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Globally, 2.8 billion people rely on household solid fuels. Reducing the resulting adverse health, environmental, and development consequences will involve transitioning through a mix of clean fuels and improved solid fuel stoves (IS) of demonstrable effectiveness. To date, achieving uptake of IS has presented significant challenges. We performed a systematic review of factors that enable or limit large-scale uptake of IS in low- and middle-income countries. We conducted systematic searches through multidisciplinary databases, specialist websites, and consulting experts. The review drew on qualitative, quantitative, and case studies and used standardized methods for screening, data extraction, critical appraisal, and synthesis. We summarized our findings as \"factors\" relating to one of seven domains-fuel and technology characteristics; household and setting characteristics; knowledge and perceptions; finance, tax, and subsidy aspects; market development; regulation, legislation, and standards; programmatic and policy mechanisms-and also recorded issues that impacted equity. We identified 31 factors influencing uptake from 57 studies conducted in Asia, Africa, and Latin America. All domains matter. Although factors such as offering technologies that meet household needs and save fuel, user training and support, effective financing, and facilitative government action appear to be critical, none guarantee success: All factors can be influential, depending on context. The nature of available evidence did not permit further prioritization. Achieving adoption and sustained use of IS at a large scale requires that all factors, spanning household/community and program/societal levels, be assessed and supported by policy. We propose a planning tool that would aid this process and suggest further research to incorporate an evaluation of effectiveness.

Abstract Rationale Hypertension during pregnancy is a leading cause of maternal mortality. Exposure to household air pollution elevates blood pressure (BP). Objectives To investigate the ability of a clean cookstove intervention to lower BP during pregnancy. Methods We conducted a randomized controlled trial in Nigeria. Pregnant women cooking with kerosene or firewood were randomly assigned to an ethanol arm (n = 162) or a control arm (n = 162). BP measurements were taken during six antenatal visits. In the primary analysis, we compared ethanol users with control subjects. In subgroup analyses, we compared baseline kerosene users assigned to the intervention with kerosene control subjects and compared baseline firewood users assigned to ethanol with firewood control subjects. Measurements and Main Results The change in diastolic blood pressure (DBP) over time was significantly different between ethanol users and control subjects (P = 0.040); systolic blood pressure (SBP) did not differ (P = 0.86). In subgroup analyses, there was no significant intervention effect for SBP; a significant difference for DBP (P = 0.031) existed among preintervention kerosene users. At the last visit, mean DBP was 2.8 mm Hg higher in control subjects than in ethanol users (3.6 mm Hg greater in control subjects than in ethanol users among preintervention kerosene users), and 6.4% of control subjects were hypertensive (SBP ≥140 and/or DBP ≥90 mm Hg) versus 1.9% of ethanol users (P = 0.051). Among preintervention kerosene users, 8.8% of control subjects were hypertensive compared with 1.8% of ethanol users (P = 0.029). Conclusions To our knowledge, this is the first cookstove randomized controlled trial examining prenatal BP. Ethanol cookstoves have potential to reduce DBP and hypertension during pregnancy. Accordingly, clean cooking fuels may reduce adverse health impacts associated with household air pollution. Clinical trial registered with www.clinicaltrials.gov (NCT02394574).

Smoke from cooking in the kitchen is one of the world's leading causes of premature child death, claiming the lives of 500,000 children under five annually. This study analyses the role of outdoor cooking and the prevalence of respiratory diseases among children under five years by means of probit regressions using information from 41 surveys conducted in 30 developing countries from Asia, Africa and Latin America. I find that outdoor cooking reduces respiratory diseases among young children aged 0-4 by around 9 percent, an effect that reaches 13 percent among children aged 0-1. The results suggest that simple behavioral interventions, such as promoting outdoor cooking, can have a substantial impact on health hazards.

In this randomized trial involving pregnant women in low- and middle-income countries, birth weight was not higher among infants born to women who used LPG stoves than among those born to women who used biomass stoves.

Household air pollution due to biomass combustion for residential heating adversely affects vulnerable populations. Randomized controlled trials to improve indoor air quality in homes of children with asthma are limited, and no such studies have been conducted in homes using wood for heating. Our aims were to test the hypothesis that household-level interventions, specifically improved-technology wood-burning appliances or air-filtration devices, would improve health measures, in particular Pediatric Asthma Quality of Life Questionnaire (PAQLQ) scores, relative to placebo, among children living with asthma in homes with wood-burning stoves. A three-arm placebo-controlled randomized trial was conducted in homes with wood-burning stoves among children with asthma. Multiple preintervention and postintervention data included PAQLQ (primary outcome), peak expiratory flow (PEF) monitoring, diurnal peak flow variability (dPFV, an indicator of airway hyperreactivity) and indoor particulate matter (PM) PM2.5. Relative to placebo, neither the air filter nor the woodstove intervention showed improvement in quality-of-life measures. Among the secondary outcomes, dPFV showed a 4.1 percentage point decrease in variability [95% confidence interval (CI)=-7.8 to -0.4] for air-filtration use in comparison with placebo. The air-filter intervention showed a 67% (95% CI: 50% to 77%) reduction in indoor PM2.5, but no change was observed with the improved-technology woodstove intervention. Among children with asthma and chronic exposure to woodsmoke, an air-filter intervention that improved indoor air quality did not affect quality-of-life measures. Intent-to-treat analysis did show an improvement in the secondary measure of dPFV. ClincialTrials.gov NCT00807183. https://doi.org/10.1289/EHP849.

Household air pollution (HAP) from biomass combustion in traditional cooking methods poses significant health risks, particularly in rural communities of low- and middle-income countries. Improved cookstoves (ICS), designed to enhance combustion efficiency and reduce emissions, have been promoted as a transitional alternative towards cleaner cooking. However, evidence of their benefits remains mixed and context-specific. A randomized controlled trial was conducted to evaluate the impact of introducing the Save80 ICS on the respiratory health of adults in rural settlements in Rwanda. The study comprised two assessment rounds, and participants ( n  = 1001) were divided into two groups: one using traditional cooking methods and one using improved cookstoves. Baseline and follow-up data were collected through structured questionnaires and lung function tests. Furthermore, HAP was measured in a field campaign at households cooking with the ICS or traditional methods. The primary outcomes included respiratory symptoms, spirometry (FVC, FEV 1 , and PEF), and exposure to particulate matter (PM 0.3−2.5 ) and its components (EC, OC, BC, BrC, and PAH). We found that households using the ICS spent, on average, 34% less time cooking and had 77% lower indoor PM 0.3−2.5 levels. BC and BrC exposure decreased by 50% and 78%, respectively; OC and TC concentrations were 58% and 45% lower. PAH concentrations showed inconsistent patterns, with most species presenting non-statistically significant changes, constraining objective conclusions. Over the study period (3 years), ICS users reported lower prevalence of cough (-11%) and mucus production (-9%), and showed better forced vital capacity than users of traditional methods. A comparison of lung function decline over time showed that the ICS users had lower deterioration of FVC over three years. This study documents the effects and benefits of introducing ICS. While limitations such as the lack of baseline HAP data during the first health assessment and inconclusive PAH concentrations constrain interpretations and quantified causality, the results contribute to the evidence on the health and indoor air pollution impacts of ICS adoption in rural East African areas.

Background In low- and middle-income countries, households mainly use solid fuels like wood, charcoal, dung, agricultural residues, and coal for cooking. This poses significant public health concerns due to the emission of harmful particles and gases. To address these issues and support Sustainable Development Goals (SDGs), adopting cleaner cooking fuels like electricity and gas are acknowledged as a viable solution. However, access to these cleaner fuels is limited, especially in rural areas. Methods This study conducted a face-to-face survey with 1240 individuals in rural Bangladesh to explore the link between health issues and cooking fuel type, as well as barriers to transitioning to clean cooking. Using a convenient sampling technique across four divisions/regions, the survey gathered socio-demographic and health data, along with information on clean cooking barriers through a semi-structured questionnaire. Binary and multivariable logistic regression analyses were then employed to identify significant associations between cooking fuel type and health problems. Results The study revealed that a majority of participants (73.3%) relied on solid fuel for cooking. The use of solid fuel was significantly correlated with factors such as lower education levels, reduced family income, location of residence, and the experience of health issues such as cough, chest pressure while breathing, eye discomfort, diabetes, asthma, and allergies. Economic challenges emerged as the foremost obstacle to the adoption of clean cooking, accompanied by other contributing factors. Conclusion The use of solid fuel in rural Bangladeshi households poses substantial health risks, correlating with respiratory, eye, cardiovascular, and metabolic issues. Lower education and income levels, along with specific residential locations, were associated with higher solid fuel usage. Economic challenges emerged as the primary obstacle to adopting clean cooking practices. These findings emphasize the need for implementing strategies to promote clean cooking, address barriers, and contribute to achieving Sustainable Development Goal targets for health and sustainable energy access in Bangladesh.

Background Poor indoor air quality (IAQ) is a leading cause of respiratory and cardiopulmonary illnesses. Particulate matter (PM 2.5 ) and carbon monoxide (CO) are critical indicators of IAQ, yet there is limited evidence of their concentrations in informal urban settlements in low-income countries. Objective This study assessed household characteristics that predict the concentrations of PM 2.5 and CO within households in an informal settlement in Fort Portal City, Uganda. Methodology A cross-sectional study was conducted in 374 households. Concentrations of PM 2.5 and CO were measured using a multi-purpose laser particle detector and a carbon monoxide IAQ meter, respectively. Data on household characteristics were collected using a structured questionnaire and an observational checklist. Data were analysed using STATA version 14.0. Linear regression was used to establish the relationship between PM 2.5, CO concentrations and household cooking characteristics. Results The majority (89%, 332/374) of the households used charcoal for cooking. More than half (52%, 194/374) cooked outdoors. Cooking areas had significantly higher PM 2.5 and CO concentrations (t = 18.14, p  ≤ 0.05) and (t = 5.77 p  ≤ 0.05), respectively. Cooking outdoors was associated with a 0.112 increase in the PM 2.5 concentrations in the cooking area (0.112 [95% CI: -0.069, 1.614; p  = 0.033]). Cooking with moderately polluting fuel was associated with a 0.718 increase in CO concentrations (0.718 [95% CI: 0.084, 1.352; p  = 0.027]) in the living area. Conclusions The cooking and the living areas had high concentrations of PM 2.5 and CO during the cooking time. Cooking with charcoal resulted in higher CO in the living area. Furthermore, cooking outdoors did not have a protective effect against PM 2.5 , and ambient PM 2.5 exceeded the WHO Air quality limits. Interventions to improve the indoor air quality in informal settlements should promote a switch to cleaner cooking energy and improvement in the ambient air quality.

Clean cooking has emerged as a major concern for global health and development because of the enormous burden of disease caused by traditional cookstoves and fires. The World Health Organization has developed new indoor air quality guidelines that few homes will be able to achieve without replacing traditional methods with modern clean cooking technologies, including fuels and stoves. However, decades of experience with improved stove programs indicate that the challenge of modernizing cooking in impoverished communities includes a complex, multi-sectoral set of problems that require implementation research. The National Institutes of Health, in partnership with several government agencies and the Global Alliance for Clean Cookstoves, has launched the Clean Cooking Implementation Science Network that aims to address this issue. In this article, our focus is on building a knowledge base to accelerate scale-up and sustained use of the cleanest technologies in low- and middle-income countries. Implementation science provides a variety of analytical and planning tools to enhance effectiveness of clinical and public health interventions. These tools are being integrated with a growing body of knowledge and new research projects to yield new methods, consensus tools, and an evidence base to accelerate improvements in health promised by the renewed agenda of clean cooking.

Exposure to biomass smoke has been related to adverse health effects. In Mexico, one household in four still cooks with biomass fuel, but there has been no evaluation of the health impact of reducing indoor air pollution. To evaluate the health impact of the introduction of an improved biomass stove (Patsari; Interdisciplinary Group for Appropriate Rural Technology [GIRA], Patzcuaro, Mexico) in Mexican women. A randomized controlled trial was conducted in the Central Mexican state of Michoacán. Households were randomized to receive the Patsari stove or keep their traditional open fire. A total of 552 women were followed with monthly visits over 10 months to assess stove use, inquire about respiratory and other symptoms, and obtain lung function measurements. Statistical analysis was conducted using longitudinal models. Adherence to the intervention was low (50%). Women who reported using the Patsari stove most of the time compared with those using the open fire had significantly lower risk of respiratory symptoms (relative risk [RR], 0.77; 95% confidence interval [CI], 0.62-0.95 for cough and RR, 0.29; 95% CI, 0.11-0.77 for wheezing) adjusted for confounders. Similar results were found for other respiratory symptoms as well as for eye discomfort, headache, and back pain. Actual use of the Patsari stove was associated with a lower FEV(1) decline (31 ml) compared with the open fire use (62 ml) over 1 year of follow-up (P = 0.012) for women 20 years of age and older, adjusting for confounders. The use of the Patsari stove was significantly associated with a reduction of symptoms and of lung function decline comparable to smoking cessation.