'If Providers Had Recommended It, We Would Have Had It Tested': Rural Mothers' Perspectives on Barriers and Facilitators to Testing for Arsenic in Their Well Water.

Author:Adachi-Mejia, Anna M.


Studies of populations with high exposure to arsenic in well water raise multiple public health concerns, including associations with cancer (e.g., skin, bladder, pancreatic, liver, lung, kidney) (Ayotte et al., 2006; Celik et al., 2008; Chen, Chen, Wu, & Kuo, 1992; Chiou et al., 1995; Gilbert-Diamond et al., 2013; Liaw et al., 2008; Liu-Mares et al., 2013) and other health impairments (Chen et al., 2011; McClintock et al., 2014; Mosaferi, Yunesian, Dastgiri, Mesdaghinia, & Esmailnasab, 2008; Rocha-Amador, Navarro, Carrizales, Morales, & Calderon, 2007; Smith et al., 2011; von Ehrenstein et al., 2007; Wasserman et al., 2014). Exposures that occur in utero and in early life can have distinct impacts on child growth and development, in particular related to immune function and neurodevelopment (Farzan, Karagas, & Chen, 2013). As an odorless, colorless, and tasteless metalloid, the only way to determine the presence of arsenic in well water is to test for it. In spite of global recommendations to regularly test well water and potential health risks, however, most residents with private water wells do not routinely test their well water for arsenic (Flanagan, Marvinney, & Zheng, 2015).

In the state of New Hampshire, arsenic occurs naturally in the groundwater and is prevalent in the drinking water supply. Due to increasing evidence of adverse human health effects related to arsenic exposure, in 2002 the U.S. Environmental Protection Agency (U.S. EPA) reduced the amount of arsenic that could be present in public drinking water systems from 50 [micro]g/L to 10 [micro]g/L. In July 2019, New Hampshire HB 261 was signed into law and the state become the second in the country to reduce the maximum contaminant level for arsenic in public water to 5 ppb. This regulatory limit, however, does not apply to private water wells, which provide drinking water for nearly 40% of households in New Hampshire. The U.S. Geological Survey (USGS) estimates that 20-30% of New Hampshire private water wells exceed this 10 [micro]g/L U.S. EPA maximum contaminant level (MCL) for arsenic (Ayotte, Cahillane, Hayes, & Robinson, 2012). The burden of testing well water falls on the well owner. Testing for arsenic in well water can range in cost from approximately $15 for arsenic alone to $80 and higher for more comprehensive water quality testing (New Hampshire Department of Environmental Services, 2017).

The prevalence of elevated arsenic in groundwater in New Hampshire and the high percentage of the population on private water systems offer an ideal setting to study the health effects of arsenic exposure in a U.S. population. The New Hampshire Birth Cohort Study (NHBCS) was designed specifically to explore the mechanism of effects of arsenic in drinking water on pregnant women and their children and to address potential in utero and early life effects that had been reported in other studies. Women were eligible for NHBCS if they live in a New Hampshire residence that relies on a private water well. Upon entry into the study, families engaged in comprehensive well water testing at the mother's 24- to 28-week gestation point, approximately, and results were shared with the participants. Consistent with USGS survey estimates, approximately 14% of the birth cohort participants had wells that exceeded the U.S. EPA arsenic MCL (Gilbert-Diamond et al., 2011).

We used the opportunity of the existing NHBCS study to conduct focus groups with a subset of participants to determine their knowledge and perspectives on testing for arsenic in their well water. Our goal was to identify rural mothers' perceived barriers and facilitators to testing for arsenic in well water. In this article, we convey focus group findings, share lessons learned from the focus groups, and offer suggestions for next steps. Our ultimate aim is to inform future public health initiatives promoting testing for arsenic and other contaminants in well water, particularly for programs geared toward rural mothers.


We recruited participants from enrolled study subjects within NHBCS. Eligibility for enrollment in NHBCS included relying on a private water well for their drinking water and willingness to provide a water sample. We recruited participants for this study from NHBCS enrollees who had enrolled in the study in the previous 6-12 months. This study was approved by the Dartmouth Committee for the Protection of Human Subjects. We obtained written informed consent from each participant prior to participation.

Data Collection Procedure and Analysis

We used the qualitative method of conducting focus groups to understand perspectives of mothers on testing for arsenic in well water. Through e-mail, we invited 97 mothers to participate in the focus groups. Of those, 33 expressed an interest in participating in a focus group. Our final sample size was 12 mothers. We held three focus groups: one in person and two by webinar. Each mother participated in a single focus group. For the first focus group held in person, four attended. Of those, three brought their babies to the group. The two subsequent focus groups were held using an online teleconferencing platform. For the focus groups conducted this way, mothers spoke on the phone or through their computer and reviewed materials online or on their own from handouts received by e-mail. The focus group duration ranged from 47 min to 1 hr and 16 min. All participants were given a $25 Visa gift card as a thank you for their participation.

A trained and experienced focus group facilitator led all focus groups using a structured interview guide that addressed the major questions of interest. The facilitator reminded participants of confidentiality procedures and set the ground rules for discussion, which included that there were no right or wrong answers to set the expectation that different points of view were acceptable. Questions included participant past experiences with having well water tested, learning about the results, and any related resultant actions taken; thoughts about the potential influence on their behavior if their healthcare provider made recommendations to obtain well water testing; barriers to well water testing; knowledge about arsenic; and suggestions for information types and modalities to best help mothers of young children.

The focus groups were audio recorded and transcribed. Transcripts were then coded and analyzed for emergent themes (Krueger, 1998). An additional study investigator attended all focus groups along with the focus group leader, took handwritten notes during the sessions, and later discussed the emergent themes with the research team.


Characteristics of the 12 mothers in our sample are described in Table 1. Barriers and facilitators to testing for arsenic in well water include themes about messaging from providers, cost, and access to information. These themes are summarized in Table 2 and...

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