondents adopted both water treatment and frequent testing, in concurrence with limited risk perception and poor awareness of the nexus between risk factors (e.g. floods, contamination sources) and groundwater quality. Perceived risk, personal norms and social norms were the best predictors of protective behaviour adoption and should be considered when developing future awareness campaigns.

Recommended Sampling Intervals for Arsenic in Private Wells

Geogenic arsenic in drinking water is a worldwide problem. For private well owners, testing (e.g., private or government laboratory) is the main method to determine arsenic concentration. However, the temporal variability of arsenic concentrations is not well characterized and it is not clear how often private wells should be tested. To answer this question, three datasets, two new and one publicly available, with temporal arsenic data were utilized: 6370 private wells from New Jersey tested at least twice since 2002, 2174 wells from the USGS NAWQA database, and 391 private wells sampled 14 years apart from Bangladesh. Two arsenic drinking water standards are used for the analysis: 10 µg/L, the WHO guideline and EPA standard or maximum contaminant level (MCL) and 5 µg/L, the New Jersey MCL. A rate of change was determined for each well and these rates were used to predict the temporal change in arsenic for a range of initial arsenic concentrations below an MCL. For each MCL and initial concentration, the probability of exceeding an MCL over time was predicted. Results show that to limit a person to below a 5% chance of drinking water above an MCL, wells that are ½ an MCL and above should be tested every year and wells below ½ an MCL should be tested every 5 years. These results indicate that one test result below an MCL is inadequate to ensure long-term compliance. Future recommendations should account for temporal variability when creating drinking water standards and guidance for private well owners.

Improve private well testing outreach efficiency by targeting households based on proximity to a high arsenic well

Research into precautionary action suggests outreach with personally-relevant risk information may help overcome optimistic biases, which have been shown to impede voluntary testing for arsenic by at-risk private well households. Since 2002, New Jersey's Private Well Testing Act (PWTA) has required testing for arsenic during real estate transactions. The PWTA database of over 35,000 geocoded well arsenic tests offers a unique opportunity to evaluate the efficacy of targeted outreach to neighbors living in proximity to a known high arsenic well with variable risk messaging to motivate testing. In this study, residents of properties (n = 1743) located within 500 ft and between 500 and 1000 ft of a known high arsenic well (>5 μg/L, New Jersey's drinking water arsenic standard) were mailed a notice of the high arsenic result in their neighborhood and offered a free water test. Overall 274 households (16%) requested a test kit and 230 (13%) ultimately submitted a water sample; with significantly higher participation rates among those told their neighborhood well had an arsenic concentration "over 5 times higher" than the standard, compared to those told the concentration was "above." Overall, 25% of wells tested (n = 230), and 47% (n = 66) of non-treated wells located within 500 ft of a well with >25 μg/L arsenic, exceeded the standard for arsenic. Both the arsenic concentration and distance to the neighboring well were significant predictors of exceedance. Given the high proportion of previously untested wells (70%) and their owners' lack of awareness of arsenic in their area (80%), this targeting approach succeeded not only in identifying a much higher proportion of at risk wells than blanket testing by town or county, but also in motivating testing among households unreached by prior awareness-raising activities. In conclusion, geographically and personally-relevant risk targeted messaging and outreach are both efficient and effective.

Reduction in drinking water arsenic exposure and health risk through arsenic treatment among private well households in Maine and New Jersey, USA

Over 2 million mostly rural Americans are at risk of drinking water from private wells that contain arsenic (As) exceeding the U.S. Environmental Protection Agency (USEPA) Maximum Contaminant Level (MCL) of 10 micrograms per liter (μg/L). How well existing treatment technologies perform in real world situations, and to what extent they reduce health risks, are not well understood. This study evaluates the effectiveness of household As treatment systems in southern-central Maine (ME, n = 156) and northern New Jersey (NJ, n = 94) and ascertains how untreated well water chemistry and other factors influence As removal. Untreated and treated water samples, as well as a treatment questionnaire, were collected. Most ME households had point-of-use reverse-osmosis systems (POU RO), while in NJ, dual-tank point-of-entry (POE) whole house systems were popular. Arsenic treatment systems reduced well water arsenic concentrations ([As]) by up to two orders of magnitude, i.e. from a median of 71.7 to 0.8 μg/L and from a mean of 105 to 14.3 μg/L in ME, and from a median of 8.6 to 0.2 μg/L and a mean of 15.8 to 2.1 μg/L in NJ. More than half (53%) of the systems in ME reduced water [As] to below 1 μg/L, compared to 69% in NJ. The treatment system failure rates were 19% in ME (>USEPA MCL of 10 μg/L) and 16% in NJ (>NJ MCL of 5 μg/L). In both states, the higher the untreated well water [As] and the As(III)/As ratio, the higher the rate of treatment failure. POE systems failed less than POU systems, as did the treatment systems installed and maintained by vendors than those by homeowners. The 7-fold reduction of [As] in the treated water reduced skin cancer risk alone from 3765 to 514 in 1 million in ME, and from 568 to 75 in 1 million in NJ.

Prevalence of Arsenic in chicken feed and its contamination pattern in different parts of chicken flesh: a market basket study

Organoarsenic compounds are widely used in chicken feed for control of coccidial parasite, quick weight gain, and for imparting attractive color to the chicken flesh. A study was conducted to assess the level of arsenic in both chicken feed and flesh. Chicken feed was collected from 10 farm houses and total arsenic was estimated. The quantitative estimation suggests that the four levels of chicken feed contain different quantities of arsenic load. The results demonstrated that feed at stages III and IV levels contain 0.01 mg/g and 0.018 mg/g of arsenic respectively. However, at stages I and II levels, the feed contains 0.005 mg/g and 0.0052 mg/g of arsenic respectively. Proceeding similarly, chicken flesh was collected from ten vendors in the local markets of Burdwan. The experimental results revealed that deposition of arsenic in different parts of chicken body is not same. The highest accumulation was recorded in the flesh of chest followed by stomach, whereas flesh of the legs and heart showed lower levels of arsenic accumulation. A comprehensive calculation was thereafter done to assess the total amount of arsenic ingestion through consumption of chicken. If a person takes 60.0 g of chicken flesh (leg, breast, muscles, and stomach) everyday, then the person may consume 0.186-0.372 μg of arsenic per day. This study therefore clearly suggests that excessive consumption of poultry chicken may prove to be fatal. However, further research is necessary to confirm the present findings. To the best of our knowledge, this is probably the first report on the likelihood of arsenic contamination in the flesh of different body parts of poultry chicken from Eastern India.

Analysis of Kansas Water Well Policies and Proposal of Nonpublic Household Water Well Recommendations

BACKGROUND

Many nonpublic water well users unknowingly consume contaminated groundwater containing unsafe levels of pollutants. This has important implications for more than 13 million households in the United States that rely upon nonpublic water wells for drinking, cooking, and other household uses. Although public water quality is regulated through the Safe Drinking Water Act, there are no drinking water standards for nonpublic water well quality in Kansas, nor is there an adequate public health infrastructure in place to prevent or address potential exposures to contamination.

OBJECTIVES

This project was conducted to identify promising action steps that would protect Kansans relying on nonpublic water wells for drinking, cooking, and other household purposes.

METHODS

The project team consisted of public health, environmental health, and legal professionals with experience working on groundwater quality issues impacting nonpublic water wells in Kansas. From 2015 through 2018, the team established and convened an advisory group; reviewed relevant state statutes and regulations, all Kansas county environmental codes, and a representative sample of 23 city water well codes; conducted an extensive review of academic literature to identify best practices; conducted dozens of key informant interviews; proposed recommendations; engaged dozens of stakeholders through a survey of these proposed recommendations; and conducted interactive webinars to identify which organizations need to lead each of the recommendations.

DISCUSSION

The project team developed 18 recommendations. The recommendations are organized by survey respondents' perceptions of potential public health impact. There are very few standard practices in Kansas that ensure safe water for nonpublic household water wells. Although not all of the 18 recommendations may be applicable to other communities and states, many likely would be useful for governmental agencies, academic institutions, nonprofit organizations, and others to consider. These recommendations offer more protections for nonpublic household water well users than any resource we have found. https://doi.org/10.1289/EHP5507.

Risk Communication and Factors Influencing Private Well Testing Behavior: A Systematic Scoping Review

Unregulated private wells may be at risk for certain types of contamination associated with adverse health effects. Well water testing is a primary method to identify such risks, although testing rates are generally low. Risk communication is used as an intervention to promote private well testing behavior; however, little is known about whether these efforts are effective as well as the mechanisms that influence effectiveness. A systematic scoping review was conducted to evaluate the current evidence base for risk communication effectiveness and factors that influence well testing behavior. The review was conducted with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework. Data were synthesized using a health behavior model (Health Belief Model) to identify areas amenable to intervention and factors to consider when designing risk communication interventions. We identified a significant shortage of studies examining the effectiveness of risk communication interventions targeted to well testing behavior, with only two quasi-experimental studies identified. The review also identified seventeen studies that examined or described factors relating to well testing behavior. The two empirical studies suggest risk communication methods can be successful in motivating private well owners to test their water, while the remaining studies present considerations for developing effective, community-specific content.

Factors influencing perceptions of private water quality in North America: a systematic review

BACKGROUND

An estimated four million and 43 million people in Canada and the USA use private water supplies. Private water supplies are vulnerable to waterborne disease outbreaks. Private water supplies in Canada and the USA are often unregulated and private water management is often a choice left to the owner. Perceptions of water quality become important in influencing the adoption of private water stewardship practices, therefore safeguarding public health.

METHODS

We conducted a systematic literature review to understand factors that shape perceptions of water quality among private water users. We searched six computer databases (Web of science, Medline, Scopus, EBSCO, PubMed and Agricola). The search was limited to primary peer-reviewed publications, grey literature and excluded conference proceedings, review articles, and non-peer review articles. We restricted the search to papers published in English and to articles which published data on surveys of private water users within Canada and the USA. The search was also restricted to publications from 1986 to 2017. The literature search generated 36,478 records. Two hundred and four full text were reviewed.

RESULTS

Fifty-two articles were included in the final review. Several factors were found to influence perceptions of water quality including organoleptic preferences, chemical and microbiological contaminants, perceived risks, water well infrastructure, past experience with water quality, external information, demographics, in addition to the values, attitudes, and beliefs held by well owners.

CONCLUSIONS

Understanding the factors that shape perceptions of water quality among private water users is an important step in developing private water management policies to increase compliance towards water testing and treatment in Canada and the USA. As many jurisdictions in Canada and the USA do not have mandatory private water testing or treatment guidelines, delineating these factors is an important step in informing future research and guiding policy on the public health of private water systems.

Seasonal Variation of Water Quality in Unregulated Domestic Wells

In the United States (U.S.), up to 14% of the population depend on private wells as their primary drinking water source. The U.S. government does not regulate contaminants in private wells. The goals of this study were to investigate the quality of drinking water from unregulated private wells within one mile (1.6 kilometers) of an effluent-dominated river in the arid Southwest, determine differences in contaminant levels between wet and dry seasons, and identify contributions from human sources by specifically measuring man-made organic contaminants (perfluorooctanoic acid (PFOA), perfluorooctane sulfate (PFOS), and sucralose). Samples were collected during two dry seasons and two wet seasons over the course of two years and analyzed for microbial (Escherichia coli), inorganic (arsenic, cadmium, chromium, copper, lead, mercury, nitrate), and synthetic organic (PFOA, PFOS, and sucralose) contaminants. Arsenic, nitrate, and Escherichia coli concentrations exceeded their respective regulatory levels of 0.01 mg/L, 10 mg/L, and 1 colony forming unit (CFU)/100 mL, respectively. The measured concentrations of PFOA and PFOS exceeded the respective Public Health Advisory level. Arsenic, PFOA, PFOS, and sucralose were significantly higher during the dry seasons, whereas E. coli was higher during the wet seasons. While some contaminants were correlated (e.g., As and Hg ρ = 0.87; PFOA and PFOS ρ = 0.45), the lack of correlation between different contaminant types indicates that they may arise from different sources. Multi-faceted interventions are needed to reduce exposure to drinking water above health-based guidelines.

Development and Validation of an Environmental Health Literacy Assessment Screening Tool for Domestic Well Owners: The Water Environmental Literacy Level Scale (WELLS)

In the U.S., privately owned wells are not subject to any regulatory testing requirements. Well owners must have sufficient environmental health literacy (EHL) to understand and interpret information that contain complex terms and labels to manage their water quality. The objective of this paper is to assess the performance and validity of a new EHL screening tool. The Water Environmental Literacy Level Scale (WELLS) is based on the Newest Vital Sign (NVS) and contains six questions on comprehension, calculations and application of information. Content validity was assessed from expert review. Criterion-related and construct validity were evaluated using an online, convenience sample of adults (n = 869). Percent of correct responses for items ranged from 53% to 96% for NVS and from 41% to 97% for WELLS. Completion time, mean scores, distributions, and internal consistency were equivalent between both scales. Higher scores suggest higher EHL. The scales were moderately correlated (ρ = 0.47, p < 0.001). Kappa agreement was 74%. Bland-Altman plots depicted little mean difference between the scales. Education and income level were positively associated with EHL. WELLS showed criterion-validity with NVS and construct validity with education and income. In practice or research, WELLS could quickly screen individuals for low EHL.

The Strong Heart Water Study: Informing and designing a multi-level intervention to reduce arsenic exposure among private well users in Great Plains Indian Nations

Elevated arsenic exposure from drinking water is associated with an increased risk of cardiovascular disease, diabetes, kidney disease, and skin, lung, and bladder cancer. Arsenic contamination in groundwater supplies disproportionately affects rural populations using private wells. Arsenic mitigation programs for American Indian communities are limited. There is an urgent need for targeted approaches to reduce arsenic exposure for at-risk communities using private wells. Formative research was conducted to inform and design a community-based arsenic mitigation intervention for Lakota and Dakota Nations in the Great Plains Area of the United States, where, in some communities, one-quarter of private wells are estimated to have elevated arsenic. Formative research included semi-structured interviews, a community workshop, intervention-planning workshops, and a pilot study of the developed intervention. Community members prioritize aesthetic qualities of water (e.g. taste, color), safety, and other situational factors (e.g. cost) when considering their drinking and cooking water. Although water safety is a concern, awareness and concern for arsenic vary substantially within communities. To reduce arsenic exposure, community members recommended communication of water test results, home visits for intervention delivery, and reminders to use arsenic-safe water. Findings informed the development of an intervention to prevent arsenic exposure through drinking water and cooking, including health promotion messages and household items to facilitate use of an arsenic removal device (e.g. tankards to store filtered water). The pilot study indicated promising acceptability and operability of the developed intervention. This research provides a model for the development of environmental health interventions in partnership with American Indian and other private well-using communities.

Health protective behavior following required arsenic testing under the New Jersey Private Well Testing Act

Exposure to naturally occurring arsenic in groundwater is a public health concern, particularly for households served by unregulated private wells. At present, one of the greatest barriers to exposure reduction is a lack of private well testing due to difficulties in motivating individual private well owners to take protective actions. Policy and regulations requiring testing could make a significant contribution towards universal screening of private well water and arsenic exposure reduction. New Jersey's Private Well Testing Act (PWTA) requires tests for arsenic during real estate transactions; however, the regulations do not require remedial action when maximum contaminant levels (MCLs) are exceeded. A follow-up survey sent to residents of homes where arsenic was measured above the state MCL in PWTA-required tests reveals a range of mitigation behavior among respondents (n = 486), from taking no action to reduce exposure (28%), to reporting both treatment use and appropriate maintenance and monitoring behavior (15%). Although 86% of respondents recall their well was tested during their real estate transaction, only 60% report their test showed an arsenic problem. Treatment systems are used by 63% of households, although half were installed by a previous owner. Among those treating their water (n = 308), 57% report that maintenance is being performed as recommended, although only 31% have tested the treated water within the past year. Perceived susceptibility and perceived barriers are strong predictors of mitigation action. Among those treating for arsenic, perceived severity is associated with recent monitoring, and level of commitment is associated with proper maintenance. Mention of a treatment service agreement is a strong predictor of appropriate monitoring and maintenance behavior, while treatment installed by a previous owner is less likely to be maintained. Though the PWTA requires that wells be tested, this study finds that not all current well owners are aware the test occurred or understood the implications of their arsenic results. Among those that have treatment installed to remove arsenic, poor monitoring and maintenance behaviors threaten to undermine intentions to reduce exposure. Findings suggest that additional effort, resources, and support to ensure home buyers pay attention to, understand, and act on test results at the time they are performed may help improve management of arsenic water problems over the long term and thus the PWTA's public health impact.

Private-well stewardship among a general population based sample of private well-owners

Private well stewardship, including on-going testing and treatment, can ensure private well users are able to maintain source-water quality and prevent exposures to potentially harmful constituents in primary drinking water supplies. Unlike municipal water supplies, private well users are largely responsible for their own testing and treatment and well stewardship is often minimal. The importance of factors influencing regular testing, and treatment behaviors, including knowledge, risk perception, convenience and social norms, can vary by geography and population characteristics. The primary goals of this study were to survey a general statewide population of private well users in Wisconsin in order to quantify testing and treatment patterns and gather data on motivations and barriers to well stewardship. The majority of respondents reported using and drinking well water daily but only about one half of respondents reported testing their wells in the last ten years and of these, only 10% reported testing in the last 12months. Bacteria and nitrates were contaminants most often tested; and, a private laboratory most often conducted testing. The most commonly reported water treatment was a water softener. Living in a particular geographic region and income were the most significant predictors of water testing and treatment. Iron and hardness, which influence water aesthetics but not always safety, were the most commonly reported water quality problems. Health concerns or perceived lack thereof were, respectively, motivators and barriers to testing and treatment. Limited knowledge of testing and treatment options were also identified as barriers. Results confirm previous findings that well stewardship practices are minimal and often context specific. Understanding the target population's perceptions of risk and knowledge are important elements to consider in identifying vulnerable populations and developing education and policy efforts to improve well stewardship.

Hazard Ranking Method for Populations Exposed to Arsenic in Private Water Supplies: Relation to Bedrock Geology

Approximately one million people in the UK are served by private water supplies (PWS) where main municipal water supply system connection is not practical or where PWS is the preferred option. Chronic exposure to contaminants in PWS may have adverse effects on health. South West England is an area with elevated arsenic concentrations in groundwater and over 9000 domestic dwellings here are supplied by PWS. There remains uncertainty as to the extent of the population exposed to arsenic (As), and the factors predicting such exposure. We describe a hazard assessment model based on simplified geology with the potential to predict exposure to As in PWS. Households with a recorded PWS in Cornwall were recruited to take part in a water sampling programme from 2011 to 2013. Bedrock geologies were aggregated and classified into nine Simplified Bedrock Geological Categories (SBGC), plus a cross-cutting “mineralized” area. PWS were sampled by random selection within SBGCs and some 508 households volunteered for the study. Transformations of the data were explored to estimate the distribution of As concentrations for PWS by SBGC. Using the distribution per SBGC, we predict the proportion of dwellings that would be affected by high concentrations and rank the geologies according to hazard. Within most SBGCs, As concentrations were found to have log-normal distributions. Across these areas, the proportion of dwellings predicted to have drinking water over the prescribed concentration value (PCV) for As ranged from 0% to 20%. From these results, a pilot predictive model was developed calculating the proportion of PWS above the PCV for As and hazard ranking supports local decision making and prioritization. With further development and testing, this can help local authorities predict the number of dwellings that might fail the PCV for As, based on bedrock geology. The model presented here for Cornwall could be applied in areas with similar geologies. Application of the method requires independent validation and further groundwater-derived PWS sampling on other geological formations.

Lessons Learned from Arsenic Mitigation among Private Well Households

PURPOSE OF REVIEW

Many thousands of research papers have been published on the occurrence, health effects, and mitigation of arsenic in drinking water sourced from groundwater around the world. Here, an attempt is made to summarize this large body of knowledge into a small number of lessons.

RECENT FINDINGS

This is an opinion paper reflecting on why we are far from the goal of eliminating this silent and widespread poison to protect the health of many millions. The lessons are drawn from research in countries representing a range of economic development and cultural contexts. The replacement of household wells with centralized water supplies has reduced population level exposure to moderate (50-100 μg/L) and high (>100 μg/L) levels of arsenic in drinking water in some countries as they become wealthier. However, there remains a very large rural population in all countries where the exposure to low levels (10-50 μg/L) of arsenic continues due to its dispersed occurrence in the environment and frequent reliance on private well. A set of natural (geological and biological), socioeconomic, and behavioral barriers to progress are summarized as lessons. They range from challenges in identifying the exposed households due to spatially heterogeneous arsenic distribution in groundwater, difficulties in quantifying the exposure let alone reducing the exposure, failures in maintaining compliance to arsenic drinking water standards, to misplaced risk perceptions and environmental justice issues. Environmental health professionals have an ethical obligation to help As mitigation among private well water households, along with physicians, hydrogeologists, water treatment specialists, community organizations, and government.

The Case for Universal Screening of Private Well Water Quality in the U.S. and Testing Requirements to Achieve It: Evidence from Arsenic

BACKGROUND

The 1974 Safe Drinking Water Act (SDWA) regulates >170,000 public water systems to protect health, but not >13 million private wells. State and local government requirements for private well water testing are rare and inconsistent; the responsibility to ensure water safety remains with individual households. Over the last two decades, geogenic arsenic has emerged as a significant public health concern due to high prevalence in many rural American communities.

OBJECTIVES

We build the case for universal screening of private well water quality around arsenic, the most toxic and widespread of common private water contaminants. We argue that achieving universal screening will require policy intervention, and that testing should be made easy, accessible, and in many cases free to all private well households in the United States, considering the invisible, tasteless, odorless, and thus silent nature of arsenic.

DISCUSSION

Our research has identified behavioral, situational and financial barriers to households managing their own well water safety, resulting in far from universal screening despite traditional public health outreach efforts. We observe significant socioeconomic disparities in arsenic testing and treatment when private water is unregulated. Testing requirements can be a partial answer to these challenges.

CONCLUSIONS

Universal screening, achieved through local testing requirements complemented by greater community engagement targeting biologically and socioeconomically vulnerable groups, would reduce population arsenic exposure greater than any promotional efforts to date. Universal screening of private well water will identify the dangers hidden in America's drinking water supply and redirect attention to ensure safe water among affected households. https://doi.org/10.1289/EHP629.

Arsenic in private well water part 3 of 3: Socioeconomic vulnerability to exposure in Maine and New Jersey

Arsenic is a naturally occurring toxic element often concentrated in groundwater at levels unsafe for human consumption. Private well water in the United States is mostly unregulated by federal and state drinking water standards. It is the responsibility of the over 13 million U.S. households regularly depending on private wells for their water to ensure it is safe for drinking. There is a consistent graded association with health outcomes at all levels of socioeconomic status (SES) in the U.S. Differential exposure to environmental risk may be contributing to this persistent SES-health gradient. Environmental justice advocates cite overwhelming evidence that income and other SES measures are consistently inversely correlated with exposure to suboptimal environmental conditions including pollutants, toxins, and their impacts. Here we use private well household surveys from two states to investigate the association between SES and risks for arsenic exposure, examining the potentially cumulative effects of residential location, testing and treatment behavior, and psychological factors influencing behavior. We find that the distribution of natural arsenic hazard in the environment is socioeconomically random. There is no evidence that higher SES households are avoiding areas with arsenic or that lower SES groups are disproportionately residing in areas with arsenic. Instead, disparities in exposure arise from differing rates of protective action, primarily testing well water for arsenic, and secondly treating or avoiding contaminated water. We observe these SES disparities in behavior as well as in the psychological factors that are most favorable to these behaviors. Assessment of risk should not be limited to the spatial occurrence of arsenic alone. It is important that social vulnerability factors are incorporated into risk modeling and identifying priority areas for intervention, which should include strategies that specifically target socioeconomically vulnerable groups as well as all the conditions which cause these disparities in testing and treatment behavior.

Arsenic in private well water part 2 of 3: Who benefits the most from traditional testing promotion?

Arsenic, a toxic element naturally found in groundwater, is a public health concern for households drinking from wells. Private well water is not regulated to meet the federal drinking water arsenic Maximum Contaminant Level (MCL) of 10μg/L, or the more protective 5μg/L New Jersey (NJ) state MCL. In the absence of consistent private well regulation, public health efforts have relied on promoting testing in affected communities to various degrees of success. Few interventions publish results, and more often focus on the outcome of tested wells rather than who completed a test, and more importantly, who did not. Through our survey of randomly selected addresses (n=670) in 17 NJ towns we find higher rates of arsenic testing in areas with a history of testing promotion. However, we also see a stronger correlation of testing behavior with income and education in high promotion areas, suggesting that community engagement activities may be exacerbating socioeconomic status (SES) testing disparities. Well owners with a bachelor's degree had ten times greater odds of participating in our direct mail testing intervention than those with less education when tests cost $40. After all households (n=255) were offered free tests to overcome many of the usual testing barriers - awareness, convenience, and cost - only 47% participated and those who chose to return water samples were of higher income and education than those who did not. Our findings highlight that while efforts to promote and provide arsenic testing succeed in testing more wells, community testing interventions risk increasing SES disparities if those with more education and resources are more likely to take advantage of testing programs. Therefore, testing interventions can benefit by better targeting socially vulnerable populations in an effort to overcome SES-patterned self-selection when individuals are left alone with the responsibility of managing their drinking water quality.