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Table 1 Example behavioral determinants measured in the SHWS, and corresponding behavior change techniques delivered in the SHWS intervention

From: 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

Type of factor

Factor

Definition

Example behavior change technique delivered

Example items

Hypothesized change

Risk factors

Perceived vulnerability

Perceived risk of health problems from arsenic exposure [46]

All: Phone calls at 1-week, and 1-, 3-, and 5-months after arsenic filter installation to provide information on the health risks associated with arsenic exposure.

Intensive: Video testimonials about the health risks associated with exposure to arsenic through drinking water, including cancers, heart disease, and diabetes.

How high or low are the chances of you getting health problems from arsenic if it is in your well water?

Higher perceived vulnerability

Because no one in my house has developed health problems from arsenic, I am not concerned about arsenic in my well water.

Higher perceived vulnerability (lower score = greater concern)

Arsenic knowledge

Understanding of the properties of arsenic, and comprehension of the health effects from water arsenic exposure and related mitigation options

All: FAQ and letter to the household including information about arsenic, health effects of arsenic exposure, and mitigation options.

Intensive: Video testimonials about the properties of arsenic (e.g., cannot be seen, smelled, or tasted), health risks associated with exposure to arsenic through drinking water, behaviors that may increase exposure to arsenic (e.g., boiling arsenic unsafe water for consumption), and mitigation options (e.g., testing private well water for arsenic, installing an arsenic filter, and drinking and cooking with arsenic safe water).

Name two health conditions that can happen from arsenic exposure.

Higher arsenic knowledge

Name two tasks where it is NOT OK to use water with high arsenic.

Higher arsenic knowledge

How could you remove arsenic from drinking water?

Higher arsenic knowledge

Norm factors

Descriptive norms

Perceptions about the behaviors commonly performed by others [47]

All: Informing households that the same intervention was provided to other households with elevated arsenic in their community to improve water quality for people with private wells.

Intensive: Video testimonials about community members testing private wells for arsenic, installing an arsenic filter, and using arsenic safe water for drinking and cooking.

How many people in your community with arsenic in their wells drink this water without filtration?

Lower descriptive norms

How many people in your community with arsenic in their wells use an arsenic filter for their drinking water?

Higher descriptive norms

Injunctive norms

Perceptions about behaviors that others commonly approve or disapprove of [48]

Intensive: Video testimonials from community elders encouraging testing private wells for arsenic, installing an arsenic filter, and using arsenic safe water for drinking and cooking.

How much would people who are important to you approve or disapprove of you using water containing high arsenic for drinking?

Higher injunctive norms (increased disapproval = lower score)

Ability factors

Self-efficacy

The belief in one’s abilities to confront and manage possible situations [49]

All: Phone calls at 1-week, and 1-, 3-, and 5-months after arsenic filter installation to troubleshoot challenges households faced when using the arsenic filter, discuss strategies to overcome challenges, and provide suggestions for how to facilitate using water from the filter faucet for all drinking and cooking needs.

Intensive: Video testimonials from community members about trouble-shooting arsenic filter use; Important Reminders Sheet with advice on how to make sure one is able to use arsenic safe water for drinking and cooking.

How sure are you that you can use your arsenic filter faucet every time you need water for drinking in your home?

Higher self-efficacy

  

All: Provision of one replacement arsenic filter cartridge and written instructions (device manual) on how to change the filter cartridge; phone calls at 3-, and 5-months after arsenic filter installation with reminders of when to change the filter cartridge and to refer to provided instructions.

Intensive: Step-by-step video on how to change the arsenic filter cartridge, as demonstrated by a community member; making an action plan for when to change the arsenic filter cartridge.

How sure are you that you yourself can change your arsenic filter cartridge when needed?

Higher self-efficacy

Commitment strength

Level of dedication to the decision to perform a behavior [50]

Intensive: Video testimonial from an arsenic filter user about using the filter despite challenges (e.g., slow water flow).

How committed do you feel to drinking water only from your arsenic filter faucet?

Higher commitment strength

Other

Perceived cost

The belief about the true cost of a behavior and its alternatives [45]

All: Phone calls at 1-week, and 1-, 3-, and 5-months after arsenic filter installation to explain how to maintain the arsenic filter over time.

I can afford to fix my arsenic filter if it breaks.

Decreased perceived costs (higher score = decreased perceived cost)

Competing priorities

Priority of adopting a new behavior (or behavior change) compared to competing concerns or goals (that may require the same resources) [51]

Intensive: Important Reminders sheet with advice on time-saving techniques to manage time to use the arsenic filter faucet when there might be competing priorities in the home.

Of all the things I have to worry about, the arsenic filter is not at the top of my list.

Increased prioritization of the arsenic filter (lower score = greater prioritization)

Perceived safety of tribal water system

The belief that the municipal water system provides safe water [45]

All: FAQ stating that the tribal municipal water supply is monitored to make sure it meets EPA standards for arsenic.

Intensive: Video testimonial from community elder stating that the municipal water is arsenic safe.

The tribal water system in my area has a safe level of arsenic.

Increased perceived safety

Perceived extent of contamination in community

The belief that arsenic is present in water sources in the community [45]

All: FAQ stating that arsenic above the EPA standard has been found in private wells in the partner community; providing households with contact information for the wellcare® Hotline for additional information on arsenic contamination in private wells.

How many people in your community have arsenic in their wells?

Increased perceived extent contamination

User preferences

Preference for one safe water source over another [45]

Intensive: Provision of travel water bottles to fill with arsenic safe water from the filter faucet for convenience.

If given the choice, I would prefer bottled water over water from an arsenic filter.

Decreased preference for bottled water