Promoting LPG usage during pregnancy: A pilot study in rural Maharashtra, India

The psychological status mediates the effect of indoor air pollution on recurrent spontaneous abortion

BACKGROUND

Indoor air pollution (IAP) exposure and psychological status have been recognized as important risk factors for adverse pregnancy outcomes, but their mediating effects on recurrent spontaneous abortion (RSA) have not been analyzed. Therefore, the purpose of this study is to explore the association between IAP and RSA and to examine the mediating effect of psychological status on their association.

METHODS

This study included 830 RSA cases and 2156 controls in Gansu province, China. The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) questionnaires were used to collect information on participants' psychological status. The IAP exposure was collected by the survey on cooking fuel use, kitchen ventilation characteristics, cooking styles, and indoor smoking, etc. Multivariable logistic regression was used to examine the associations between IAP exposure and RSA. The mediation analysis was used to evaluate the mediation effects of IAP and psychological status on RSA while controlling for confounding.

RESULTS

Among these cases, 16.87% cooked with unclean cooking fuel (UCF) and 37.00% lacked cooking ventilation, which was much higher than the controls. Active smoking and the use of UCF were associated with RSA, with an odds ratio (OR) of 3.374 [95% confidence interval (CI): 1.510-7.541] and 1.822 (95% CI: 1.328-2.500), respectively. We found that the use of a range hood was a protective factor for RSA, with an OR of 0.590 (95% CI: 0.463-0.752). There was a significant mediation effect of depression on the association between IAP and RSA, which accounted for 5.61%-9.22% of the total effect of IAP on RSA.

CONCLUSION

The IAP may be an important risk factor for RSA, which may be intensified by the poor psychological status, and the use of ventilation equipment when cooking is a protective factor for RSA.

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

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.

LPG stove and fuel intervention among pregnant women reduce fine particle air pollution exposures in three countries: Pilot results from the HAPIN trial

The Household Air Pollution Intervention Network trial is a multi-country study on the effects of a liquefied petroleum gas (LPG) stove and fuel distribution intervention on women's and children's health. There is limited data on exposure reductions achieved by switching from solid to clean cooking fuels in rural settings across multiple countries. As formative research in 2017, we recruited pregnant women and characterized the impact of the intervention on personal exposures and kitchen levels of fine particulate matter (PM2.5) in Guatemala, India, and Rwanda. Forty pregnant women were enrolled in each site. We measured cooking area concentrations of and personal exposures to PM2.5 for 24 or 48 h using gravimetric-based PM2.5 samplers at baseline and two follow-ups over two months after delivery of an LPG cookstove and free fuel supply. Mixed models were used to estimate PM2.5 reductions. Median kitchen PM2.5 concentrations were 296 μg/m3 at baseline (interquartile range, IQR: 158-507), 24 μg/m3 at first follow-up (IQR: 18-37), and 23 μg/m3 at second follow-up (IQR: 14-37). Median personal exposures to PM2.5 were 134 μg/m3 at baseline (IQR: 71-224), 35 μg/m3 at first follow-up (IQR: 23-51), and 32 μg/m3 at second follow-up (IQR: 23-47). Overall, the LPG intervention was associated with a 92% (95% confidence interval (CI): 90-94%) reduction in kitchen PM2.5 concentrations and a 74% (95% CI: 70-79%) reduction in personal PM2.5 exposures. Results were similar for each site. CONCLUSIONS: The intervention was associated with substantial reductions in kitchen and personal PM2.5 overall and in all sites. Results suggest LPG interventions in these rural settings may lower exposures to the WHO annual interim target-1 of 35 μg/m3. The range of exposure contrasts falls on steep sections of estimated exposure-response curves for birthweight, blood pressure, and acute lower respiratory infections, implying potentially important health benefits when transitioning from solid fuels to LPG.

Gender and LPG use after government intervention in rural north India

Exposure to air pollution from cooking with solid fuels has important consequences for public health. This paper focuses on rural north India, where despite robust economic growth and government subsidies, the vast majority of households mainly use solid fuels. We draw on new qualitative and quantitative data collected in the context of a policy environment that dramatically expanded ownership of liquid petroleum gas (LPG) to examine why households are slow to adopt clean fuels in rural north India. We find that patriarchal gender norms and attitudes encourage the use of solid fuels in this region. North Indian society confers low status to women, promotes women's seclusion, and constrains women's engagement in economic activities outside of the home. These beliefs encourage women to preserve gas, promote women's work that facilitates the use of solid fuels, and hinder communication between the cook and the decision-maker regarding LPG refills. When rural north Indian households use gas, it is frequently to facilitate the adherence to norms of seclusion that prevent women from leaving the home to collect solid fuels. In addition to expanding access and improving economic conditions, future research and policy interventions should pay careful attention to the gender norms and attitudes that discourage the use of gas. Addressing these beliefs and norms is essential to sustained LPG use and health improvements.

Transition to clean household energy through an application of integrated model: Ensuring sustainability for better health, climate and environment

Sustained use and adoption of clean cooking fuels have become an important concern for developing countries due to the enormous burden of diseases attributable to household air pollution (HAP). The transition and adoption of clean household energy involve various socio-economic, behavioral, and technological barriers at different community levels. Hence, the present paper aims to scrutinize the factors, key determinants, and other interventions among rural households that limit clean cookstoves' sustained uses. The study proposes an integrated model to enhance clean cooking fuel uptake and uses based on the available evidence. The health, climate and environmental factors were identified as the key to trigger the adoption of clean cooking fuel alternatives. The model comprises the integration of components for targeted clean fuel policy interventions and promotes green recovery. The elements include Knowledge, Housing characteristics, Awareness, Interventions, Willingness to pay, Adoption, Lower emissions and Gender Equality (THE KHAIWAL model) to ascertain the intervention focus regions. Integration of model components in policy implementation will promote clean household energy to reduce emissions, leading to improve quality of life, good health, women empowerment, better air quality and climate.

Impact of the COVID-19 pandemic on clean fuel programmes in India and ensuring sustainability for household energy needs

Clean cooking energy strategies are critical for reducing air pollution, improving health, and achieving related Sustainable Development Goals. The recent COVID-19 lockdowns may impact the transition towards clean cooking fuels. The nationwide lockdown is likely to affect key factors such as energy access, income, transportation, etc., that play a role in decisions influencing household fuel use. The rural population already bears the burden of poverty and may not be able to afford and access clean cooking fuels during the lockdown. They are thus vulnerable to reversion to their traditional cooking methods using solid biomass fuels. The household air pollution caused due to the use of polluting fuels increases their susceptibility to non-communicable diseases, and thus may intensify the risk and severity of COVID-19 infection. Hence, there is an urgent need to expand sustainable energy solutions worldwide. The present study applies the DPSIR modeling framework to establish a set of comprehensive indicators for addressing the transition towards clean cooking fuels during the COVID-19 pandemic. The study also provides insights on various strategies adopted in India in response to the COVID-19 pandemic for maintaining continuity of delivering benefits under a clean cookstove program. The study offers future directions to ensure the transition towards cleaner fuels and sustainability.

Incentivizing Elimination of Biomass Cooking Fuels with a Reversible Commitment and a Spare LPG Cylinder

In India, approximately 480,000 deaths occur annually from exposure to household air pollution from the use of biomass cooking fuels. Displacing biomass use with clean fuels, such as liquefied petroleum gas (LPG), can help reduce these deaths. Through government initiatives, most Indian households now own an LPG stove and one LPG cylinder. Many households, however, continue to regularly use indoor biomass-fueled mud stoves (chulhas) alongside LPG. Focusing on this population in rural Maharashtra, India, this study (N = 186) tests the effects of conditioning a sales offer for a spare LPG cylinder on a reversible commitment requiring initially disabling indoor chulhas. We find that almost all relevant households (>98%) were willing to accept this commitment. Indoor chulha use decreased by 90% (95% CI = 80% to 101%) when the sales offer included the commitment, compared to a 23% decrease (95% CI = 14% to 32%) without it. For both treatment groups, we find that 80% purchased the spare cylinder at the end of the study.

Exposure contrasts associated with a liquefied petroleum gas (LPG) intervention at potential field sites for the multi-country household air pollution intervention network (HAPIN) trial in India: results from pilot phase activities in rural Tamil Nadu

BACKGROUND

The Household Air Pollution Intervention Network (HAPIN) trial aims to assess health benefits of a liquefied petroleum gas (LPG) cookfuel and stove intervention among women and children across four low- and middle-income countries (LMICs). We measured exposure contrasts for women, achievable under alternative conditions of biomass or LPG cookfuel use, at potential HAPIN field sites in India, to aid in site selection for the main trial.

METHODS

We recruited participants from potential field sites within Villupuram and Nagapattinam districts in Tamil Nadu, India, that were identified during a feasibility assessment. We performed. (i) cross-sectional measurements on women (N = 79) using either biomass or LPG as their primary cookfuel and (ii) before-and-after measurements on pregnant women (N = 41), once at baseline while using biomass fuel and twice - at 1 and 2 months - after installation of an LPG stove and free fuel intervention. We involved participants to co-design clothing and instrument stands for personal and area sampling. We measured 24 or 48-h personal exposures and kitchen and ambient concentrations of fine particulate matter (PM2.5) using gravimetric samplers.

RESULTS

In the cross-sectional analysis, median (interquartile range, IQR) kitchen PM2.5 concentrations in biomass and LPG using homes were 134 μg/m3 [IQR:71-258] and 27 μg/m3 [IQR:20-47], while corresponding personal exposures were 75 μg/m3 [IQR:55-104] and 36 μg/m3 [IQR:26-46], respectively. In before-and-after analysis, median 48-h personal exposures for pregnant women were 72 μg/m3 [IQR:49-127] at baseline and 25 μg/m3 [IQR:18-35] after the LPG intervention, with a sustained reduction of 93% in mean kitchen PM2.5 concentrations and 78% in mean personal PM2.5 exposures over the 2 month intervention period. Median ambient concentrations were 23 μg/m3 [IQR:19-27). Participant feedback was critical in designing clothing and instrument stands that ensured high compliance.

CONCLUSIONS

An LPG stove and fuel intervention in the candidate HAPIN trial field sites in India was deemed suitable for achieving health-relevant exposure reductions. Ambient concentrations indicated limited contributions from other sources. Study results provide critical inputs for the HAPIN trial site selection in India, while also contributing new information on HAP exposures in relation to LPG interventions and among pregnant women in LMICs.

TRIAL REGISTRATION

ClinicalTrials.Gov. NCT02944682 ; Prospectively registered on October 17, 2016.

Marriage-based pilot clean household fuel intervention in India for improved pregnancy outcomes

INTRODUCTION

Health interventions often target pregnant women and their unborn children. Interventions in rural India targeting pregnant women, however, often do not cover the critical early windows of susceptibility during the first trimester and parts of the second trimester. This pilot seeks to determine if targeting newlyweds could protect entire pregnancies with a clean stove and fuel intervention.

METHODS

We recruited 50 newlywed couples who use biomass as a cooking fuel into a clean cooking intervention that included a liquefied petroleum gas (LPG) stove, two gas cylinders, a table to place the stove on and health education. We first evaluated whether community health workers in this region could identify and recruit couples at marriage. We quantified how many additional days of pregnancy could be covered by an intervention if we recruited at marriage versus recruiting after detection of pregnancy.

RESULTS

On average, we identified and visited newlywed couples within 40 (SD 21) days of marriage. Of the 50 couples recruited, 25 pregnancies and 18 deliveries were identified during this 1-year study. Due to challenges securing fuel from the LPG supply system, not all couples received their intervention prior to pregnancy. Regardless, couples recruited in the marriage arm had substantially more days with the intervention than couples recruited into a similar arm recruited at pregnancy (211 SD 46 vs 120 SD 45). At scale, a stove intervention targeting new marriages would cover about twice as many weeks of first pregnancies as an intervention recruiting after detection of pregnancy.

CONCLUSIONS

We were able to recruit in early marriage using existing community health workers. Households recruited early in marriage had more days with clean fuel coverage than those recruited at pregnancy. Our findings indicate that recruitment at marriage is feasible and warrants further exploration for stove and other interventions targeting pregnancy-related outcomes.

Can We Vacuum Our Air Pollution Problem Using Smog Towers?

In November 2019, the Supreme Court of India issued a notification to all the states in the National Capital Region of Delhi to install smog towers for clean air and allocated INR 36 crores (~USD 5.2 million) for a pilot. Can we vacuum our air pollution problem using smog towers? The short answer is “no”. Atmospheric science defines the air pollution problem as (a) a dynamic situation where the air is moving at various speeds with no boundaries and (b) a complex mixture of chemical compounds constantly forming and transforming into other compounds. With no boundaries, it is unscientific to assume that one can trap air, clean it, and release into the same atmosphere simultaneously. In this paper, we outline the basics of atmospheric science to describe why the idea of vacuuming outdoor air pollution is unrealistic, and the long view on air quality management in Indian cities.

Beyond cost: Exploring fuel choices and the socio-cultural dynamics of liquefied petroleum gas stove adoption in Peru

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.

The drivers of sustained use of liquified petroleum gas in India

Ninety-five per cent of Indian households now have access to liquified petroleum gas (LPG), with 80 million acquiring it under the Pradhan Mantri Ujjwala Yojana (PMUY) since 2016. Still, having a connection is not enough to eliminate household air pollution. Studying panel data from rural households in six major states from 2014-2015 and 2018, we assess the determinants of cooking energy transition from solid fuels to LPG. We find that PMUY beneficiaries have much lower odds of using LPG as the primary or exclusive fuel compared with general customers, irrespective of their economic status. Village-level penetration of LPG as a primary fuel and the years of LPG use positively influence its sustained use, while ease of access to freely available biomass and reliance on uncertain and irregular income sources hinder LPG use. The findings highlight the need to interlace cooking fuel policies with rural development, to enable a complete transition towards cleaner cooking fuels.

Everybody Stacks: Lessons from household energy case studies to inform design principles for clean energy transitions

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.

An Integrated Sensor Data Logging, Survey, and Analytics Platform for Field Research and Its Application in HAPIN, a Multi-Center Household Energy Intervention Trial

Researchers rely on sensor-derived data to gain insights on numerous human behaviors and environmental characteristics. While commercially available data-logging sensors can be deployed for a range of measurements, there have been limited resources for integrated hardware, software, and analysis platforms targeting field researcher use cases. In this paper, we describe Geocene, an integrated sensor data logging, survey, and analytics platform for field research. We provide an example of Geocene’s ongoing use in the Household Air Pollution Intervention Network (HAPIN). HAPIN is a large, multi-center, randomized controlled trial evaluating the impacts of a clean cooking fuel and stove intervention in Guatemala, India, Peru, and Rwanda. The platform includes Bluetooth-enabled, data-logging temperature sensors; a mobile application to survey participants, provision sensors, download sensor data, and tag sensor missions with metadata; and a cloud-based application for data warehousing, visualization, and analysis. Our experience deploying the Geocene platform within HAPIN suggests that the platform may have broad applicability to facilitate sensor-based monitoring and evaluation efforts and projects. This data platform can unmask heterogeneity in study participant behavior by using sensors that capture both compliance with and utilization of the intervention. Platforms like this could help researchers measure adoption of technology, collect more robust intervention and covariate data, and improve study design and impact assessments.

The Role of Education and Attitudes in Cooking Fuel Choice: Evidence from two states in India

Widespread adoption of clean cooking fuels is a necessary step toward reducing household air pollution and improving population health. Here we use large-scale surveys (10,000 households) from two Indian states, Kerala and Rajasthan, to examine how education and attitudes toward cooking associate with the adoption of liquefied petroleum gas (LPG), India's most popular clean cooking fuel. We report three main results. First, education is a strong predictor of LPG adoption. Second, perceptions that LPG is good and affordable and progressive health-related perceptions are associated with LPG ownership. Third, and surprisingly, education does not predict positive attitudes toward clean cooking fuels. These results suggest that education leads to LPG adoption, but not through attitudinal changes. Further research should examine the mediators of the observed robust education-adoption association.

Persistence of Solid Fuel Use in Rural North India

Survey evidence from rural North India showing persistent solid fuel use despite increases in liquefied petroleum gas ownership is presented. Although three-quarters of survey households in these states had LPG, almost all also had a stove that uses solid fuels. Among those owning both, almost three-quarters used solid fuels the day before the survey. Household economic status, relative costs of cooking fuels, gender inequality, and beliefs about solid fuels were important contributors to high solid fuel use. To realise the full health benefits of the LPG expansion, attention must now be turned towards encouraging exclusive LPG use.

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

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.