The health impacts of exposure to indoor air pollution from solid fuels in developing countries: knowledge,gaps, and data needs

Globally, almost 3 billion people rely on biomass (wood, charcoal, crop residues, and dung) and coal as their primary source of domestic energy. Exposure to indoor air pollution (IAP) from the combustion of solid fuels is an important cause of morbidity and mortality in developing countries. In this paper, we review the current knowledge on the relationship between IAP exposure and disease and on interventions for reducing exposure and disease. We take an environmental health perspective and consider the details of both exposure and health effects that are needed for successful intervention strategies. We also identify knowledge gaps and detailed research questions that are essential in successful design and dissemination of preventive measures and policies. In addition to specific research recommendations, we conclude that given the interaction of housing, household energy, and day-to-day household activities in determining exposure to indoor smoke, research and development of effective interventions can benefit tremendously from integration of methods and analysis tools from a range of disciplines in the physical, social, and health sciences.     

Environmental risks in the developing world: exposure indicators for evaluating interventions, programmes, and policies

BACKGROUND: Monitoring and empirical evaluation are essential components of evidence based public health policies and programmes. Consequently, there is a growing interest in monitoring of, and indicators for, major environmental health risks, particularly in the developing world. Current large scale data collection efforts are generally disconnected from micro-scale studies in health sciences, which in turn have insufficiently investigated the behavioural and socioeconomic factors that influence exposure. STUDY DESIGN: A basic framework is proposed for development of indicators of exposure to environmental health risks that would facilitate the (a) assessment of the health effects of risk factors, (b) design and evaluation of interventions and programmes to deliver the interventions, and (c) appraisal and quantification of inequalities in health effects of risk factors, and benefits of intervention programmes and policies. Specific emphasis is put on the features of environmental risks that should guide the choice of indicators, in particular the interactions of technology, the environment, and human behaviour in determining exposure. The indicators are divided into four categories: (a) access and infrastructure, (b) technology, (c) agents and vectors, and (d) behaviour. The study used water and sanitation, indoor air pollution from solid fuels, urban ambient air pollution, and malaria as illustrative examples for this framework. CONCLUSIONS: Organised and systematic indicator selection and monitoring can provide an evidence base for design and implementation of more effective and equitable technological interventions, delivery programmes, and policies for environmental health risks in resource poor settings.     

A framework for targeting water,sanitation and hygiene interventions in pastoralist populations in the Afar region of Ethiopia

Globally, many populations face structural and environmental barriers to access safe water, sanitation and hygiene (WASH) services. Among these populations are many of the 200 million pastoralists whose livelihood patterns and extreme environmental settings challenge conventional WASH programming approaches. In this paper, we studied the Afar pastoralists in Ethiopia to identify WASH interventions that can mostly alleviate public health risks, within the population's structural and environmental living constraints. Surveys were carried out with 148 individuals and observational assessments made in 12 households as part of a Pastoralist Community WASH Risk Assessment. The results show that low levels of access to infrastructure are further compounded by risky behaviours related to water containment, storage and transportation. Additional behavioural risk factors were identified related to sanitation, hygiene and animal husbandry. The Pastoralist Community WASH Risk Assessment visually interprets the seriousness of the risks against the difficulty of addressing the problem. The assessment recommends interventions on household behaviours, environmental cleanliness, water storage, treatment and hand hygiene via small-scale educational interventions. The framework provides an approach for assessing risks in other marginal populations that are poorly understood and served through conventional approaches.     

Protective Behaviors and Secondary Harms Resulting From Nonpharmaceutical Interventions During the COVID-19 Epidemic in South Africa: Multisite,Prospective Longitudinal Study

BackgroundIn March 2020, South Africa implemented strict nonpharmaceutical interventions (NPIs) to contain the spread of COVID-19. Over the subsequent 5 months, NPI policies were eased in stages according to a national strategy. COVID-19 spread throughout the country heterogeneously; the disease reached rural areas by July and case numbers peaked from July to August. A second COVID-19 wave began in late 2020. Data on the impact of NPI policies on social and economic well-being and access to health care are limited.ObjectiveWe aimed to determine how rural residents in three South African provinces changed their behaviors during the first COVID-19 epidemic wave.MethodsThe South African Population Research Infrastructure Network nodes in the Mpumalanga (Agincourt), KwaZulu-Natal, (Africa Health Research Institute) and Limpopo (Dikgale-Mamabolo-Mothiba) provinces conducted up to 14 rounds of longitudinal telephone surveys among randomly sampled households from rural and periurban surveillance populations every 2-3 weeks. Interviews included questions on the following topics: COVID-19–related knowledge and behaviors, the health and economic impacts of NPIs, and mental health. We analyzed how responses varied based on NPI stringency and household sociodemographics.ResultsIn total, 5120 households completed 23,095 interviews between April and December 2020. Respondents’ self-reported satisfaction with their COVID-19–related knowledge and face mask use rapidly rose to 85% and 95%, respectively, by August. As selected NPIs were eased, the amount of travel increased, economic losses were reduced, and the prevalence of anxiety and depression symptoms fell. When the number of COVID-19 cases spiked at one node in July, the amount of travel dropped rapidly and the rate of missed daily medications doubled. Households where more adults received government-funded old-age pensions reported concerns about economic matters and medication access less often.ConclusionsSouth Africans complied with stringent, COVID-19–related NPIs despite the threat of substantial social, economic, and health repercussions. Government-supported social welfare programs appeared to buffer interruptions in income and health care access during local outbreaks. Epidemic control policies must be balanced against the broader well-being of people in resource-limited settings and designed with parallel support systems when such policies threaten peoples’ income and access to basic services.     

Building social capital in post-conflict communities: Evidence from Nicaragua

Studies of social capital have focused on the static relationship between social capital and health, governance and economic conditions. This study is a first attempt to evaluate interventions designed to improve the levels of social capital in post-conflict communities in Nicaragua and to relate those increases to health and governance issues. The two-year study involved a baseline household survey of approximately 200 households in three communities in Nicaragua, the implementation of systematic interventions designed to increase social capital in two of the locales (with one control group), and a second household survey administered two years after the baseline survey. We found that systematic interventions promoting management and leadership development were effective in improving some aspects of social capital, in particular the cognitive attitudes of trust in the communities. Interventions were also linked to higher levels of civic participation in governance processes. As in other empirical studies, we also found that higher levels of social capital were significantly associated with some positive health behaviors. The behavioral/structural components of social capital (including participation in groups and social networks) were associated with more desirable individual health behaviors such as the use of modern medicine to treat children's respiratory illnesses. Attitudinal components of social capital were positively linked to community health behaviors such as working on community sanitation campaigns. The findings presented here should be of interest to policy makers interested in health policy and social capital, as well as those working in conflict-ridden communities in the developing world.     

Factors affecting environmental awareness among Head Start families in Mississippi

BACKGROUND: Socioeconomic and racial/ethnic disparities in health status in the United States may be attributed in part to environmental injustice and differential exposure to environmental hazards among low-income and/or minority populations. However, the environmental justice movement has historically focused on equity in the siting of point-source polluting facilities, giving little attention to environmental hazards and environmental awareness at the level of the individual household. METHODS: Heads of 763 low-income households participating in Head Start programs in 20 counties of the Mississippi Delta region were surveyed regarding their education, the physical environment of their home and workplace, sources of food and water, awareness of local polluting sites/facilities, knowledge of government agencies, and behaviors that may affect their health or impact their local environment. Survey results were compared to demographic, socioeconomic, and environmental quality indicators. RESULTS: Significant associations existed between both education and race/ethnicity and the responses of survey participants. Being African American was more commonly associated with poor quality-of-life indicators such as renting substandard older homes and living in close proximity to areas of unfavorable watershed quality. Higher education was more commonly and positively associated with indicators of heightened environmental awareness and increased political empowerment. No association was observed between race/ethnicity and the prevalence of polluting facilities. However, a significant association existed between race/ethnicity and indicators of environmental quality/integrity. CONCLUSIONS: Environmental health education interventions that target individual households may be a useful mechanism for increasing the access of low-income communities to government health resources and reducing adverse health effects from the environment. However, racial/ethnic disparities in education and health remain an important consideration.     

Activity spaces in place and health research: Novel exposure measures,data collection tools,and designs

Activity space research provides a framework to consider mobility while linking environments to behaviors in the study of neighborhood effects on health. Increased use of wearable location sensors provides new opportunities to observe and analyze fine-grained spatial and temporal information on individuals' mobility patterns, environmental exposures and behaviors; however, these analysis does not easily translate into causal inference. Additional dimensions underlying behavioral decision-making likely influence or even modify environmental effects on behaviors. This commentary discusses how further progresses in exposure measurement, integration of data collection tools, and development of study designs could support future interventions to optimize how environments shape health profiles and inequities.     

Environment, wealth, inequality and the burden of disease in the Accra metropolitan area, Ghana

The study examines environmental problems and adverse impacts on the health of urban households in the Accra metropolitan area, Ghana. Accra is faced with severe inadequacy of urban infrastructure in the face of rapid population growth in the metropolis. More than half of the city's population do not have access to solid waste collection services. Only 39.8% of households have indoor pipe and over 35.0% of households depend on unsanitary public latrines whilst 2.5% do not have access to toilet facilities. Human excrement, garbage and wastewater are usually deposited in surface drains, open spaces and streams in poor neighbourhoods. The resultant poor sanitation has serious health impacts as more than half of reported diseases are related to poor environmental sanitation. The majority of households depend on solid fuels for cooking and this leads to indoor air pollution and high incidence of respiratory infections. Poor households bear a disproportionately large share of the burden of environmental health hazards than their wealthy counterparts, due to their particular vulnerability resulting from inadequate access to environmental health facilities and services.     

Women's strategies for handling household detergents

Performing household-cleaning chores involves the use of chemical detergents; these are commonly believed to provide cleaner and safer households. Occupational health studies have associated health risks with detergents, including respiratory and skin problems. Women are the major users of household detergents, as they are in general the primary homemakers. Detergent-handling strategies including storage, use, and precautionary measures affect women's exposure to chemical detergents and thus affect their health. Studies investigating the behavioral component of chemical exposure to detergents at the domestic level are scarce. In this study of detergent-handling strategies, women's potential exposure was investigated by an ergonomics methodology combining in-depth interviews and observations. The participants were 28 women who were responsible for cleaning chores in their households. The women lived in Nabaa, a low socioeconomic, religiously and ethnically diverse neighborhood on the outskirts of Beirut, Lebanon. Information on how women in Nabaa used and perceived household detergent, added to the understanding of their potential chemical exposure. All the study subjects washed dishes, cleaned bathrooms, and swept floors on at least a daily basis. We found that more than half of the participants stored different incompatible detergents in close proximity to each other. Many of the women stated that they over-consumed detergents. A large proportion mixed different detergents together but most of them opened the windows while cleaning for ventilation. The majority did not wear gloves and did not follow label directions. The participants were consistently exposed to chemical detergents and minimal precautionary measures were taken. Cleanliness and hygiene had a strong cultural value and were of utmost importance to women who prioritized them over excessive exposure to chemicals. The use of an ergonomics methodology provided access to important information concerning how women make choices that affect their environmental exposure.     

Housing Characteristics of Farmworker Families in North Carolina

Adequate housing is a basic human right and an important determinant of environmental health. Little research has documented the housing quality of immigrant Latino farmworker families. This analysis uses data from four surveys of North Carolina farmworker communities conducted in 2001 and 2003 to document aspects of housing quality that could affect farmworker family health. Three housing domains are considered: dwelling characteristics, household characteristics, and household behaviors. Most farmworker families live in mobile homes, and few own their dwellings. Many are located near agricultural fields. Most houses are small, but household size is large, containing adults, in addition to the nuclear family. Crowding is common among farmworker families. Many farmworker households lack basic facilities, such as washing machines. Farmworkers attempt to reduce exposure by frequently cleaning their dwellings. These findings suggest that the health of farmworker families is at risk due to inadequate housing. Further research on housing-related health effects among farmworker families is needed.