Addressing Water Contamination and Associated Health Issues through Community-Based Interventions: A Case Study in Khon Kaen Province

A recent study conducted in Khon Kaen Province, Thailand, evaluated the effectiveness of a technology-assisted intervention aimed at improving water quality and addressing related health issues in communities around key water bodies. The intervention targeted health concerns associated with water contamination, including chronic kidney diseases, skin conditions, hypertension, and neurological symptoms. The study included water quality assessments and health evaluations of 586 residents and implemented a Learning Innovation Platform (LIP) across 13 communities. Results showed significant improvements in the community, including a decrease in hypertension and skin-related health issues, as well as enhanced community awareness and proficiency in implementing simple water quality assessments and treatment. The study demonstrated the value of a comprehensive, technology-driven community approach, effectively enhancing water quality and health outcomes, and promoting greater community awareness and self-sufficiency in managing environmental health risks.


Introduction
Water contamination stands as a critical public health issue, contributing significantly to a range of health disorders such as chronic kidney disease (CKD), skin ailments, hypertension, gastrointestinal complications, and neurologic symptoms [1,2].The presence of hazardous chemical pollutants in water sources amplifies the risk of long-term health effects [3].This crisis is particularly acute in northeastern Thailand, where this study targets ten specific sub-districts within Khon Kaen province (Figure 1) to investigate these concerns.

Introduction
Water contamination stands as a critical public health issue, contributing significantly to a range of health disorders such as chronic kidney disease (CKD), skin ailments, hypertension, gastrointestinal complications, and neurologic symptoms [1,2].The presence of hazardous chemical pollutants in water sources amplifies the risk of long-term health effects [3].This crisis is particularly acute in northeastern Thailand, where this study targets ten specific sub-districts within Khon Kaen province (Figure 1) to investigate these concerns.Critical water reservoirs, such as Ubonrat Dam and Lam Nam Phong River, are crucial for sustaining the socioeconomic structure of Northern Khon Kaen.Ubonrat Dam plays a vital role in providing electricity and supporting agriculture, and aquaculture.It intercepts the Lam Nam Pong River, which serves as a lifeline for the Nam Phong District's 12 sub-districts and 168 villages/communities [4].These reservoirs are not only essential for water provision but are also major tourist sites in the region.Similarly, Kaeng La Wa and Kaeng Nam Ton Pond support local agriculture and household water, enriched by their connection to the Chi River.
Recent studies have demonstrated the efficacy of advanced filtration systems in significantly reducing contaminants such as heavy metals and pesticides in drinking water.Multi-stage filtration processes, including activated carbon filters, reverse osmosis, and UV sterilization, have shown substantial improvements in water quality and public health outcomes.Additionally, community-based monitoring programs have been successful in various regions.These programs train local residents to regularly test and monitor water Critical water reservoirs, such as Ubonrat Dam and Lam Nam Phong River, are crucial for sustaining the socioeconomic structure of Northern Khon Kaen.Ubonrat Dam plays a vital role in providing electricity and supporting agriculture, and aquaculture.It intercepts the Lam Nam Pong River, which serves as a lifeline for the Nam Phong District's 12 subdistricts and 168 villages/communities [4].These reservoirs are not only essential for water provision but are also major tourist sites in the region.Similarly, Kaeng La Wa and Kaeng Nam Ton Pond support local agriculture and household water, enriched by their connection to the Chi River.

Target communities in Khon Kaen Province
Recent studies have demonstrated the efficacy of advanced filtration systems in significantly reducing contaminants such as heavy metals and pesticides in drinking water.Multi-stage filtration processes, including activated carbon filters, reverse osmosis, and UV sterilization, have shown substantial improvements in water quality and public health outcomes.Additionally, community-based monitoring programs have been successful in various regions.These programs train local residents to regularly test and monitor water quality, fostering a sense of ownership and responsibility toward maintaining safe water sources.Public health campaigns have also played a crucial role in educating the public about the dangers of contaminated water and promoting safe water consumption practices.These initiatives have helped reduce the incidence of waterborne diseases and improve overall community health [3,4].
Despite these advances, several critical questions remain unanswered.Most existing studies have focused on short-term interventions without addressing long-term sustainability and community self-sufficiency.Additionally, there is a lack of comprehensive studies that simultaneously address multiple contaminants and their combined health effects.Many interventions have also failed to integrate local knowledge and practices, essential for the successful implementation and acceptance of water quality improvement measures.
Initiated in 2019, our research aims to shed light on water consumption and potential contaminants affecting health around these critical water bodies.We surveyed 1036 residents and performed in-depth analyses of water and sediment samples.The tests included examinations for metals, heavy metals, pesticides, and herbicides, and identifying contaminants that could be causally linked to local health issues [4].Consequently, we focused on ten sub-districts known for water quality concerns, with eight being part of our initial survey and two newly identified based on previous health research (Figure 1).
After selecting these areas, health assessments were conducted before and after implementing our interventions, focusing on symptoms and conditions indicative of water quality-related health concerns [5].Our approach mobilized the community, training over 40 individuals through the Learning Innovation Platform (LIP) to act as local 'innovators' in water quality monitoring and simple purification methods [6].
The "Learning and Innovation Platform" (LIP) is a learning program designed to foster technology and innovation implementation.This platform aims to train innovators who can effectively use our technology, knowledge, and innovation to screen and monitor hazardous chemical contaminations in water sources and community drinking water, while also facilitating the improvement of water quality.This platform involves the local community as the key actor, research teams as the facilitator, and government agencies, state enterprises, and the private sector in the community area as the network management.(Figure 2) Each participant has important roles and responsibilities in designing and implementing learning activities at various levels to support skill and knowledge development in society and organizations comprehensively and systematically.In measuring the effectiveness of activities, the innovation learning levels of innovators were assessed as follows: Level 1-able to expand and link community resources continuously, Level 2-capable of researching and generating knowledge, technology, and innovation, Level 3-able to disseminate knowledge, technology, and innovation, and Level 4-capable of receiving, adapting, and applying technology and innovation.
The core objective of this research is to study the effectiveness of these interventions.We intend to compare community health metrics before and after implementing surveillance and remediation measures.Key health indicators, such as CKD rates, will provide an allencompassing view of the interventions' impact on water quality and public health [7].Through this comprehensive strategy, the study aims to establish a community-based model to effectively combat water contamination.We envision this model serving as a scalable, sustainable framework capable of informing national policy [8].
opment in society and organizations comprehensively and systematically.In measuring the effectiveness of activities, the innovation learning levels of innovators were assessed as follows: Level 1-able to expand and link community resources continuously, Level 2-capable of researching and generating knowledge, technology, and innovation, Level 3-able to disseminate knowledge, technology, and innovation, and Level 4-capable of receiving, adapting, and applying technology and innovation.

Identification of Study Areas
Before conducting any surveys or water quality assessments, a comprehensive meeting was held to identify and finalize the study areas.The meeting brought together representatives from various key stakeholders involved in the regions surrounding the Ubonrat Dam and Lam Nam Phong River.Attendees included representatives from the Khon Kaen governor's office, the Provincial Administrative Organization, the Sub-district Administrative Organization, and local companies and factories.Additionally, medical specialists, including nephrologists and public health physicians from the Chronic Kidney Disease Prevention in the Northeast of Thailand (CKDNET) and Khon Kaen University, also presented to provide specialized insights.Collectively, these stakeholders deliberated on the specific areas that would serve as the focus of this study, keeping in mind the objectives and the scope of the research.

Questionnaire Survey
The questionnaire was crafted to gather insights into water consumption patterns, health conditions, and public awareness about water quality.Before administration, the survey underwent a pre-test to confirm its clarity, relevance, and suitability.Ethical approval for the study was secured under code HE601035, granted by the Office of the Khon Kaen University Ethics Committee in Human Research (Institutional Review Board number IRB00001189), located at Khon Kaen University, Thailand.A total of 1036 residents were randomly selected to participate in the survey.Informed consent was obtained from all participants before their involvement in the study.

Water Contaminant Survey
Concurrent with the questionnaire, water and sediment samples were gathered from various locations within the designated study areas.In the case of the Lam Nam Phong River, samples comprising both water and sediment were collected at 5 km intervals along the river.This approach aimed to mitigate bias and prevent the unfair attribution of contamination to specific communities or stakeholders.The samples were rigorously tested for an array of potential contaminants, following standardized procedures to ensure the validity and reliability of the results.These tests targeted metals such as aluminum (Al), chromium (Cr), manganese (Mn), iron (Fe), cobalt (Co), copper (Cu), arsenic (As), cadmium (Cd), and lead (Pb).For pesticide analysis, substances like chlorpyrifos, glyphosate and its metabolite (aminomethyphosphonic acid), 2,4-dichlorophenoxyacetic acid (2,4-D), paraquat dichloride, and bispyribac sodium were examined.By adhering to these procedures, the study sought to provide a comprehensive assessment of water quality, focusing on contaminants with known or suspected health implications.The sampling and measurement of heavy metal contamination and pesticides in sediment and water along Lam Nam Phong River and Ubonrat Dam followed the processes and standard methods of the Pollution Control Department, Ministry of Natural Resources and Environment, Thailand, 2018.These methods reference international standards: ISO 5667-6:2014-Water quality-Sampling-Part 6: Guidance on sampling of rivers and streams [9], ISO 5667-12:2017-Water quality-Sampling-Part 12: Guidance on sampling of bottom sediments [10], and US EPA Standard Operating Procedures for Surface Water Sampling (U.S. EPA, 2023) [11].

Data Analysis
The amassed data were subjected to rigorous statistical analysis using Excel and Origin (Version 6.0) software.This process facilitated data cleaning and enabled the identification of patterns related to water quality and health outcomes within the local community.

Criteria for Identifying Target Areas for Training Local Innovators and Deploying Water Quality Interventions
Study areas were selected based on a comprehensive approach that considered four key criteria: (1) existing infrastructure and prior relationships with the community; (2) preliminary assessments of community interest, leadership strength, and willingness to participate, gathered through surveys and interviews; (3) pre-existing health and water contamination data; and (4) geographical and environmental conditions, specifically the communities' use of diverse water sources such as Ubonrat Dam, Lam Nam Phong River, Kaeng Nam Ton, and Kaeng La Wa Pond.This comprehensive set of criteria ensured a well-informed selection of study areas conducive to implementing water quality innovations.The sampling and measurement of heavy metal contamination in water samples collected from ten community-operated water treatment plants adhered to the processes and standard methods of the Thailand Provincial Waterworks Authority.These procedures align with the guidelines outlined in the World Health Organization's "Guidelines for Drinking-Water Quality," 4th edition (2011) [12].All samples were analyzed by a laboratory accredited with the ISO/IEC 17025 standard [13], ensuring that the analytical results are reliable and meet international quality and technical competency criteria.

Pre-and Post-Intervention Health Assessments to Evaluate LIP and Water Quality Improvements
Comprehensive health assessments were carried out on 568 residents aged 18 years or older, both before and after local innovators were trained through the Learning Innovation Platform (LIP) to implement water quality improvements (Figure 2).
These assessments took place in 10 targeted sub-districts and were facilitated in partnership with local Health Promoting Hospitals and public health volunteers.Participants underwent a standardized health questionnaire [14] along with a set of clinical laboratory tests.Blood and urine samples were collected to assess kidney and liver function, specifically evaluating levels of serum creatinine and the urine albumin-to-creatinine ratio, as well as conducting general urinalysis.Liver function was evaluated through alanine aminotransferase (ALT) tests, and a complete blood count (CBC) was performed for anemia screening.All clinical tests were conducted at Srinagarind Hospital.Each participant received individual health screening results and personalized medical advice from qualified doctors.This study was conducted following the Declaration of Helsinki and approved by the Institutional Review Board of the Office of the Khon Kaen University Ethics Committee in Human Research (Institutional Review Board number IRB00001189), Khon Kaen University, Thailand.

Survey Results on Water Consumption and Quality Concerns
Investigations into the water consumption habits and health perceptions of 1036 residents living near the Ubonrat Dam and Lam Nam Phong River revealed that a substantial majority of the community (92%) relied on tap water for their daily needs.This tap water was sourced either from the Provincial Waterworks Authority (47.55%) or local community/village water supply systems (45.92%).Smaller fractions of the population used groundwater (5.42%) or natural water sources (2%), as shown in Figure 3a.Despite the prevalent use of tap water, residents expressed concerns over its quality, noting attributes such as color, turbidity, foul smell, and unpleasant taste.Notably, these local water sources were tested for quality only once a year, and the results, even when they did not meet standards, were not communicated to the residents.

Survey Results on Water Consumption and Quality Concerns
Investigations into the water consumption habits and health perceptions of 1036 residents living near the Ubonrat Dam and Lam Nam Phong River revealed that a substantial majority of the community (92%) relied on tap water for their daily needs.This tap water was sourced either from the Provincial Waterworks Authority (47.55%) or local community/village water supply systems (45.92%).Smaller fractions of the population used groundwater (5.42%) or natural water sources (2%), as shown in Figure 3a.Despite the prevalent use of tap water, residents expressed concerns over its quality, noting attributes such as color, turbidity, foul smell, and unpleasant taste.Notably, these local water sources were tested for quality only once a year, and the results, even when they did not meet standards, were not communicated to the residents.(a) Daily water usage primarily comes from the Provincial Waterworks Authority (47.55%) and local community/village supply (45.92%), with lesser amounts from groundwater (5.42%) and natural sources (2%).(b) Drinking water preferences show that the majority use bottled water (75.65%),followed by filtered or boiled tap water (12.8%),groundwater (6.4%), natural sources (2.81%), and public dispensers (2.33%).Note: The percentages provided are rounded for simplicity in the chart representation.
In addition to tap water usage, we found that most residents (75.65%) primarily rely on bottled drinking water.Only 12.8% used tap water for drinking, and even then, only after boiling or filtering it.The remaining residents used groundwater (6.4%), natural water sources like rain or well water (2.81%), and water from public dispensers (2.33%), as shown in Figure 3b.Intriguingly, much of the bottled water consumed was produced locally, using water from the Nam Phong River as the raw material.This situation underscored the need for consistent quality control and regular monitoring of both tap and bottled water sources.

Comprehensive Analysis of Water and Sediment Quality: Implications for Public Health and Environmental Safety
Upon evaluating the water and sediment quality in the surrounding area of the Ubonrat Dam and along a 35-km segment of the Lam Nam Phong River, the analysis revealed the presence of multiple chemical contaminants that exceeded the established standards for both environmental and domestic use.Specifically, Fe, Mn, and Al concentrations in water (Figure 4a,b) surpassed allowable limits for household and drinking water.Additionally, sediment samples revealed detectable levels of Cd, Cr, and As, as shown in Figure 4c,d.Seasonal variations in contaminant levels were also evident, with higher (a) Daily water usage primarily comes from the Provincial Waterworks Authority (47.55%) and local community/village supply (45.92%), with lesser amounts from groundwater (5.42%) and natural sources (2%).(b) Drinking water preferences show that the majority use bottled water (75.65%),followed by filtered or boiled tap water (12.8%),groundwater (6.4%), natural sources (2.81%), and public dispensers (2.33%).Note: The percentages provided are rounded for simplicity in the chart representation.
In addition to tap water usage, we found that most residents (75.65%) primarily rely on bottled drinking water.Only 12.8% used tap water for drinking, and even then, only after boiling or filtering it.The remaining residents used groundwater (6.4%), natural water sources like rain or well water (2.81%), and water from public dispensers (2.33%), as shown in Figure 3b.Intriguingly, much of the bottled water consumed was produced locally, using water from the Nam Phong River as the raw material.This situation underscored the need for consistent quality control and regular monitoring of both tap and bottled water sources.

Comprehensive Analysis of Water and Sediment Quality: Implications for Public Health and Environmental Safety
Upon evaluating the water and sediment quality in the surrounding area of the Ubonrat Dam and along a 35-km segment of the Lam Nam Phong River, the analysis revealed the presence of multiple chemical contaminants that exceeded the established standards for both environmental and domestic use.Specifically, Fe, Mn, and Al concentrations in water (Figure 4a,b) surpassed allowable limits for household and drinking water.Additionally, sediment samples revealed detectable levels of Cd, Cr, and As, as shown in Figure 4c,d.Seasonal variations in contaminant levels were also evident, with higher concentrations during the hot season and lower concentrations during the rainy season, as detailed in Figure 4. Notably, glyphosate was present in both water and sediment samples.Although these concentrations were within current permissible limits, their existence indicates a state of environmental contamination.It is important to note that the half-life of glyphosate can be less than 19 weeks, depending on water conditions [15], suggesting that continued use might elevate levels beyond acceptable thresholds.concentrations during the hot season and lower concentrations during the rainy season, as detailed in Figure 4. Notably, glyphosate was present in both water and sediment samples.Although these concentrations were within current permissible limits, their existence indicates a state of environmental contamination.It is important to note that the half-life of glyphosate can be less than 19 weeks, depending on water conditions [15], suggesting that continued use might elevate levels beyond acceptable thresholds.Further analysis of household and drinking water quality around the Ubonrat Dam and Lam Nam Phong River confirmed elevated levels of Fe, Mn, and Al.Although these levels were not immediately toxic, prolonged exposure could pose potential health risks, as indicated in Figure 5.Further analysis of household and drinking water quality around the Ubonrat Dam and Lam Nam Phong River confirmed elevated levels of Fe, Mn, and Al.Although these levels were not immediately toxic, prolonged exposure could pose potential health risks, as indicated in Figure 5.Our water quality surveys aligned with previous health assessment surveys conducted by CKDNET on 973 residents in communities around these aquatic environments.CKDNET's earlier studies showed that areas with chemical contaminants in both freshwater and household water sources exhibited abnormal biomarkers associated with kidney dysfunction.In three out of the eight areas examined, the incidence of chronic kidney disease (CKD) was found to be higher than 25%.Although not all areas with identified water contaminants corresponded to adverse health findings from CKDNET's surveys, the results still raised significant concerns.These findings point to shortcomings in community-managed water treatment systems, which often operate due to the absence of Provincial Waterworks Authority service or the higher costs associated with them.

Seasonal Variability and Treatment Efficacy in Heavy Metal Concentrations in Community Water Treatment Plants
Water samples were collected from ten community-operated water treatment plants located in various villages around Ubonrat Dam, Lam Nam Phong River, Kaeng Nam Ton, and Kaeng La Wa Pond in Khon Kaen Province (Table 1).The samples were obtained at three distinct stages in the treatment process: from raw water before entering the plant, from the water within the precipitation container, and from the treated water ready for community distribution.These samples were analyzed for concentrations of Al, Cr, Cu, Mn, Fe, Co, Cd, As, and Pb using advanced laboratory techniques such as Atomic The metal content in water samples analyzed using the ICP-MS technique and compared with the standards of the Provincial Waterworks Authority.Our water quality surveys aligned with previous health assessment surveys conducted by CKDNET on 973 residents in communities around these aquatic environments.CKD-NET's earlier studies showed that areas with chemical contaminants in both freshwater and household water sources exhibited abnormal biomarkers associated with kidney dysfunction.In three out of the eight areas examined, the incidence of chronic kidney disease (CKD) was found to be higher than 25%.Although not all areas with identified water contaminants corresponded to adverse health findings from CKDNET's surveys, the results still raised significant concerns.These findings point to shortcomings in community-managed water treatment systems, which often operate due to the absence of Provincial Waterworks Authority service or the higher costs associated with them.

Seasonal Variability and Treatment Efficacy in Heavy Metal Concentrations in Community Water Treatment Plants
Water samples were collected from ten community-operated water treatment plants located in various villages around Ubonrat Dam, Lam Nam Phong River, Kaeng Nam Ton, and Kaeng La Wa Pond in Khon Kaen Province (Table 1).The samples were obtained at three distinct stages in the treatment process: from raw water before entering the plant, from the water within the precipitation container, and from the treated water ready for community distribution.These samples were analyzed for concentrations of Al, Cr, Cu, Mn, Fe, Co, Cd, As, and Pb using advanced laboratory techniques such as Atomic Absorption Spectroscopy (AAS), Inductively Coupled Plasma Mass Spectrometry (ICP-MS), and Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES).The findings are detailed in Table 2.In this study, water samples were collected during three crucial periods: the late hot to early rainy season (16 July-8 August 2022), the mid-rainy season (29-30 August 2022), and the late rainy to early cool season (September-October 2022).Table 2 presents heavy metal concentrations at both inlet and outlet sample points for 13 community water treatment plants, with samples collected during the late hot to early rainy season.Primarily, levels of Al, Cr, Fe, Co, and Cu mostly remained within regulatory limits, except for elevated Mn concentrations at the Don Chang and Kok Nam Kliang plants.Manganese is a metal commonly found in high concentrations in surface water sources in Thailand.Although Mn concentrations appear to have decreased after treatment, they still exceed standard limits (as shown in Table 2; at the Don Chang and Kok Nam Kliang plant outlets).These indicate the efficacy of water treatment processes at the plant.Additionally, Kok Nam Kliang showed Fe levels above the permissible threshold after treatment.Notably, the increased Fe levels at this facility could not be linked to their raw water sources, as other plants with similar sources demonstrated lower levels of these metals (Table 2).
Regarding As, Cd, Pb, and Hg concentrations, the study found that all 13 water treatment plants exhibited levels of these metals that exceeded standard limits.Furthermore, minimal differences in these concentrations were observed before and after the water treatment process, suggesting that the existing treatment systems might be ineffective or inadequate in removing these metals (Table 2).Therefore, to test the hypothesis that the metal contamination might originate from the water production process, an additional water sampling point was added at the precipitation chamber of the water production system during the second and third sampling periods.These sampling periods took place during the mid-rainy season (29-30 August 2022) and the transition from the late rainy to early cool season (September-October 2022) (Table 3).During subsequent sampling in the rainy and transition-to-cool seasons, most contaminants remained within acceptable limits, except for persistent elevated Mn levels at the Kok Nam Kliang and Nong Ma Khuea plants.Considering the findings across all three sampling phases, considerable fluctuations in Mn, As, Pb, Cd, and Hg levels were observed.While most measurements remained within regulatory guidelines during the rainy and transition-to-cool seasons (as displayed in Table 3), the study highlighted the seasonal impact on water quality.Samples collected during the transition from the late hot to the early rainy season, which marks the end of Thailand's long dry season, showed a considerable accumulation of various contaminants in the water, resulting in high levels of detected contamination.The contamination levels gradually improved during the rainy season.These data informed the selection of appropriate technological solutions for each community, such as point-of-test sensors for Mn, As, Pb, Cd, and Cu.Additionally, the data called into question the effectiveness of current community water treatment systems in consistently reducing contaminant levels.Data from Table 3 show that the contamination might have originated from the precipitation chamber of the water production system.This is illustrated by the Mn levels detected in some sampling areas in Table 3, where no contamination was found in the inlet samples, but contamination was present in the precipitation chamber.This finding is consistent with the results for Fe and certain heavy metals in Table 2, where the contamination levels in the outlet water were higher than those in the inlet.Therefore, it is recommended that the village water supply system administrators regularly maintain the precipitation chamber.
In treatment systems that did not meet quality standards, simple filtration materials and engineering designs were integrated to enhance water quality.Additionally, it was noted from the Al concentrations listed in Table 3 that some areas exhibited high levels of Al in the precipitation chamber, while none was detected at the inlet.In other areas, higher Al levels were found at the outlet, which is the water after the quality improvement process.These Al concentrations may result from the excessive addition of alum in the coagulation process.Thus, routine turbidity and Mini Jar tests were conducted to monitor raw water clarity and optimize the use of potassium alum for precipitation.Even though they were provided with standard protocols, the community faced challenges adapting these guidelines to their specific needs.Notably, these water treatment plants are located near agricultural fields that frequently use pesticides and fertilizers.These fertilizers might contain a mix of heavy metals as inert ingredients in their formulations [16], underscoring the importance of regular monitoring and adjustments by the community.

Baseline Health Assessment of Community Volunteers before Water Quality Improvement and Learning Innovation Platform (LIP) Training: Demographics, Physical Measurements, and Laboratory Findings
Characteristics of Participants: The study included 568 volunteers with an average age of 61.6 ± 23.0 years.Of these, 156 were male (27.5%) and 412 were female (72.5%).The average weight for 527 participants (41 of whom had dropped out) was 59.9 ± 11.3 kg, and their body mass index (BMI) averaged 24.8 ± 4.25 kg/m 2 .Overweight and obesity were prevalent in 65.1% and 44% of this subgroup, respectively.The average systolic blood pressure was 138.0 ± 19.8 mmHg, and the average diastolic blood pressure was 80.7 ± 11.9 mmHg.High systolic pressure (>140 mmHg) was observed in 42.5%, while high diastolic pressure (>90 mmHg) was observed in 21% of the participants (Table 4).

Strategy for Implementing and Monitoring Water Quality Improvement through Innovation and Technology
Following the criteria mentioned earlier for selecting target areas to train local innovators and implement water quality interventions, the Nong Tae water treatment plant was chosen as a community model.This selection was for improving water quality using LIP training combined with infrastructure enhancements in the water plant.For infrastructure improvement in the Nong Tae water plant, repairs and enhancements were focused on the existing system without making structural changes.These improvements included upgrading the raw water pump to efficiently pump water into the system, modifying the sedimentation tank for easier cleaning by using a tube settler, installing a chemical dosing system, and adding a carbon filter tank before distributing the water to users.In the LIP activities, besides providing knowledge on the maintenance of village water supply systems and water quality monitoring, we introduced equipment sets for monitoring chemicals commonly found in water.These include test kits for metals/heavy metals and pesticides, such as Mn, Cu, F, Hg, Pb, As, Glyphosate, and Paraquat.Additionally, we provided tools for assessing appropriate coagulant dosages, such as a simple turbidity measurement device and a Mini Jar Test for coagulant evaluation.We also created a manual for maintaining village water supply systems and using these tools, which was handed over to the community for their use.In contrast, other communities only underwent the LIP training program, as illustrated in Table 5.
For Ban Nong Tae, which was used as a model in the study, it was found that water quality before (Table 2) and after the infrastructure enhancements (Table 3, 3rd round) showed significant improvement.There was no contamination of heavy metals, and the amount of aluminum in the finished water (outlet), primarily resulting from improper alum dosing, was significantly reduced.
Before initiating the LIP-driven community, 527 participants from the target communities received comprehensive health checks.Physical examinations and clinical laboratory tests were conducted, and individual results were provided to participants, accompanied by medical consultations during the LIP training.A summary of these health assessments is presented in Table 4.
The initial session of the LIP played a crucial role in developing a group of trained community members.These first 10 participants went through an extensive training program, which highlighted the potential risks of water contaminants, especially those identified in local water sources and at both the inlet and outlet of community water treatment plants.This education aimed to increase awareness about the importance of using water that adheres to safety standards, thereby connecting public health to water management.
In the second LIP session, the initial cohort of 10 community innovators assumed a mentorship role, guiding the training of at least another 10 interested individuals.This transfer of knowledge and skills fostered a second generation of community innovators, as illustrated in Table 5.Throughout the LIP, continuous support, evaluations, and reviews were provided and facilitated by key local agencies.This comprehensive and iterative approach not only ensures community empowerment in water resource management but also amplifies awareness and action regarding water quality and health, making the program's impact widespread and lasting.After completing the LIP activities, a total of 46 innovators were developed.Among them, 17 innovators have the capability to serve as station masters or community representatives.The community innovator levels are divided into four categories based on their learning abilities: Level 1: Able to continuously expand and connect community resources (Station Master); Level 2: Able to discover and create knowledge, technology, and innovations; Level 3: Able to transfer knowledge, technology, and innovations; and Level 4: Able to receive and adapt technology and innovations.
Additionally, after the completion of the LIP training program, several positive changes were observed in the community.There was a shift in attitudes and an increase in awareness among the local population about the importance of monitoring water quality and detecting chemical contamination that could affect their health.People became more interested in tracking chemical contaminants in the water and expressed a desire to manage and maintain their community's water supply themselves.This was evident as more village technicians and health volunteers participated in subsequent LIP activities on their own initiative.Moreover, it was found that more residents brought water samples from their households for quality testing during the water quality monitoring stations set up alongside LIP activities.The number of water samples tested increased by 30% each time a LIP activity was held.According to surveys conducted in the model community of "Nong Tae", residents felt that the water was cleaner and had greater confidence in the water produced by their village water supply system.As a result, they started using this water for their daily needs more frequently, reducing their reliance on bottled drinking water.The outcomes of the comparative health assessment before and after the introduction of the LIP-driven community are presented in Table 6.Statistically significant improvements were noted in various symptoms, including lethargy, arthralgia, muscle ache, backache, abdominal bloating, headache, loss of appetite, insomnia, cramps, jaundice, palpitations, gasping for breath, and diarrhea.Over 6 months, there was also a decrease in the prevalence of conditions such as high blood pressure, skin rashes, gastrointestinal disorders, and neurological problems.However, no statistically significant changes were observed in the overall prevalence of kidney disease or the average glomerular filtration rate after the platform's implementation.Notably, there was a decline in urinary albumin levels, a biomarker indicating initial changes in kidney disease.In a sub-analysis focused on kidney health and categorized by geographical areas (Table 7), significant declines in the glomerular filtration rate were notably observed in the regions of Kok Samran and Nong Makuea, Haet District, Na Kham, and Kok Namkliang.A decrease in median urinary albumin levels was detected in most regions (9 out of 13), with the exceptions being Pa Lium, Kok Samran, Nong Bua Noi, and Kam Bon.Interestingly, while considering the total number and severity of all chronic kidney disease patients, no statistically significant changes emerged post-implementation.However, significant shifts in the prevalence of idiopathic kidney diseases were observed in two specific areas: a decrease in the pilot community for water treatment in the project, Nong Tae, Dong Sub-district (from 16.22% to 2.70%), and an increase in Kam Bon, Kok Sung Sub-district (from 2.94% to 14.71%).Particularly in the area of Kam Bon, Kok Sung Sub-district, our previous survey identified Cd, Cr, and As levels that surpassed the standard limits in soil sediments.

Discussion
The LIP has proven to be an effective community-based intervention for addressing both water quality and health issues in Khon Kaen Province.The program successfully developed a training model emphasizing the implications of water contamination [17,18] and tailored its educational content to address local water management challenges [17].Notably, the initiative led to improvements in general health markers such as sleep quality, emotional well-being, and cognitive functions [1].Additionally, there was a significant reduction in hypertension cases [19], highlighting the combined benefits of enhancing water quality and community health education [20].
One of the primary strengths of this study is its comprehensive approach, integrating community training with rigorous health and environmental assessments.The LIP model empowered local residents to monitor water quality and implement simple purification methods, fostering community ownership and sustainability.This empowerment is crucial for ensuring long-term improvements in water quality and health outcomes.
However, the study has several limitations.The relatively short follow-up period limits the ability to assess long-term health outcomes and the sustainability of the intervention.Additionally, the study did not control for all potential confounding variables, such as dietary habits and other environmental exposures, which could influence the health outcomes observed [21].Future research should include longer follow-up periods and more comprehensive control of confounding variables to better understand the long-term impacts of such interventions.
The elevated levels of heavy metals such as Cd, Cr, and As in soil sediments in Kam Bon and Kok Sung Sub-districts raise significant health concerns.Chronic exposure to these metals can lead to various adverse health effects [22].Cd exposure is associated with kidney damage and an increased risk of osteoporosis.Cr, particularly hexavalent chromium, is a known carcinogen, while As exposure is linked to skin lesions, developmental effects, cardiovascular disease, neurotoxicity, and diabetes.These findings underscore the necessity for a multifaceted approach that addresses both health education and environmental remediation [23].Strategies to mitigate these risks should include regular monitoring of environmental contaminants, community education on the sources and health effects of these metals, and interventions to reduce exposure, such as improving water treatment processes and soil remediation efforts.

Conclusions
In summary, the LIP demonstrated its efficacy as a community-based intervention tailored to address the pressing concerns of water contamination and associated health issues in Khon Kaen Province.The program has shown significant improvements in general health indicators, including reductions in hypertension and enhancements in sleep quality and emotional well-being.Additionally, there was a noted improvement in the community's ability to monitor and manage water quality independently.However, the findings also highlight the presence of environmental contaminants such as Cd, Cr, and As, which pose significant health risks.These findings emphasize the need for ongoing environmental monitoring and remediation efforts, alongside community education and health interventions.
Future research should focus on longer-term follow-up studies to assess the sustainability of health improvements and the long-term effectiveness of the LIP model.Additionally, future studies should aim to control for a wider range of confounding variables, such as dietary habits and other environmental exposures, to provide a clearer understanding of the factors influencing health outcomes.Furthermore, research should explore the development and implementation of more advanced water treatment and soil remediation technologies to address the identified environmental contaminants effectively.By addressing these areas, future research can build on the current study's findings and contribute to the development of more comprehensive and sustainable strategies for improving water quality and public health in communities facing similar challenges.

Figure 2 .
Figure 2. Illustration of the LIP-driven process for continuous health screening and water quality improvement, facilitated by four key organizations: NANOTEC (National Nanotechnology Center), CKDNET (Chronic Kidney Disease Prevention in the Northeast of Thailand), PWA (Provincial Waterworks Authority), and EPO (Environmental and Pollution Control Office).Each activity incorporates comprehensive assessments and training, anchored by central reviews to ensure iterative improvement and thorough oversight.

Figure 4 .
Figure 4. Geographic distribution of chemical contaminants around the Ubonrat Dam.The map pinpoints areas where levels of Fe (indicated in yellow), Mn (in purple), and Al (in green) in both water and sediment samples did not meet the established standards.Panel (a) reveals locations where water samples containing Fe, Mn, and Al failed to meet Provincial Waterworks Authority guidelines during the rainy season.Panel (b) similarly indicates areas during the hot season.Panel (c) presents locations where sediment samples containing Cr (marked in yellow), As (in blue), and Cd (in red) fell short of Pollution Control Department standards in the hot season.Panel (d) does the same for the rainy season.Note: The collection dates for freshwater samples in Panels (a,c) were 22 August 2020.Sediment samples for Panel (b) were collected on 3 April 2021, while those for Panel (d) were collected between 21-22 March 2021.
metal content in water samples from Ubonrat Dam was analyzed using the ICP-MS technique and compared with the standards of the Provincial Waterworks Authority.The metal content in sediment samples from Ubonrat Dam was analyzed using the ICP-MS technique and compared with the pollution control department standards of 2018 (B.E.2561) Fe >300 ppb Mn>100 ppb Al>200 ppb Cr >45.5 mg/kg As>10 mg/kg Cd>0.16 mg/kg

Figure 4 .
Figure 4. Geographic distribution of chemical contaminants around the Ubonrat Dam.The map pinpoints areas where levels of Fe (indicated in yellow), Mn (in purple), and Al (in green) in both water and sediment samples did not meet the established standards.Panel (a) reveals locations where water samples containing Fe, Mn, and Al failed to meet Provincial Waterworks Authority guidelines during the rainy season.Panel (b) similarly indicates areas during the hot season.Panel (c) presents locations where sediment samples containing Cr (marked in yellow), As (in blue), and Cd (in red) fell short of Pollution Control Department standards in the hot season.Panel (d) does the same for the rainy season.Note: The collection dates for freshwater samples in Panels (a,c) were 22 August 2020.Sediment samples for Panel (b) were collected on 3 April 2021, while those for Panel (d) were collected between 21-22 March 2021.

Figure 5 .
Figure 5. Geographic distribution of household water quality issues along the Lam Nam Pong River.This map highlights community locations where household water samples did not meet Provincial Waterworks Authority standards for Mn (indicated in purple), Al (in blue), and Fe (in yellow).Note: Water samples were collected between 20-21 March 2021.

Consumption
Water samples from communities around Ubonrat Dam and Nam Phong river, March 20-21, 2021

Figure 5 .
Figure 5. Geographic distribution of household water quality issues along the Lam Nam Pong River.This map highlights community locations where household water samples did not meet Provincial Waterworks Authority standards for Mn (indicated in purple), Al (in blue), and Fe (in yellow).Note: Water samples were collected between 20-21 March 2021.

3. 6 .
Evaluation of Health Indicators and Kidney Function following the Implementation of the Learning Innovation Platform (LIP) Int. J. Environ.Res.Public Health 2024, 21, 729 7 of 23

Table 1 .
District, Sub-District, and village names of 15 surveyed community water treatment plants and their corresponding raw water sources.

Table 2 .
Concentrations of metals in water samples from community treatment plants collected during the transition from late hot to early rainy season (16 July-8 August 2022) (First sample collection).

Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet Inlet Outlet
'Red' indicates contaminant levels exceeding water quality standards; 'ND' means not detected via standard ICP-MS and AAS methods; '-' signifies untested; Aluminum and Cobalt are not in standard criteria.

Table 3 .
Concentrations of heavy metals in water samples from various locations collected during different periods: 1st rd (transition from late hot to early rainy season; 16 July-8 August 2022), 2nd rd (mid-rainy season; 29-30 August 2022), and 3rd rd (transition from late rainy to early cool season; September-October 2022).
Nong Buanoi's water system was under repair, with SCG (Siam Cement Group Co., Ltd.) providing weekly raw water replenishment.Nakhum and Kok Nam Kliang relied on groundwater.'Red' indicates contamination exceeding metal standards, while 'ND' signifies non-detection.The dash (-) indicates tests not conducted.Aluminum and Cobalt are not included in water quality standards.

Table 4 .
Findings of health assessments, sorted by resident communities, before water improvement and LIP training.

Table 5 .
Summary of the target communities and strategy for implementing and monitoring water quality improvement through innovation and technology.

Table 6 .
Changes in health indicators and kidney function pre-and post-implementation of the LIP-driven community.