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Williams KN, Kamenar K, Kephart JL, Chiang M, Hartinger SM, Checkley W. Testing the effectiveness of household fuel conservation strategies: Policy implications for increasing the affordability of exclusive clean cooking. ENVIRONMENT INTERNATIONAL 2023; 180:108223. [PMID: 37748372 PMCID: PMC10732248 DOI: 10.1016/j.envint.2023.108223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/16/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Exclusive clean fuel use is essential for realizing health and other benefits but is often unaffordable. Decreasing household-level fuel needs could make exclusive clean fuel use more affordable, but there is a lack of knowledge on the amount of fuel savings that could be achieved through fuel conservation behaviors relevant to rural settings in low- and middle-income countries. METHODS Within a trial in Peru, we trained a random half of intervention participants, who had previously received a liquefied petroleum gas (LPG) stove and were purchasing their own fuel, on fuel conservation strategies. We measured the amount of fuel and mega joules (MJ) of energy consumed by all participants, including control participants who were receiving free fuel from the trial. We administered surveys on fuel conservation behaviors and assigned a score based on the number of behaviors performed. RESULTS Intervention participants with the training had a slightly higher conservation score than those without (7.2 vs. 6.6 points; p = 0.07). Across all participants, average daily energy consumption decreased by 9.5 MJ for each 1-point increase in conservation score (p < 0.001). Among households who used exclusively LPG (n = 99), each 1-point increase in conservation score was associated with a 0.04 kg decrease in LPG consumption per household per day (p = 0.03). Using pressure cookers and heating water in the sun decreased energy use, while using clay pots and forgetting to close stove knobs increased energy use. CONCLUSION Our findings suggest that a household could save 1.16 kg of LPG per month for each additional fuel conservation behavior, for a maximum potential savings of 8.1 kg per month. Fuel conservation messaging could be integrated into national household energy policies to increase the affordability of exclusive clean fuel use, and subsequently achieve the environmental and health benefits that could accompany such a transition.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Katarina Kamenar
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Stella M Hartinger
- Facultad de Salud Publica y Administración, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Fujita-Conrads R, Williams KN, Underhill LJ, Herrera P, Rahman N, Romani-Huacani E, Flores-Flores O, Checkley W, Pollard SL. Successes and challenges to implementing the Fondo de Inclusión Social Energético LPG access Program in Peru: novel insights from front-end implementers. ENERGY FOR SUSTAINABLE DEVELOPMENT : THE JOURNAL OF THE INTERNATIONAL ENERGY INITIATIVE 2023; 76:101267. [PMID: 37484495 PMCID: PMC10361398 DOI: 10.1016/j.esd.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Background Household air pollution due to the burning of solid fuels is one of the leading risk factors for disease and mortality worldwide, resulting in an estimated three million deaths annually. Peru's national LPG access program, FISE, aims to reduce the use of biomass fuels and increase access to cleaner fuels for cooking in low-income Peruvian households through public-private partnerships. Perspectives from front-end program implementers are needed to better understand barriers and facilitators to program implementation and to identify strategies to strengthen program reach, uptake, and health impact. Methods We conducted fourteen 30-60-minute, semi-structured interviews with FISE-authorized LPG vendors (also known as agents) in Puno, Peru from November to December of 2019. Questions focused on barriers and facilitators to program enrollment and participation as an LPG agent, and agents' motivations for participating in the program. Results Overall, agents expressed satisfaction with the FISE program and a willingness to continue participating in the program. Distance from main cities and the homes of program participants, knowledge of FISE and LPG stoves among community members, cell service, and lack of communication with FISE authorities were cited as barriers to implementation and LPG distribution. Agents' previous experience selling LPG, as well as their social networks and understanding of the health impacts of household air pollution, aided agents in more effectively navigating the system of FISE rules and regulations and in better serving their clients. Many agents were motivated to participate in FISE because they saw it as a service to their community and were willing to find ways to prioritize the needs of beneficiaries. Conclusion The FISE program provides an example of how a large-scale national program can successfully partner with local private enterprises for program implementation. Building upon the strengths of community-based LPG agents, educating community members on the use and benefits of LPG, incentivizing, and supporting delivery services, and improving communication will be key for increasing program utilization and exclusive use of LPG, and improving health outcomes among Peru's most vulnerable populations.
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Affiliation(s)
- Ryanne Fujita-Conrads
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Lindsay J Underhill
- Division of Cardiology, School of Medicine, Washington University in St. Louis, St. Louis, USA
| | - Phabiola Herrera
- Division of Pulmonary, Critical Care and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Nihaal Rahman
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
| | | | - Oscar Flores-Flores
- Universidad de San Martín de Porres, Facultad de Medicina Humana, Centro de Investigación del Envejecimiento (CIEN), Lima, Peru
- Universidad Científica del Sur, Facultad de Ciencias de la Salud, Lima, Peru
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Suzanne L Pollard
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, USA
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Tarazona-Meza C, Williams KN, Malpartida G, Kephart JL, Fandiño-Del-Río M, Simkovich S, Hossen S, Chiang M, Koehler K, Checkley W. Effects of a household air pollution intervention using liquefied petroleum gas stoves, continuous fuel distribution and behavioural messaging on dietary and sodium intake of adult women in Puno, Peru: a randomised controlled trial. Public Health Nutr 2023; 26:1686-1695. [PMID: 36793234 PMCID: PMC10410368 DOI: 10.1017/s1368980023000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/27/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Household air pollution (HAP) is a widespread environmental exposure worldwide. While several cleaner fuel interventions have been implemented to reduce personal exposures to HAP, it is unclear if cooking with cleaner fuels also affects the choice of meals and dietary intake. DESIGN Individually randomised, open-label controlled trial of a HAP intervention. We aimed to determine the effect of a HAP intervention on dietary and Na intake. Intervention participants received a liquefied petroleum gas (LPG) stove, continuous fuel delivery and behavioural messaging during 1 year whereas control participants continued with usual cooking practices that involved the use of biomass-burning stoves. Dietary outcomes included energy, energy-adjusted macronutrients and Na intake at baseline, 6 months and 12 months post-randomisation using 24-h dietary recalls and 24-h urine. We used t-tests to estimate differences between arms in the post-randomisation period. SETTING Rural settings in Puno, Peru. PARTICIPANTS One hundred women aged 25-64 years. RESULTS At baseline, control and intervention participants were similar in age (47·4 v. 49·5 years) and had similar daily energy (8894·3 kJ v. 8295·5 kJ), carbohydrate (370·8 g v. 373·3 g) and Na intake (4·9 g v. 4·8 g). One year after randomisation, we did not find differences in average energy intake (9292·4 kJ v. 8788·3 kJ; P = 0·22) or Na intake (4·5 g v. 4·6 g; P = 0·79) between control and intervention participants. CONCLUSIONS Our HAP intervention consisting of an LPG stove, continuous fuel distribution and behavioural messaging did not affect dietary and Na intake in rural Peru.
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Affiliation(s)
- Carla Tarazona-Meza
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Nutrition and Dietetics, Universidad Científica del Sur, Lima, Perú
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
| | | | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Magdalena Fandiño-Del-Río
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Suzanne Simkovich
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
| | - Shakir Hossen
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
| | | | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, Room 555, Baltimore, MD21287, USA
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Kephart JL, Gouveia N, Rodriguez DA, Indvik K, Alfaro T, Texcalac JL, Miranda JJ, Bilal U, Roux AVD. Ambient nitrogen dioxide in 47,187 neighborhoods across 326 cities in eight Latin American countries: population exposures and associations with urban features. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.02.23289390. [PMID: 37205591 PMCID: PMC10187449 DOI: 10.1101/2023.05.02.23289390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background Health research on ambient nitrogen dioxide (NO2) is sparse in Latin America, despite the high prevalence of NO2-associated respiratory diseases in the region. This study describes within-city distributions of ambient NO2 concentrations at high spatial resolution and urban characteristics associated with neighborhood ambient NO2 in 326 Latin American cities. Methods We aggregated estimates of annual surface NO2 at 1 km2 spatial resolution for 2019, population counts, and urban characteristics compiled by the SALURBAL project to the neighborhood level (i.e., census tracts). We described the percent of the urban population living with ambient NO2 levels exceeding WHO Air Quality Guidelines. We used multilevel models to describe associations of neighborhood ambient NO2 concentrations with population and urban characteristics at the neighborhood and city levels. Findings We examined 47,187 neighborhoods in 326 cities from eight Latin American countries. Of the ≈236 million urban residents observed, 85% lived in neighborhoods with ambient annual NO2 above WHO guidelines. In adjusted models, higher neighborhood-level educational attainment, closer proximity to the city center, and lower neighborhood-level greenness were associated with higher ambient NO2. At the city level, higher vehicle congestion, population size, and population density were associated with higher ambient NO2. Interpretation Almost nine out of every 10 residents of Latin American cities live with ambient NO2 concentrations above WHO guidelines. Increasing neighborhood greenness and reducing reliance on fossil fuel-powered vehicles warrant further attention as potential actionable urban environmental interventions to reduce population exposure to ambient NO2. Funding Wellcome Trust, National Institutes of Health, Cotswold Foundation.
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Affiliation(s)
- Josiah L. Kephart
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, USA
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Nelson Gouveia
- Department of Preventive Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel A. Rodriguez
- Department of City and Regional Planning and Institute for Transportation Studies, University of California, Berkeley, California, USA
| | - Katy Indvik
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Tania Alfaro
- Escuela de Salud Pública, Universidad de Chile, Santiago de Chile, Chile
| | - José Luis Texcalac
- Department of Environmental Health, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - J. Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Usama Bilal
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, USA
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Ana V. Diez Roux
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, USA
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, USA
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Williams KN, Kephart JL, Fandiño-Del-Rio M, Nicolaou L, Koehler K, Harvey SA, Checkley W. Sustained use of liquefied petroleum gas following one year of free fuel and behavioral support in Puno, Peru. ENERGY FOR SUSTAINABLE DEVELOPMENT : THE JOURNAL OF THE INTERNATIONAL ENERGY INITIATIVE 2023; 73:13-22. [PMID: 36798733 PMCID: PMC9928150 DOI: 10.1016/j.esd.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Background Existing efforts to promote cleaner fuels have not achieved exclusive use. We investigated whether receiving 12 months of free liquefied petroleum gas (LPG) and behavioral support could motivate continued purchase and use. Methods The Cardiopulmonary outcomes and Household Air Pollution (CHAP) trial enrolled 180 women. Half were randomly assigned to an intervention group, which included free LPG delivered in months 1-12 followed by a post-intervention period in which they no longer received free fuel (months 13-24). For the purposes of comparison, we also include months 1-12 of data from control participants. We tracked stove use with temperature monitors, surveys, and observations, and conducted in-depth interviews with 19 participants from the intervention group at the end of their post-intervention period. Results Participants from the intervention group used their LPG stove for 85.4 % of monitored days and 63.2 % of cooking minutes during the post-intervention months (13-24) when they were not receiving free fuel from the trial. They used a traditional stove (fogón) on 45.1 % of days post-intervention, which is significantly lower than fogón use by control participants during the intervention period (72.2 % of days). In months 13-24 post-intervention, participants from the intervention group purchased on average 12.3 kg and spent 34.1 soles (10.3 USD) per month on LPG. Continued LPG use was higher among participants who said they could afford two tanks of LPG per month, did not cook for animals, and removed their traditional stove. Women described that becoming accustomed to LPG, support and training from the project, consistent LPG supply, choice between LPG providers, and access to delivery services facilitated sustained LPG use. However, high cost was a major barrier to exclusive use. Conclusion A 12-month period of intensive LPG support achieved a high level of sustained LPG use post-intervention, but other strategies are needed to sustain exclusive use.
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Affiliation(s)
- Kendra N. Williams
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Josiah L. Kephart
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Laura Nicolaou
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Steven A. Harvey
- Department of International Health, Social and Behavioral Interventions Program, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Gould CF, Bejarano ML, Kioumourtzoglou MA, Lee AG, Pillarisetti A, Schlesinger SB, Terán E, Valarezo A, Jack DW. Widespread Clean Cooking Fuel Scale-Up and under-5 Lower Respiratory Infection Mortality: An Ecological Analysis in Ecuador, 1990-2019. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:37017. [PMID: 36989076 PMCID: PMC10056314 DOI: 10.1289/ehp11016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/09/2023] [Accepted: 02/10/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Nationwide household transitions to the use of clean-burning cooking fuels are a promising pathway to reducing under-5 lower respiratory infection (LRI) mortality, the leading cause of child mortality globally, but such transitions are rare and evidence supporting an association between increased clean fuel use and improved health is limited. OBJECTIVES This study aimed to investigate the association between increased primary clean cooking fuel use and under-5 LRI mortality in Ecuador between 1990 and 2019. METHODS We documented cooking fuel use and cause-coded child mortalities at the canton (county) level in Ecuador from 1990 to 2019 (in four periods, 1988-1992, 1999-2003, 2008-2012, and 2015-2019). We characterized the association between clean fuel use and the rate of under-5 LRI mortalities at the canton level using quasi-Poisson generalized linear and generalized additive models, accounting for potential confounding variables that characterize wealth, urbanization, and child health care and vaccination rates, as well as canton and period fixed effects. We estimated averted under-5 LRI mortalities accrued over 30 y by predicting a counterfactual count of canton-period under-5 LRI mortalities were clean fuel use to not have increased and comparing with predicted canton-period under-5 LRI mortalities from our model and observed data. RESULTS From 1990 to 2019, the proportion of households primarily using a clean cooking fuel increased from 59% to 95%, and under-5 LRI mortality fell from 28 to 7 per 100,000 under-5 population. Canton-level clean fuel use was negatively associated with under-5 LRI mortalities in linear and nonlinear models. The nonlinear association suggested a threshold at approximately 60% clean fuel use, above which there was a negative association. Increases in clean fuel use between 1990 and 2019 were associated with an estimated 7,300 averted under-5 LRI mortalities (95% confidence interval: 2,600, 12,100), accounting for nearly 20% of the declines in under-5 LRI mortality observed in Ecuador over the study period. DISCUSSION Our findings suggest that the widespread household transition from using biomass to clean-burning fuels for cooking reduced under-5 LRI mortalities in Ecuador over the last 30 y. https://doi.org/10.1289/EHP11016.
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Affiliation(s)
- Carlos F. Gould
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Earth System Science, Stanford University, Stanford, California, USA
| | - M. Lorena Bejarano
- Institute for Energy and Materials, Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Marianthi-Anna Kioumourtzoglou
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Alison G. Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health Science, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Environmental Health Sciences, University of California, Berkeley, California, USA
| | | | - Enrique Terán
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador
| | - Alfredo Valarezo
- Institute for Energy and Materials, Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Darby W. Jack
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
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Witinok-Huber R, Clark ML, Volckens J, Young BN, Benka-Coker ML, Walker E, Peel JL, Quinn C, Keller JP. Effects of household and participant characteristics on personal exposure and kitchen concentration of fine particulate matter and black carbon in rural Honduras. ENVIRONMENTAL RESEARCH 2022; 214:113869. [PMID: 35820656 PMCID: PMC10696621 DOI: 10.1016/j.envres.2022.113869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/10/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
Traditional cooking with solid fuels (biomass, animal dung, charcoals, coal) creates household air pollution that leads to millions of premature deaths and disability worldwide each year. Exposure to household air pollution is highest in low- and middle-income countries. Using data from a stepped-wedge randomized controlled trial of a cookstove intervention among 230 households in Honduras, we analyzed the impact of household and personal variables on repeated 24-h measurements of fine particulate matter (PM2.5) and black carbon (BC) exposure. Six measurements were collected approximately six-months apart over the course of the three-year study. Multivariable mixed models explained 37% of variation in personal PM2.5 exposure and 49% of variation in kitchen PM2.5 concentrations. Additionally, multivariable models explained 37% and 47% of variation in personal and kitchen BC concentrations, respectively. Stove type, season, presence of electricity, primary stove location, kitchen enclosure type, stove use time, and presence of kerosene for lighting were all associated with differences in geometric mean exposures. Stove type explained the most variability of the included variables. In future studies of household air pollution, tracking the cooking behaviors and daily activities of participants, including outdoor exposures, may explain exposure variation beyond the household and personal variables considered here.
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Affiliation(s)
- Rebecca Witinok-Huber
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Maggie L Clark
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - John Volckens
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA; Department of Mechanical Engineering, Colorado State University, Fort Collins, CO, USA
| | - Bonnie N Young
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | | | - Ethan Walker
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Jennifer L Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Casey Quinn
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO, USA
| | - Joshua P Keller
- Department of Statistics, Colorado State University, Fort Collins, CO, USA.
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Lim S, Bassey E, Bos B, Makacha L, Varaden D, Arku RE, Baumgartner J, Brauer M, Ezzati M, Kelly FJ, Barratt B. Comparing human exposure to fine particulate matter in low and high-income countries: A systematic review of studies measuring personal PM 2.5 exposure. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 833:155207. [PMID: 35421472 PMCID: PMC7615091 DOI: 10.1016/j.scitotenv.2022.155207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/02/2022] [Accepted: 04/08/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Due to the adverse health effects of air pollution, researchers have advocated for personal exposure measurements whereby individuals carry portable monitors in order to better characterise and understand the sources of people's pollution exposure. OBJECTIVES The aim of this systematic review is to assess the differences in the magnitude and sources of personal PM2.5 exposures experienced between countries at contrasting levels of income. METHODS This review summarised studies that measured participants personal exposure by carrying a PM2.5 monitor throughout their typical day. Personal PM2.5 exposures were summarised to indicate the distribution of exposures measured within each country income category (based on low (LIC), lower-middle (LMIC), upper-middle (UMIC), and high (HIC) income countries) and between different groups (i.e. gender, age, urban or rural residents). RESULTS From the 2259 search results, there were 140 studies that met our criteria. Overall, personal PM2.5 exposures in HICs were lower compared to other countries, with UMICs exposures being slightly lower than exposures measured in LMICs or LICs. 34% of measured groups in HICs reported below the ambient World Health Organisation 24-h PM2.5 guideline of 15 μg/m3, compared to only 1% of UMICs and 0% of LMICs and LICs. There was no difference between rural and urban participant exposures in HICs, but there were noticeably higher exposures recorded in rural areas compared to urban areas in non-HICs, due to significant household sources of PM2.5 in rural locations. In HICs, studies reported that secondhand smoke, ambient pollution infiltrating indoors, and traffic emissions were the dominant contributors to personal exposures. While, in non-HICs, household cooking and heating with biomass and coal were reported as the most important sources. CONCLUSION This review revealed a growing literature of personal PM2.5 exposure studies, which highlighted a large variability in exposures recorded and severe inequalities in geographical and social population subgroups.
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Affiliation(s)
- Shanon Lim
- MRC Centre for Environment and Health, Imperial College London, UK.
| | - Eridiong Bassey
- MRC Centre for Environment and Health, Imperial College London, UK
| | - Brendan Bos
- MRC Centre for Environment and Health, Imperial College London, UK
| | - Liberty Makacha
- MRC Centre for Environment and Health, Imperial College London, UK; Place Alert Labs, Department of Surveying and Geomatics, Faculty of Science and Technology, Midlands State University, Zimbabwe; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Diana Varaden
- MRC Centre for Environment and Health, Imperial College London, UK; NIHR-HPRU Environmental Exposures and Health, School of Public Health, Imperial College London, UK
| | - Raphael E Arku
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, USA
| | - Jill Baumgartner
- Institute for Health and Social Policy, and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Michael Brauer
- School of Population and Public Health, The University of British Columbia, Vancouver, Canada; Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
| | - Majid Ezzati
- MRC Centre for Environment and Health, Imperial College London, UK; Abdul Latif Jameel Institute for Disease and Emergency Analytics, Imperial College London, UK; Regional Institute for Population Studies, University of Ghana, Legon, Ghana
| | - Frank J Kelly
- MRC Centre for Environment and Health, Imperial College London, UK; NIHR-HPRU Environmental Exposures and Health, School of Public Health, Imperial College London, UK
| | - Benjamin Barratt
- MRC Centre for Environment and Health, Imperial College London, UK; NIHR-HPRU Environmental Exposures and Health, School of Public Health, Imperial College London, UK
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Fandiño-Del-Rio M, Kephart JL, Williams KN, Shade T, Adekunle T, Steenland K, Naeher LP, Moulton LH, Gonzales GF, Chiang M, Hossen S, Chartier RT, Koehler K, Checkley W. Household Air Pollution Concentrations after Liquefied Petroleum Gas Interventions in Rural Peru: Findings from a One-Year Randomized Controlled Trial Followed by a One-Year Pragmatic Crossover Trial. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:57007. [PMID: 35549716 PMCID: PMC9097958 DOI: 10.1289/ehp10054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 05/29/2023]
Abstract
BACKGROUND Household air pollution (HAP) from biomass fuel combustion remains a leading environmental risk factor for morbidity worldwide. OBJECTIVE Measure the effect of liquefied petroleum gas (LPG) interventions on HAP exposures in Puno, Peru. METHODS We conducted a 1-y randomized controlled trial followed by a 1-y pragmatic crossover trial in 180 women age 25-64 y. During the first year, intervention participants received a free LPG stove, continuous fuel delivery, and regular behavioral messaging, whereas controls continued their biomass cooking practices. During the second year, control participants received a free LPG stove, regular behavioral messaging, and vouchers to obtain LPG tanks from a nearby distributor, whereas fuel distribution stopped for intervention participants. We collected 48-h kitchen area concentrations and personal exposures to fine particulate matter (PM) with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ), black carbon (BC), and carbon monoxide (CO) at baseline and 3-, 6-, 12-, 18-, and 24-months post randomization. RESULTS Baseline mean [ ± standard deviation ( SD ) ] PM 2.5 (kitchen area concentrations 1,220 ± 1,010 vs. 1,190 ± 880 μ g / m 3 ; personal exposure 126 ± 214 vs. 104 ± 100 μ g / m 3 ), CO (kitchen 53 ± 49 vs. 50 ± 41 ppm ; personal 7 ± 8 vs. 7 ± 8 ppm ), and BC (kitchen 180 ± 120 vs. 210 ± 150 μ g / m 3 ; personal 19 ± 16 vs. 21 ± 22 μ g / m 3 ) were similar between control and intervention participants. Intervention participants had consistently lower mean ( ± SD ) concentrations at the 12-month visit for kitchen (41 ± 59 μ g / m 3 , 3 ± 6 μ g / m 3 , and 8 ± 13 ppm ) and personal exposures (26 ± 34 μ g / m 3 , 2 ± 3 μ g / m 3 , and 3 ± 4 ppm ) to PM 2.5 , BC, and CO when compared to controls during the first year. In the second year, we observed comparable HAP reductions among controls after the voucher-based intervention for LPG fuel was implemented (24-month visit PM 2.5 , BC, and CO kitchen mean concentrations of 34 ± 74 μ g / m 3 , 3 ± 5 μ g / m 3 , and 6 ± 6 ppm and personal exposures of 17 ± 15 μ g / m 3 , 2 ± 2 μ g / m 3 , and 3 ± 4 ppm , respectively), and average reductions were present among intervention participants even after free fuel distribution stopped (24-month visit PM 2.5 , BC, and CO kitchen mean concentrations of 561 ± 1,251 μ g / m 3 , 82 ± 124 μ g / m 3 , and 23 ± 28 ppm and personal exposures of 35 ± 38 μ g / m 3 , 6 ± 6 μ g / m 3 , and 4 ± 5 ppm , respectively). DISCUSSION Both home delivery and voucher-based provision of free LPG over a 1-y period, in combination with provision of a free LPG stove and longitudinal behavioral messaging, reduced HAP to levels below 24-h World Health Organization air quality guidelines. Moreover, the effects of the intervention on HAP persisted for a year after fuel delivery stopped. Such strategies could be applied in LPG programs to reduce HAP and potentially improve health. https://doi.org/10.1289/EHP10054.
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Affiliation(s)
- Magdalena Fandiño-Del-Rio
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Josiah L. Kephart
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kendra N. Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Timothy Shade
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
| | - Temi Adekunle
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Luke P. Naeher
- Environmental Health Science Department, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Lawrence H. Moulton
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gustavo F. Gonzales
- Laboratories of Investigation and Development, Department of Biological and Physiological Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
- High Altitude Research Institute, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Marilu Chiang
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú
| | - Shakir Hossen
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cardiopulmonary outcomes and Household Air Pollution (CHAP) Trial Investigators
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Environmental Health Science Department, College of Public Health, University of Georgia, Athens, Georgia, USA
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Laboratories of Investigation and Development, Department of Biological and Physiological Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Perú
- High Altitude Research Institute, Universidad Peruana Cayetano Heredia, Lima, Perú
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Perú
- RTI International, Durham, North Carolina, USA
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10
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Carrillo-Larco RM, Guzman-Vilca WC, Leon-Velarde F, Bernabe-Ortiz A, Jimenez MM, Penny ME, Gianella C, Leguía M, Tsukayama P, Hartinger SM, Lescano AG, Cuba-Fuentes MS, Cutipé Y, Diez-Canseco F, Mendoza W, Ugarte-Gil C, Valdivia-Gago A, Zavaleta-Cortijo C, Miranda JJ. Peru - Progress in health and sciences in 200 years of independence. LANCET REGIONAL HEALTH. AMERICAS 2022; 7:100148. [PMID: 36777656 PMCID: PMC9904031 DOI: 10.1016/j.lana.2021.100148] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population. Resumen translated abstract El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.
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Affiliation(s)
- Rodrigo M. Carrillo-Larco
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St Mary's Campus, London, United Kingdom
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Fabiola Leon-Velarde
- Departamento de Ciencias Biológicas y Fisiológicas, Facultad de Ciencias y Filosofia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | - Camila Gianella
- Departmento de Psicología, Facultad de Psicología, Pontificia Universidad Católica del Perú, Lima, Peru
- Chr. Michelsen Institute, Bergen, Norway
| | - Mariana Leguía
- Laboratorio de Genómica, Pontificia Universidad Católica del Perú, Lima, Peru
| | - Pablo Tsukayama
- Laboratorio de Genómica Microbiana, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
- Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, United Kingdom
| | - Stella M. Hartinger
- Clima, Latin American Center of Excellence for Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
- University of Basel, Basel, Switzerland
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Andres G. Lescano
- Clima, Latin American Center of Excellence for Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
- Emerge, Emerging Diseases and Climate Change Research Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Walter Mendoza
- Fondo de Población de las Naciones Unidas (UNFPA), Lima, Peru
| | - Cesar Ugarte-Gil
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Peru
- TB Center, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States
| | - Andrea Valdivia-Gago
- Faculty of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
- Intercultural Citizenship and Indigenous Health Unit (UCISI), Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Carol Zavaleta-Cortijo
- Faculty of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
- Intercultural Citizenship and Indigenous Health Unit (UCISI), Universidad Peruana Cayetano Heredia, Lima, Peru
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, United Kingdom
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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11
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Abstract
There is global concern regarding access to energy, especially in developing countries, as set forth in the Sustainable Development Goals. Although Peru is classified as an emerging economy and would be expected to have achieved full energy coverage, the status of the access to fuels in Peru is unknown. The objective of this study was to comprehensively document the instruments and the progress made on the issue of access to modern fuels and technologies for cooking in Peru to explain the current situation and to highlight the main challenges that the country must face to achieve total access to modern energy sources. A comprehensive literature review was carried out for this work, covering a wide range of publications from 1983 to 2019. A total of 18 political and economic instruments and 95 voluntary instruments were analyzed. It made it possible to build a historical series of the main events leading to access to modern cooking fuels in Peru and to identify eight key challenges. The results show that the country has made remarkable progress in recent years, but this progress is not enough to close the access gap. Therefore, seems advisable to act on the current policy framework, formulate more inclusive policies, promote unified institutional efforts and generate technological options that respond to territory and population as diverse as Peru.
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12
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Quinn AK, Williams KN, Thompson LM, Harvey SA, Piedrahita R, Wang J, Quinn C, Pillarisetti A, McCracken JP, Rosenthal JP, Kirby MA, Diaz Artiga A, Thangavel G, Rosa G, Miranda JJ, Checkley W, Peel JL, Clasen TF. Fidelity and Adherence to a Liquefied Petroleum Gas Stove and Fuel Intervention during Gestation: The Multi-Country Household Air Pollution Intervention Network (HAPIN) Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12592. [PMID: 34886324 PMCID: PMC8656791 DOI: 10.3390/ijerph182312592] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Clean cookstove interventions can theoretically reduce exposure to household air pollution and benefit health, but this requires near-exclusive use of these types of stoves with the simultaneous disuse of traditional stoves. Previous cookstove trials have reported low adoption of new stoves and/or extensive continued traditional stove use. METHODS The Household Air Pollution Intervention Network (HAPIN) trial randomized 3195 pregnant women in Guatemala, India, Peru, and Rwanda to either a liquefied petroleum gas (LPG) stove and fuel intervention (n = 1590) or to a control (n = 1605). The intervention consisted of an LPG stove and two initial cylinders of LPG, free fuel refills delivered to the home, and regular behavioral messaging. We assessed intervention fidelity (delivery of the intervention as intended) and adherence (intervention use) through to the end of gestation, as relevant to the first primary health outcome of the trial: infant birth weight. Fidelity and adherence were evaluated using stove and fuel delivery records, questionnaires, visual observations, and temperature-logging stove use monitors (SUMs). RESULTS 1585 women received the intervention at a median (interquartile range) of 8.0 (5.0-15.0) days post-randomization and had a gestational age of 17.9 (15.4-20.6) weeks. Over 96% reported cooking exclusively with LPG at two follow-up visits during pregnancy. Less than 4% reported ever running out of LPG. Complete abandonment of traditional stove cooking was observed in over 67% of the intervention households. Of the intervention households, 31.4% removed their traditional stoves upon receipt of the intervention; among those who retained traditional stoves, the majority did not use them: traditional stove use was detected via SUMs on a median (interquartile range) of 0.0% (0.0%, 1.6%) of follow-up days (median follow-up = 134 days). CONCLUSIONS The fidelity of the HAPIN intervention, as measured by stove installation, timely ongoing fuel deliveries, and behavioral reinforcement as needed, was high. Exclusive use of the intervention during pregnancy was also high.
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Affiliation(s)
- Ashlinn K. Quinn
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA
- Berkeley Air Monitoring Group, Fort Collins, CO 80524, USA;
| | - Kendra N. Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (K.N.W.); (W.C.)
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Lisa M. Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA;
| | - Steven A. Harvey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | | | - Jiantong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.W.); (A.P.); (T.F.C.)
| | - Casey Quinn
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO 80523, USA;
| | - Ajay Pillarisetti
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.W.); (A.P.); (T.F.C.)
| | - John P. McCracken
- Department of Epidemiology and Biostatistics, Global Health Institute, College of Public Health, University of Georgia, Athens, GA 30606, USA;
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala;
| | - Joshua P. Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Miles A. Kirby
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - Anaité Diaz Artiga
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City 01015, Guatemala;
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, Faculty of Public Health, Sri Ramachandra Institute for Higher Education and Research, Porur, Chennai 600116, India;
| | - Ghislaine Rosa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - J. Jaime Miranda
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima 15102, Peru;
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima 15074, Peru
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (K.N.W.); (W.C.)
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD 21287, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jennifer L. Peel
- Department of Environmental & Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA;
| | - Thomas F. Clasen
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (J.W.); (A.P.); (T.F.C.)
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13
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Sempé L, Lloyd-Sherlock P, Martínez R, Ebrahim S, McKee M, Acosta E. Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic. LANCET REGIONAL HEALTH. AMERICAS 2021; 2:None. [PMID: 34693394 PMCID: PMC8507430 DOI: 10.1016/j.lana.2021.100039] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/21/2021] [Accepted: 07/21/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time. METHODS Our analytical framework and empirical strategy account for registered mortality and under-registration. This provides a better estimate of the actual mortality impact of the first wave of the COVID-19 pandemic in Peru. We use population and crude mortality rate projections from Peru's National Institute of Statistics and Information (INEI, in Spanish), individual-level registered COVID-19 deaths from the Ministry of Health (MoH), and individual-level registered deaths by region and age since 2017 from the National Electronic Deaths Register (SINADEF, in Spanish).We develop a novel framework combining different estimates and using quasi-Poisson models to estimate total excess mortality across regions and age groups. Also, we use logistic mixed-effects models to estimate the coverage of the new SINADEF system. FINDINGS We estimate that registered mortality underestimates national mortality by 37•1% (95% CI 23% - 48•5%) across 26 regions and nine age groups. We estimate total all-cause excess mortality during the period of analysis at 173,099 (95% CI 153,669 - 187,488) of which 108,943 (95% CI 96,507 - 118,261) were captured by the vital registration system. Deaths at age 60 and over accounted for 74•1% (95% CI 73•9% - 74•7%) of total excess deaths, and there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for the highest share of excess deaths, 87,781 (95% CI 82,294 - 92,504), while in the opposite side regions of Apurimac and Huancavelica account for less than 300 excess deaths. INTERPRETATION Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account. FUNDING None.
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Affiliation(s)
- Lucas Sempé
- University of East Anglia, Norwich, UK & Universidad Católica San Pablo, Arequipa, Peru
| | | | | | - Shah Ebrahim
- London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | - Enrique Acosta
- Max Planck Institute for Demographic Research, Rostock, Germany
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14
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Checkley W, Williams KN, Kephart JL, Fandiño-Del-Rio M, Steenland NK, Gonzales GF, Naeher LP, Harvey SA, Moulton LH, Davila-Roman VG, Goodman D, Tarazona-Meza C, Miele CH, Simkovich S, Chiang M, Chartier RT, Koehler K. Effects of a Household Air Pollution Intervention with Liquefied Petroleum Gas on Cardiopulmonary Outcomes in Peru. A Randomized Controlled Trial. Am J Respir Crit Care Med 2021; 203:1386-1397. [PMID: 33306939 DOI: 10.1164/rccm.202006-2319oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Approximately 40% of people worldwide are exposed to household air pollution (HAP) from the burning of biomass fuels. Previous efforts to document health benefits of HAP mitigation have been stymied by an inability to lower emissions to target levels. Objectives: We sought to determine if a household air pollution intervention with liquefied petroleum gas (LPG) improved cardiopulmonary health outcomes in adult women living in a resource-poor setting in Peru. Methods: We conducted a randomized controlled field trial in 180 women aged 25-64 years living in rural Puno, Peru. Intervention women received an LPG stove, continuous fuel delivery for 1 year, education, and behavioral messaging, whereas control women were asked to continue their usual cooking practices. We assessed for stove use adherence using temperature loggers installed in both LPG and biomass stoves of intervention households. Measurements and Main Results: We measured blood pressure, peak expiratory flow (PEF), and respiratory symptoms using the St. George's Respiratory Questionnaire at baseline and at 3-4 visits after randomization. Intervention women used their LPG stove exclusively for 98% of days. We did not find differences in average postrandomization systolic blood pressure (intervention - control 0.7 mm Hg; 95% confidence interval, -2.1 to 3.4), diastolic blood pressure (0.3 mm Hg; -1.5 to 2.0), prebronchodilator peak expiratory flow/height2 (0.14 L/s/m2; -0.02 to 0.29), postbronchodilator peak expiratory flow/height2 (0.11 L/s/m2; -0.05 to 0.27), or St. George's Respiratory Questionnaire total score (-1.4; -3.9 to 1.2) over 1 year in intention-to-treat analysis. There were no reported harms related to the intervention. Conclusions: We did not find evidence of a difference in blood pressure, lung function, or respiratory symptoms during the year-long intervention with LPG. Clinical trial registered with www.clinicaltrials.gov (NCT02994680).
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine, and.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, Department of Medicine, and.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Environmental Health and Engineering
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Environmental Health and Engineering
| | - N Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Gustavo F Gonzales
- Department of Biological and Physiological Sciences and.,Laboratory for Research and Development, School of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, University of Georgia, Athens, Georgia
| | - Steven A Harvey
- Department of International Health, Program in Social Behavioral Interventions, and
| | - Lawrence H Moulton
- Department of International Health, Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Victor G Davila-Roman
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Cardiovascular Imaging and Clinical Research Core Lab, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Dina Goodman
- Division of Pulmonary and Critical Care, Department of Medicine, and.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Carla Tarazona-Meza
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Biomedical Research Unit, PRISMA, Lima, Peru; and
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, Department of Medicine, and.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Suzanne Simkovich
- Division of Pulmonary and Critical Care, Department of Medicine, and.,Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Kirsten Koehler
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Environmental Health and Engineering
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Kephart JL, Fandiño-Del-Rio M, Williams KN, Malpartida G, Lee A, Steenland K, Naeher LP, Gonzales GF, Chiang M, Checkley W, Koehler K. Nitrogen dioxide exposures from LPG stoves in a cleaner-cooking intervention trial. ENVIRONMENT INTERNATIONAL 2021; 146:106196. [PMID: 33160161 PMCID: PMC8173774 DOI: 10.1016/j.envint.2020.106196] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/08/2020] [Accepted: 10/05/2020] [Indexed: 05/05/2023]
Abstract
BACKGROUND Liquefied petroleum gas (LPG) stoves have been promoted in low- and middle-income countries (LMICs) as a clean energy alternative to biomass burning cookstoves. OBJECTIVE We sought to characterize kitchen area concentrations and personal exposures to nitrogen dioxide (NO2) within a randomized controlled trial in the Peruvian Andes. The intervention included the provision of an LPG stove and continuous fuel distribution with behavioral messaging to maximize compliance. METHODS We measured 48-hour kitchen area NO2 concentrations at high temporal resolution in homes of 50 intervention participants and 50 control participants longitudinally within a biomass-to-LPG intervention trial. We also collected 48-hour mean personal exposures to NO2 among a subsample of 16 intervention and 9 control participants. We monitored LPG and biomass stove use continuously throughout the trial. RESULTS In 367 post-intervention 24-hour kitchen area samples of 96 participants' homes, geometric mean (GM) highest hourly NO2 concentration was 138 ppb (geometric standard deviation [GSD] 2.1) in the LPG intervention group and 450 ppb (GSD 3.1) in the biomass control group. Post-intervention 24-hour mean NO2 concentrations were a GM of 43 ppb (GSD 1.7) in the intervention group and 77 ppb (GSD 2.0) in the control group. Kitchen area NO2 concentrations exceeded the WHO indoor hourly guideline an average of 1.3 h per day among LPG intervention participants. GM 48-hour personal exposure to NO2 was 5 ppb (GSD 2.4) among 35 48-hour samples of 16 participants in the intervention group and 16 ppb (GSD 2.3) among 21 samples of 9 participants in the control group. DISCUSSION In a biomass-to-LPG intervention trial in Peru, kitchen area NO2 concentrations were substantially lower within the LPG intervention group compared to the biomass-using control group. However, within the LPG intervention group, 69% of 24-hour kitchen area samples exceeded WHO indoor annual guidelines and 47% of samples exceeded WHO indoor hourly guidelines. Forty-eight-hour NO2 personal exposure was below WHO indoor annual guidelines for most participants in the LPG intervention group, and we did not measure personal exposure at high temporal resolution to assess exposure to cooking-related indoor concentration peaks. Further research is warranted to understand the potential health risks of LPG-related NO2 emissions and inform current campaigns which promote LPG as a clean-cooking option.
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Affiliation(s)
- Josiah L Kephart
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Magdalena Fandiño-Del-Rio
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Gary Malpartida
- Molecular Biology and Immunology Laboratory, Research Laboratory of Infectious Diseases, Department of Cell and Molecular Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru; Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Peru
| | | | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Luke P Naeher
- Department of Environmental Health Science, College of Public Health, The University of Georgia, Athens, GA, USA
| | - Gustavo F Gonzales
- Laboratories of Investigation and Development, Department of Biological and Physiological Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru; High Altitude Research Institute, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Marilu Chiang
- Biomedical Research Unit, Asociación Benéfica PRISMA, Lima, Peru
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Williams KN, Kephart JL, Fandiño-Del-Rio M, Simkovich SM, Koehler K, Harvey SA, Checkley W. Exploring the impact of a liquefied petroleum gas intervention on time use in rural Peru: A mixed methods study on perceptions, use, and implications of time savings. ENVIRONMENT INTERNATIONAL 2020; 145:105932. [PMID: 33032164 PMCID: PMC7578081 DOI: 10.1016/j.envint.2020.105932] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/21/2020] [Accepted: 06/26/2020] [Indexed: 05/06/2023]
Abstract
BACKGROUND Efforts to promote clean cooking through adoption of clean-burning fuels such as liquefied petroleum gas (LPG) are often based on the idea that near-exclusive use of LPG could lead to health improvements. However, benefits beyond health, such as time savings, could be more tangible and meaningful to LPG users. OBJECTIVES This study investigated the effect of an LPG intervention on time spent cooking and collecting fuel, using objective measures of stove temperatures combined with self-reports under conditions of near-exclusive LPG use. We also investigated the perceived value of any time savings and potential economic and quality of life implications. METHODS We analyzed data from the Cardiopulmonary outcomes and Household Air Pollution trial in Puno, Peru, a randomized controlled trial with 180 participants assessing exposure and health impacts of an LPG stove, fuel, and behavioral intervention. Surveys conducted with 90 intervention women receiving free LPG and 90 control women cooking primarily with biomass assessed time spent cooking and collecting biomass fuel and use of time savings. Cooking time was objectively measured with temperature sensors on all stoves. Qualitative interviews explored perceptions and use of time savings in more depth. RESULTS Intervention women spent 3.2 fewer hours cooking and 1.9 fewer hours collecting fuel per week compared to control women, but cooked on average 1.0 more meals per day. Participants perceived time saved from LPG positively, reporting more time for household chores, leisure activities, and activities with income-generating potential such as caring for animals and working in fields. DISCUSSION This paper suggests that the benefits of LPG extend beyond health and the environment. LPG use could also lead to economic and quality of life gains, through increased time for work, rest, and consumption of hot meals, and reduced arduous biomass fuel collection.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA.
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Steven A Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
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Fandiño-Del-Rio M, Kephart JL, Williams KN, Moulton LH, Steenland K, Checkley W, Koehler K. Household air pollution exposure and associations with household characteristics among biomass cookstove users in Puno, Peru. ENVIRONMENTAL RESEARCH 2020; 191:110028. [PMID: 32846169 PMCID: PMC7658004 DOI: 10.1016/j.envres.2020.110028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/26/2020] [Accepted: 07/29/2020] [Indexed: 05/24/2023]
Abstract
BACKGROUND Household air pollution (HAP) from combustion of biomass fuel, such as wood and animal dung, is among the leading environmental risk factors for preventable disease. Close to half of the world's population relies on biomass cookstoves for their daily cooking needs. Understanding factors that affect HAP can inform measures to maximize the effectiveness of cookstove interventions in a cost-effective manner. However, the impact of kitchen and household characteristics, as well as the presence of secondary stoves, on HAP concentrations is poorly understood in Puno, Peru. OBJECTIVE To explore how household characteristics explain variability of kitchen area concentrations and personal exposures to CO, PM2.5 and BC from biomass cookstoves among women in rural Peru. METHODS Household characteristics (including kitchen materials and layout, wealth, and cooking behaviors) and HAP measurements were collected from 180 households in Puno, Peru, from baseline measurements of a randomized trial. Kitchen area concentrations and personal exposures to carbon monoxide (CO), fine particulate matter (PM2.5) and black carbon (BC) were sampled for 48 h. We implemented simple and multivariable linear regression models to determine the associations between household characteristics and both kitchen area concentration and personal exposure to each pollutant. RESULTS Mean daily kitchen area concentrations and personal exposures to HAP were, on average, 48 times above World Health Organization indoor guidelines for PM2.5. We found that roof type explained the most variability in HAP and was strongly associated with both kitchen area concentrations and personal exposures for all pollutants after adjusting for other household variables. Personal exposures were 27%-36% lower for PM2.5, CO and BC, in households with corrugated metal roofs, compared to roofs made of natural materials (straw, totora or reed) after adjusting for other factors. Higher kitchen area concentrations were also associated with less wealth, owning more animals, or sampling during the dry season in multivariable models. Having a liquefied petroleum gas (LPG) stove and having a chimney were associated with lower personal exposures, but were not associated with kitchen area concentrations. Personal exposures were lower by 21% for PM2.5 and 28% for CO and BC concentrations among participants who had both LPG and biomass stoves compared to those with only biomass cookstoves adjusting for other household factors. CONCLUSIONS Characterizing HAP within different settings can help identify effective and culturally-relevant solutions to reduce HAP exposures. We found that housing roof type is strongly related to kitchen area concentrations and personal exposures to HAP, perhaps because of greater ventilation in kitchens with metal roofs compared to those with thatch roofs. Although HAP concentrations remained above guidelines for all households, promoting use of metal roof materials and LPG stoves may be actionable interventions that can help reduce exposures to HAP in high-altitude rural Peru and similar settings.
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Affiliation(s)
- Magdalena Fandiño-Del-Rio
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Josiah L Kephart
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Kendra N Williams
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, 21205, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Lawrence H Moulton
- Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA.
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, 21205, USA; Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA; Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA.
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The contribution of specific non-communicable diseases to the achievement of the Sustainable Development Goal 3.4 in Peru. PLoS One 2020; 15:e0240494. [PMID: 33045034 PMCID: PMC7549811 DOI: 10.1371/journal.pone.0240494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/26/2020] [Indexed: 12/23/2022] Open
Abstract
Background Non-communicable diseases (NCDs) have received political attention and commitment, yet surveillance is needed to measure progress and set priorities. Building on global estimates suggesting that Peru is not on target to meet the Sustainable Development Goal 3.4, we estimated the contribution of various NCDs to the change in unconditional probability of dying from NCDs in 25 regions in Peru. Methods Using national death registries and census data, we estimated the unconditional probability of dying between ages 30 and 69 from any and from each of the following NCDs: cardiovascular, cancer, diabetes, chronic respiratory diseases and chronic kidney disease. We estimated the contribution of each NCD to the change in the unconditional probability of dying from any of these NCDs between 2006 and 2016. Results The overall unconditional probability of dying improved for men (21.4%) and women (23.3%). Cancer accounted for 10.9% in men and 13.7% in women of the overall reduction; cardiovascular diseases also contributed substantially: 11.3% in men) and 9.8% in women. Consistently in men and women and across regions, diabetes moved in the opposite direction of the overall reduction in the unconditional probability of dying from any selected NCD. Diabetes contributed a rise in the unconditional probability of 3.6% in men and 2.1% in women. Conclusions Although the unconditional probability of dying from any selected NCD has decreased, diabetes would prevent Peru from meeting international targets. Policies are needed to prevent diabetes and to strengthen healthcare to avoid diabetes-related complications and delay mortality.
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Williams KN, Kephart JL, Fandiño-Del-Rio M, O'Brien CJ, Moulton LH, Koehler K, Harvey SA, Checkley W. Use of liquefied petroleum gas in Puno, Peru: Fuel needs under conditions of free fuel and near-exclusive use. ENERGY FOR SUSTAINABLE DEVELOPMENT : THE JOURNAL OF THE INTERNATIONAL ENERGY INITIATIVE 2020; 58:150-157. [PMID: 33442225 PMCID: PMC7799435 DOI: 10.1016/j.esd.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Reducing the burden of household air pollution could be achieved with exclusive adoption of cleaner fuels such as liquefied petroleum gas (LPG). However, we lack understanding of how much LPG is required to support exclusive use and how household characteristics affect this quantity. This paper used data from 90 participants in the Cardiopulmonary outcomes and Household Air Pollution (CHAP) trial in Puno, Peru who received free LPG deliveries for one year. Households with a mean of four members that cooked nearly exclusively (>98%) with LPG used an average of 19.1 kg (95% CI 18.5 to 19.6) of LPG per month for tasks similar to those done with the traditional biomass stove. LPG use per month was 0.5 kg higher for each additional pig or dog owned (p=0.003), 0.7 kg higher for each additional household member (p<0.001), 0.3 kg higher for households in the second-lowest compared to the lowest wealth quintile (p=0.01), and 1.1 kg higher if the household had previously received subsidized LPG (p=0.05). LPG use per month was 1.1 kg lower during the rainy season (p<0.001) and 1.7 kg lower during the planting season (p<0.001) compared to the cold and harvest seasons, despite the fact that LPG was not typically used for space heating. LPG use decreased by 0.05 kg per month over the course of one year after receiving the LPG stove (p=0.02). These results suggest that achieving exclusive LPG use in Puno, Peru requires that rural residents have affordable access to an average of two 10 kg LPG tanks per month. Conducting similar investigations in other countries could help policymakers set and target LPG subsidies to ensure that households have access to enough LPG to achieve exclusive LPG use and the potential health benefits.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Carolyn J O'Brien
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lawrence H Moulton
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Steven A Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Williams KN, Thompson LM, Sakas Z, Hengstermann M, Quinn A, Díaz-Artiga A, Thangavel G, Puzzolo E, Rosa G, Balakrishnan K, Peel J, Checkley W, Clasen TF, Miranda JJ, Rosenthal JP, Harvey SA. Designing a comprehensive behaviour change intervention to promote and monitor exclusive use of liquefied petroleum gas stoves for the Household Air Pollution Intervention Network (HAPIN) trial. BMJ Open 2020; 10:e037761. [PMID: 32994243 PMCID: PMC7526279 DOI: 10.1136/bmjopen-2020-037761] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/02/2020] [Accepted: 07/30/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Increasing use of cleaner fuels, such as liquefied petroleum gas (LPG), and abandonment of solid fuels is key to reducing household air pollution and realising potential health improvements in low-income countries. However, achieving exclusive LPG use in households unaccustomed to this type of fuel, used in combination with a new stove technology, requires substantial behaviour change. We conducted theory-grounded formative research to identify contextual factors influencing cooking fuel choice to guide the development of behavioural strategies for the Household Air Pollution Intervention Network (HAPIN) trial. The HAPIN trial will assess the impact of exclusive LPG use on air pollution exposure and health of pregnant women, older adult women, and infants under 1 year of age in Guatemala, India, Peru, and Rwanda. METHODS Using the Capability, Opportunity, Motivation-Behaviour (COM-B) framework and Behaviour Change Wheel (BCW) to guide formative research, we conducted in-depth interviews, focus group discussions, observations, key informant interviews and pilot studies to identify key influencers of cooking behaviours in the four countries. We used these findings to develop behavioural strategies likely to achieve exclusive LPG use in the HAPIN trial. RESULTS We identified nine potential influencers of exclusive LPG use, including perceived disadvantages of solid fuels, family preferences, cookware, traditional foods, non-food-related cooking, heating needs, LPG awareness, safety and cost and availability of fuel. Mapping formative findings onto the theoretical frameworks, behavioural strategies for achieving exclusive LPG use in each research site included free fuel deliveries, locally acceptable stoves and equipment, hands-on training and printed materials and videos emphasising relevant messages. In the HAPIN trial, we will monitor and reinforce exclusive LPG use through temperature data loggers, LPG fuel delivery tracking, in-home observations and behavioural reinforcement visits. CONCLUSION Our formative research and behavioural strategies can inform the development, implementation, monitoring and evaluation of theory-informed strategies to promote exclusive LPG use in future stove programmes and research studies. TRIAL REGISTRATION NUMBER NCT02944682, Pre-results.
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Affiliation(s)
- Kendra N Williams
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Zoe Sakas
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Mayari Hengstermann
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Ashlinn Quinn
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Anaité Díaz-Artiga
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Elisa Puzzolo
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Ghislaine Rosa
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra Institute for Higher Education and Research, Chennai, India
| | - Jennifer Peel
- Department of Environmental & Radiological Health Sciences, Colorado School of Public Health, Aurora, Colorado, USA
| | - William Checkley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Thomas F Clasen
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Joshua P Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven A Harvey
- Department of International Health, Social and Behavioral Interventions, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Díaz-Vásquez MA, Díaz-Manchay RJ, León-Jiménez FE, Thompson LM, Troncoso K, Failoc-Rojas VE. Adoption and impact of improved cookstoves in Lambayeque, Peru, 2017. Glob Health Promot 2020; 27:123-130. [PMID: 32829693 DOI: 10.1177/1757975920945248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Approximately three billion people in Asia, Africa, and the Americas cook with biomass, cleaner cooking technologies with the potential to reduce household air pollution exposure. It is necessary to assess the adoption and long-term use of these stoves, measure perceived benefits among users, and use this information to provide feedback to programs that are implementing new cooking technologies. The aim of this study is to determine the level of adoption and impact of improved biomass cookstoves in the rural area of Lambayeque, Peru, in 2017. METHODS A descriptive cross-sectional study was conducted. A total of 52 homes were surveyed in the districts of Pacora and Íllimo where improved biomass stoves were introduced between 2005 and 2013. A questionnaire for the assessment of adoption and impact indexes proposed by the Global Alliance for Clean Cookstoves was applied. The STROBE checklist was used. RESULTS The mean number of years with the improved biomass cookstove was 9.1 (standard deviation: 2.9); 51.9% always used the improved stove, and 34.6% never used it due to destruction during the El Niño phenomenon in 2017. The median impact index was 5.62; 19.2% had a very good/good adoption. The median adoption index was 6.5; 25% had a very high/high impact. The use of the traditional or open fire biomass stove persisted in 61.5% of the houses. CONCLUSION The adoption and impact of improved biomass cookstoves were acceptable, but traditional stove use persisted in more than half of the houses. Households used a mix of different stove technologies. Gas stoves were used more frequently for breakfast or dinner, while the traditional biomass stoves were used for larger lunchtime meals.
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Affiliation(s)
| | - Rosa J Díaz-Manchay
- Faculty of Medicine, Universidad Catolica Santo Toribio de Mogrovejo, Chiclayo, Peru
| | | | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | | | - Virgilio E Failoc-Rojas
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Perú
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Williams KN, Kephart JL, Fandiño-Del-Rio M, Condori L, Koehler K, Moulton LH, Checkley W, Harvey SA. Beyond cost: Exploring fuel choices and the socio-cultural dynamics of liquefied petroleum gas stove adoption in Peru. ENERGY RESEARCH & SOCIAL SCIENCE 2020; 66:101591. [PMID: 32742936 PMCID: PMC7394288 DOI: 10.1016/j.erss.2020.101591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Reducing the burden of household air pollution requires that cleaner fuels such as liquefied petroleum gas (LPG) be used nearly exclusively. However, exclusive adoption has been challenging in low- and middle-income countries. Previous studies have found that economic, social, and cultural barriers often impede adoption. We conducted in-depth qualitative interviews with 22 participants in a research trial where LPG was provided for free in Puno, Peru. We aimed to determine whether social and cultural barriers to LPG use persisted when monetary costs to the household were removed, and what factors influenced exclusive adoption of LPG in a cost-free context. Facilitators of LPG use included: support from study staff, family support, time savings, previous experience with LPG, stove design, ability to use existing pots, smoke reductions, desire for cleanliness, removal of traditional stoves, and perceptions of luck. Barriers to LPG use included: fears of LPG, problems with LPG brands, delays in obtaining LPG refills, social pressure, perceived incompatibility of traditional dishes, perceived inability to use clay pots, separate kitchens for LPG and traditional stoves, designated pots for use on the traditional stove, and lack of heat. However, these barriers did not prevent participants from using LPG nearly exclusively. Results suggest that social and cultural barriers to exclusive LPG use can be overcome when LPG stoves and fuel are provided for free and supplemented with behavioral support. Governments should evaluate the economic feasibility and sustainability of LPG subsidization, considering the potential benefits of exclusive LPG use.
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Affiliation(s)
- Kendra N Williams
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Josiah L Kephart
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Magdalena Fandiño-Del-Rio
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Leonora Condori
- Biomedical Research Unit, Asociación Benéfica PRISMA, Puno, Peru
| | - Kirsten Koehler
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lawrence H Moulton
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - William Checkley
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Steven A Harvey
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Shankar AV, Quinn A, Dickinson KL, Williams KN, Masera O, Charron D, Jack D, Hyman J, Pillarisetti A, Bailis R, Kumar P, Ruiz-Mercado I, Rosenthal J. Everybody Stacks: Lessons from household energy case studies to inform design principles for clean energy transitions. ENERGY POLICY 2020; 141:111468. [PMID: 32476710 PMCID: PMC7259482 DOI: 10.1016/j.enpol.2020.111468] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Stove stacking (concurrent use of multiple stoves and/or fuels) is a poorly quantified practice in regions where efforts to transition household energy to cleaner stoves/or fuels are on-going. Using biomass-burning stoves alongside clean stoves undermines health and environmental goals. This review synthesizes stove stacking data gathered from eleven case studies of clean cooking programs in low/middle-income country settings. Analyzed data are from ministry and program records, research studies, and informant interviews. Thematic analysis identify key drivers of stove stacking behavior in each setting. Significant (28%-100%) stacking with traditional cooking methods was observed in all cases. Reason for traditional fuel use includes: costs of clean fuel; mismatches between cooking technologies and household needs; and unreliable fuel supply. National household surveys often focus on 'primary' cookstoves and miss stove stacking data. Thus more attention should be paid to discontinuation of traditional stove use, not solely adoption of cleaner stoves/fuels. Future energy policies and programs should acknowledge the realities of stacking and incorporate strategies at the design stage to transition away from polluting stoves/fuels. Seven principles for clean cooking system program design and policy are presented, focused on a shift toward "cleaner stacking" that could yield household air pollution reductions approaching WHO targets.
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Affiliation(s)
- Anita V Shankar
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ashlinn Quinn
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Omar Masera
- Instituto de Investigaciones en Ecosistemas y Sustentabilidad, Universidad Nacional Autónoma de México, Morelia, Michoacán. Mexico
| | - Dana Charron
- Berkeley Air Monitoring Group, Berkeley, CA, USA
| | | | | | - Ajay Pillarisetti
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Rob Bailis
- Stockholm Environment Institute, Somerville, MA, USA
| | | | - Ilse Ruiz-Mercado
- Escuela Nacional de Estudios Superiores Unidad Mérida, Universidad Nacional Autónoma de México (UNAM), Mérida, Yucatán, Mexico
| | - Joshua Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
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Gould CF, Schlesinger SB, Molina E, Bejarano ML, Valarezo A, Jack DW. Household fuel mixes in peri-urban and rural Ecuador: Explaining the context of LPG, patterns of continued firewood use, and the challenges of induction cooking. ENERGY POLICY 2020; 136:111053. [PMID: 32675905 PMCID: PMC7365656 DOI: 10.1016/j.enpol.2019.111053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Nationwide transitions from cooking with solid fuels to clean fuels promise substantial health, climate, and environmental benefits. For decades, Ecuador has invested heavily in consumption subsidies for liquified petroleum gas (LPG), a leading clean fuel. With the goal of understanding household energy use in a context where LPG is ubiquitous and cheap, we administered 808 household surveys in peri-urban and rural communities in Coastal and Andean Ecuadorian provinces. We assess cooking fuel patterns after long-term LPG access and the reach of induction stoves promoted through a recent government program. Nearly all participants reported using LPG for more than a decade and frequent, convenient access to highly subsidized LPG. Nonetheless, half of rural households and 20% of peri-urban households rely on firewood to meet specific household energy needs, like space heating or heating water for bathing. Induction was rare and many induction owners reported zero use because the required equipment had never been installed by electricity companies, their stove had broken, or due to fears of high electricity costs. Our discussion is instructive for other countries because of Ecuador's long-standing clean fuel policies, robust LPG market and standardized cylinder recirculation model, and promotion of induction stoves.
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Affiliation(s)
- Carlos F. Gould
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - Emilio Molina
- Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Miryan L. Bejarano
- Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Alfredo Valarezo
- Department of Mechanical Engineering, Universidad San Francisco de Quito, Quito, Ecuador
| | - Darby W. Jack
- Department of Environmental Health Science, Columbia University Mailman School of Public Health, New York, NY, USA
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25
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Quinn AK, Williams K, Thompson LM, Rosa G, Díaz-Artiga A, Thangavel G, Balakrishnan K, Miranda JJ, Rosenthal JP, Clasen TF, Harvey SA. Compensating control participants when the intervention is of significant value: experience in Guatemala, India, Peru and Rwanda. BMJ Glob Health 2019; 4:e001567. [PMID: 31543990 PMCID: PMC6730613 DOI: 10.1136/bmjgh-2019-001567] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 11/30/2022] Open
Abstract
The Household Air Pollution Intervention Network (HAPIN) trial is a randomised controlled trial in Guatemala, India, Peru and Rwanda to assess the health impact of a clean cooking intervention in households using solid biomass for cooking. The HAPIN intervention—a liquefied petroleum gas (LPG) stove and 18-month supply of LPG—has significant value in these communities, irrespective of potential health benefits. For control households, it was necessary to develop a compensation strategy that would be comparable across four settings and would address concerns about differential loss to follow-up, fairness and potential effects on household economics. Each site developed slightly different, contextually appropriate compensation packages by combining a set of uniform principles with local community input. In Guatemala, control compensation consists of coupons equivalent to the LPG stove’s value that can be redeemed for the participant’s choice of household items, which could include an LPG stove. In Peru, control households receive several small items during the trial, plus the intervention stove and 1 month of fuel at the trial’s conclusion. Rwandan participants are given small items during the trial and a choice of a solar kit, LPG stove and four fuel refills, or cash equivalent at the end. India is the only setting in which control participants receive the intervention (LPG stove and 18 months of fuel) at the trial’s end while also being compensated for their time during the trial, in accordance with local ethics committee requirements. The approaches presented here could inform compensation strategy development in future multi-country trials.
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Affiliation(s)
- Ashlinn K Quinn
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Kendra Williams
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Ghislaine Rosa
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Anaité Díaz-Artiga
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, Sri Ramachandra Insitute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra Insitute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases and Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Joshua P Rosenthal
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Steven A Harvey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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26
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Simkovich SM, Williams KN, Pollard S, Dowdy D, Sinharoy S, Clasen TF, Puzzolo E, Checkley W. A Systematic Review to Evaluate the Association between Clean Cooking Technologies and Time Use in Low- and Middle-Income Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2277. [PMID: 31252636 PMCID: PMC6651553 DOI: 10.3390/ijerph16132277] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 11/17/2022]
Abstract
Interventions implementing clean fuels to mitigate household air pollution in low- and middle-income countries have focused on environmental and health outcomes, but few have evaluated time savings. We performed a systematic review, searching for studies of clean fuel interventions that measured time use. A total of 868 manuscripts were identified that met the search criteria, but only 2 met the inclusion criteria. Both were cross-sectional and were conducted in rural India. The first surveyed the female head of household (141 using biogas and 58 using biomass) and reported 1.2 h saved per day collecting fuel and 0.7 h saved cooking, resulting in a combined 28.9 days saved over an entire year. The second surveyed the head of household (37 using biogas and 68 using biomass, 13% female) and reported 1.5 h saved per day collecting fuel, or 22.8 days saved over a year. Based on these time savings, we estimated that clean fuel use could result in a 3.8% or 4.7% increase in daily income, respectively, not including time or costs for fuel procurement. Clean fuel interventions could save users time and money. Few studies have evaluated this potential benefit, suggesting that prospective studies or randomized controlled trials are needed to adequately measure gains.
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Affiliation(s)
- Suzanne M Simkovich
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Kendra N Williams
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Suzanne Pollard
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - David Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Sheela Sinharoy
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Thomas F Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Elisa Puzzolo
- Department of Public Health and Policy, The University of Liverpool, Liverpool L69 3BX, UK
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
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Pillarisetti A, Ghorpade M, Madhav S, Dhongade A, Roy S, Balakrishnan K, Sankar S, Patil R, Levine DI, Juvekar S, Smith KR. Promoting LPG usage during pregnancy: A pilot study in rural Maharashtra, India. ENVIRONMENT INTERNATIONAL 2019; 127:540-549. [PMID: 30981912 PMCID: PMC7213905 DOI: 10.1016/j.envint.2019.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 05/05/2023]
Abstract
Household air pollution from the combustion of biomass and coal is estimated to cause approximately 780,000 premature deaths a year in India. The government has responded by promoting uptake of liquefied petroleum gas (LPG) by tens of millions of poor rural families. Many poor households with new LPG stoves, however, continue to partially use traditional smoky chulhas. Our primary objective was to evaluate three strategies to transition pregnant women in rural Maharashtra to exclusive use of LPG for cooking. We also measured reductions in kitchen concentrations of PM2.5 before and after our interventions. Our core intervention was a free stove, 2 free LPG cylinders (one on loan until delivery), and repeated health messaging. We measured stove usage of both the traditional and intervention stoves until delivery. In households that received the core intervention, an average of 66% days had no indoor cooking on a chulha. In an adjacent area, we evaluated a conditional cash transfer (CCT) based on usage of LPG in addition to the core intervention. Results were less successful, due to challenges implementing the CCT. Pregnant women in a third nearby area received the core intervention plus a maximum of one 14.2 kg cylinder per month of free fuel. In their homes, 90% of days had no indoor cooking on a chulha. On average, exclusive LPG use decreased kitchen concentrations of PM2.5 by approximately 85% (from 520 to 72 μg/m3). 85% of participating households agreed to pay the deposit on the 2nd cylinder. This high purchase rate suggests they valued how the second cylinder permitted continuous LPG supply. A program to increase access to second cylinders may, thus, be a straightforward way to encourage use of clean fuels in rural areas.
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Affiliation(s)
- Ajay Pillarisetti
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA 94720, United States.
| | - Makarand Ghorpade
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Sathish Madhav
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Arun Dhongade
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Sudipto Roy
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Sambandam Sankar
- Department of Environmental Health Engineering, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Rutuja Patil
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - David I Levine
- Haas School of Business, University of California, Berkeley, CA 94720, United States
| | - Sanjay Juvekar
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Kirk R Smith
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA 94720, United States; Collaborative Clean Air Policy Centre, New Delhi, India
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28
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Gould CF, Urpelainen J. LPG as a Clean Cooking Fuel: Adoption, Use, and Impact in Rural India. ENERGY POLICY 2018; 122:395-408. [PMID: 32581420 PMCID: PMC7314235 DOI: 10.1016/j.enpol.2018.07.042] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Liquefied petroleum gas (LPG) is by far the most popular clean cooking fuel in rural India, but how rural households use it remains poorly understood. Using the 2014-2015 ACCESS survey with over 8,500 households from six energy-poor Indian states, we offer a broad but detailed survey of LPG use in rural India. We find that (i) fuel costs are a critical obstacle to widespread adoption, (ii) fuel stacking is the prevailing norm as few households stop using firewood when adopting LPG, and (iii) both users and non-users have highly positive views of LPG as a convenient and clean cooking fuel. These findings show that expanding LPG use offers great promise in rural India, but affordability prevents a complete transition from traditional biomass to clean cooking fuels.
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