Potential Impacts of Modifiable Behavioral and Environmental Exposures on Reducing Burden of Under-five Mortality Associated with Household Air Pollution in Nepal

Objectives Household air pollution (HAP) is one of the leading causes of respiratory illness and deaths among young children in low and lower-middle income countries. This study examines for the first time trends in the association between HAP from cooking fuel and under-five mortality and measures the potential impact of interventions to reduce HAP using Nepal Demographic and Health Survey datasets (2001–2011). Methods A total of 17,780 living children across four age-groups (neonatal 0–28 days, post-neonatal 1–11 months, child 12–59 months and under-five 0–59 months) were included and multi-level logistic regression models were used for analyses. Population attributable fractions of key risk factors and potential impact fractions assessing the impact of previous interventions to reduce exposure prevalence were also calculated. Results Use of cooking fuel was associated with total under-five mortality (OR 2.19, 95% CI 1.37–3.51, P?=?0.001) in Nepal, with stronger associations evident for sub-group analyses of neonatal mortality (OR 2.67, 95% CI 1.47–4.82, P?=?0.001). Higher association was found in rural areas and for households without a separate kitchen using polluting fuel for cooking, and in women who had never breastfed for all age-groups of children. PIF estimates, assuming a 63% of reduction of HAP based on previously published interventions in Nepal, suggested that a burden of 40% of neonatal and 33% of under-five mortality cases associated with an indoor kitchen using polluting fuel could be avoidable. Conclusion Improved infrastructure and behavioral interventions could help reduce the pollution from cooking fuel in the household resulting in further reduction in under-five mortality in Nepal.     

Trends for Neonatal Deaths in Nepal (2001–2016) to Project Progress Towards the SDG Target in 2030, and Risk Factor Analyses to Focus Action

Introduction

Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030.

Methods

This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016.

Results

In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20–9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62–2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17–2.59), household air pollution (AOR 1.37; CI 95% 1.59–1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21–1.54), residing in a rural area (AOR 1.28; CI 95% 1.13–1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06–1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067.

Conclusions

Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

     

Consequences of household air pollution on child survival: evidence from demographic and health surveys in 47 countries

Background: Over one-third of the world’s population is exposed to household air pollution (HAP) but the separate effects of cooking with solid fuel and kerosene on childhood mortality are unclear.

Objectives: To evaluate the effects of both solid fuels and kerosene on neonatal (0-28 days) and child (29 days-59 months) mortality.

Methods: We used Demographic and Health Surveys from 47 countries and calculated adjusted relative risks (aRR) using Poisson regression models.

Results: The aRR of neonatal and child mortality in households exposed to solid fuels were 1.24 (95% CI: 1.14, 1.34) and 1.21 (95% CI: 1.12, 1.30), respectively, and the aRR for neonatal and child mortality in households exposed to kerosene were 1.34 (95% CI: 1.18, 1.52) and 1.12 (95% CI: 0.99, 1.27), controlling for individual, household, and country-level predictors of mortality.

Conclusions: Kerosene should not be classified as a clean fuel. Neonates are at risk for mortality from exposure to solid fuels and kerosene.     

Influence of Cooking and Heating Fuel Use on 1–59 Month Old Mortality in South Africa

Objectives: To determine the association between the combustion of wood, animal dung, coal and paraffin (polluting fuels) for cooking and heating and 1–59 month old mortality in South Africa, whilst adjusting for a number of confounders. Methods: Data from 3,556 children (142 deaths) living in 2,828 households were extracted from the 1998 South African Demographic and Health Survey (SADHS) database. The SADHS was the first national health survey conducted across the entire country and provided the opportunity to examine the prevalence and determinants of various morbidity and mortality outcomes in a representative national population. Results: The results suggest that exposure to cooking and heating smoke from polluting fuels is significantly associated with 1–59 month mortality, after controlling for mother's age at birth, water source, asset index and household crowdedness (RR=1.95; 95% CI=1.04, 3.68). Conclusions: Although there is potential for residual confounding despite adjustment, the better documented evidence on outdoor air pollution and mortality suggest this association may be real. As nearly half of households in South Africa still rely on polluting fuels and women of childbearing age perform most cooking tasks, the attributable risk arising from this association, if confirmed, could be substantial. It is trusted that more detailed analytical intervention studies will scrutinise these results in order to develop integrated intervention programmes to reduce children's exposure to air pollution emanating from cooking and heating fuels.     

Consequences of household air pollution on child survival: evidence from demographic and health surveys in 47 countries

Background: Over one-third of the world’s population is exposed to household air pollution (HAP) but the separate effects of cooking with solid fuel and kerosene on childhood mortality are unclear.Objectives: To evaluate the effects of both solid fuels and kerosene on neonatal (0-28 days) and child (29 days-59 months) mortality.Methods: We used Demographic and Health Surveys from 47 countries and calculated adjusted relative risks (aRR) using Poisson regression models.Results: The aRR of neonatal and child mortality in households exposed to solid fuels were 1.24 (95% CI: 1.14, 1.34) and 1.21 (95% CI: 1.12, 1.30), respectively, and the aRR for neonatal and child mortality in households exposed to kerosene were 1.34 (95% CI: 1.18, 1.52) and 1.12 (95% CI: 0.99, 1.27), controlling for individual, household, and country-level predictors of mortality.Conclusions: Kerosene should not be classified as a clean fuel. Neonates are at risk for mortality from exposure to solid fuels and kerosene.     

Childhood illness in households using biomass fuels in India: secondary data analysis of nationally representative national family health surveys

Abstract

Background: Half of the world’s population uses solid fuels for energy and cooking, resulting in 1·5 million deaths annually, approximately one-third of which occur in India. Most deaths are linked to childhood pneumonia or acute lower respiratory tract infection (ALRI), conditions that are difficult to diagnose. The overall effect of biomass combustion on childhood illness is unclear.

Objectives: To evaluate whether type of household fuel is associated with symptoms of ALRI (cough and difficulty breathing), diarrhea or fever in children aged 0–36 months.

Methods: We analyzed nationally representative samples of households with children aged 0–36 months from three national family health surveys conducted between 1992 and 2006 in India. Households were categorized as using low (liquid petroleum gas/electricity), medium (coal/kerosene) or high polluting fuel (predominantly wood/agricultural waste). Odds ratios adjusted for confounders for exposure to high and medium polluting fuel were compared with low polluting fuel (LPF).

Results: Use of high polluting fuel (HPF) in India changed minimally (82 to 78 %), although LPF use increased from 8% to 18%. HPF was consistently associated with ALRI [adjusted odds ratio (95% confidence interval) 1·48 (1·08–2·03) in 1992–3; 1·54 (1·33–1·77) in 1998–9; and 1·53 (1·21–1·93) in 2005–6). Fever was associated with HPF in the first two surveys but not in the third survey. Diarrhea was not consistently associated with HPF.

Conclusions: There is an urgent need to increase the use of LPF or equivalent clean household fuel to reduce the burden of childhood illness associated with IAP in India.     

Equity and Coverage in the Continuum of Reproductive,Maternal, Newborn and Child Health Services in Nepal-Projecting the Estimates on Death Averted Using the LiST Tool

Introduction

The third Sustainable Development Goal, focused on health, includes two targets related to the reduction in maternal, newborn and under-five childhood mortality. We found it imperative to examine the equity and coverage of reproductive, maternal, newborn and child health (RMNCH) interventions from 2001 to 2016 in Nepal; and the death aversion that will take place during the SDG period.

Methods

We used the datasets from the Nepal Demographic Health Surveys (NDHS) 2001, 2006, 2011 and 2016. We calculated the coverage and equity for RMNCH interventions and the composite coverage index (CCI). Based on the Annualized Rate of Change (ARC) in the coverage for selected RMNCH indicators, we projected the trend for the RMNCH interventions by 2030. We used the Lives Saved Tools (LiST) tool to estimate the maternal, newborn, under-five childhood deaths and stillbirths averted. We categorised the interventions into four different patterns based on coverage and inequity gap.

Results

Between 2001 and 2016, a significant improvement is seen in the overall RMNCH intervention coverage-CCI increasing from 46 to 75%. The ARC was highest for skilled attendance at birth (11.7%) followed by care seeking for pneumonia (8.2%) between the same period. In 2016, the highest inequity existed for utilization of the skilled birth attendance services (51%), followed by antenatal care (18%). The inequity gap for basic immunization services reduced significantly from 27.4% in 2001 to 5% in 2016. If the current ARC continues, then an additional 3783 maternal deaths, 36,443 neonatal deaths, 66,883 under-five childhood deaths and 24,024 stillbirths is expected to be averted by the year 2030.

Conclusion

Nepal has experienced an improvement in the coverage and equity in RMNCH interventions. Reducing inequities will improve coverage for skilled birth attendants and antenatal care. The current annual rate of change in RMNCH coverage will further reduce the maternal, neonatal, under-five childhood deaths and stillbirths.

     

Prevalence and factors affecting underweight,overweight and obesity using Asian and World Health Organization cutoffs among adults in Nepal: Analysis of the Demographic and Health Survey 2016

ObjectiveThere is a little published data on prevalence and determinants of underweight, overweight and obesity among adults in Nepal. This study analysed the cross-sectional Nepal Demographic and Health Survey (NDHS) 2016 to obtain these using the World Health Organization (WHO) and Asian-specific cutoffs of body mass index (BMI).MethodsThe 2016 NDHS used a multistage cluster-sampling design to obtain data on major health indicators in Nepal. The BMI cutoffs for underweight was <18.5 kg/m². The BMI cutoffs for overweight/obesity as per the Asian and WHO classifications were ≥23, and ≥25 kg/m², respectively. After reporting the prevalence according to sex and background characteristics, multilevel logistic regression was conducted to estimate odds ratios.SubjectsThis analysis included 12,652 adults (5283 males and 7369 females) with a median age of 40 years (interquartile range [IQR]: 28–54).ResultsThe overall median BMI was 21.5 kg/m² (IQR:19.3–24.3). The overall prevalence of underweight was 16.7% (15.1% among males and 17.1% among females). The Asian-specific BMI cutoffs found the prevalence of overweight and obesity as 26.4% (27.4% among males and 25.6% among females) and 11.0% (7.7% among males and 13.3% among females), respectively. The WHO-recommended BMI cutoffs found 18.2% people overweight (16.7% among males and 19.3% among females) and 4.3% (2.5% among males and 5.6% among females) people obese. The prevalence and odds of extreme body weight categories (i.e., underweight, overweight and obesity) varied according to age, sex, education level, household wealth status, place, ecological zone and provinces of residence as per both recommended cutoffs. Overall, higher education level and wealth status were positively associated with overweight/obesity and inversely associated with underweight as per both cutoffs.ConclusionA large proportion Nepalese adults have either underweight, overweight or obesity, and could be at a greater risk of mortality and morbidity due to these extreme body weight categories. It is essential to address the factors or characteristics that are associated with the higher prevalence and likelihood of these extreme body weight categories to reduce the overall burden of underweight and overweight/obesity in Nepal.     

Physical activity attenuates the association between household air pollution and health-related quality of life in Chinese rural population: the Henan Rural Cohort Study

Background and purpose

Limited research focused on the association between household air pollution (HAP) and health-related quality of life (HRQoL). This study aimed to investigate the association of HAP with HRQoL and the effect modification of physical activity.

Method

A total of 16,761 eligible participants were derived from the Henan Rural Cohort Study. Based on structured questionnaires, HAP was assessed by fuel type, cooking duration and kitchen ventilation; HRQoL was measured with utility index and VAS score from the European Quality of Life Five Dimension Five Level Scale (EQ-5D-5L); physical activity was assessed by the International Physical Activity Questionnaire. Generalized linear models and tobit regression models were utilized to explore the relationship of HAP with HRQoL. Further sensitivity analyses were conducted using structural equation models.

Results

Compared with those who cooked with clean fuels, short-duration, or good kitchen ventilation, participants who cooked with solid fuels, long-duration, and poor ventilation had lower utility index and VAS score (All P?<?0.001). The decrease in utility index for solid fuel users vs. clean fuel users were 0.06 [95%confidence interval (CI) 003, 0.08], 0.03 (95%CI 0.01, 0.04) and 0.02 (95%CI 0.01, 0.04) in low, moderate and high physical activity group, respectively, which decreased with physical activity levels (P_{for interaction}?<?0.05). Similar results were observed in associations of kitchen ventilation with utility index and VAS score.

Conclusion

HAP negatively associated with HRQoL in rural population, and potential intervention aimed at maintaining adequate physical activity.

Trail registration

The Henan Rural Cohort Study has been registered at Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 06 July, 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

     

Acute Lower Respiratory Infection in Childhood and Household Fuel Use in Bhaktapur,Nepal

Background: Globally, solid fuels are used by about 3 billion people for cooking. These fuels have been associated with many health effects, including acute lower respiratory infection (ALRI) in young children. Nepal has a high prevalence of use of biomass for cooking and heating.Objective: This case–control study was conducted among a population in the Bhaktapur municipality, Nepal, to investigate the relationship of cookfuel type to ALRI in young children.Methods: Cases with ALRI and age-matched controls were enrolled from an open cohort of children 2–35 months old, under active monthly surveillance for ALRI. A questionnaire was used to obtain information on family characteristics, including household cooking and heating appliances and fuels. The main analysis was carried out using conditional logistic regression. Population-attributable fractions (PAF) for stove types were calculated.Results: A total of 917 children (452 cases and 465 controls) were recruited into the study. Relative to use of electricity for cooking, ALRI was increased in association with any use of biomass stoves [odds ratio (OR) = 1.93; 95% CI: 1.24, 2.98], kerosene stoves (OR = 1.87; 95% CI: 1.24, 2.83), and gas stoves (OR = 1.62; 95% CI: 1.05, 2.50). Use of wood, kerosene, or coal heating was also associated with ALRI (OR = 1.45; 95% CI: 0.97, 2.14), compared with no heating or electricity or gas heating. PAFs for ALRI were 18.0% (95% CI: 8.1, 26.9%) and 18.7% (95% CI: 8.4%–27.8%), for biomass and kerosene stoves, respectively.Conclusions: The study supports previous reports indicating that use of biomass as a household fuel is a risk factor for ALRI, and provides new evidence that use of kerosene for cooking may also be a risk factor for ALRI in young children.     

Household air pollution related to biomass cook stove emissions and its interaction with improved cookstoves

IntroductionHousehold air pollution (HAP) is associated with significant global morbidity and mortality. Newer initiatives including improved cookstove (IC) and cleaner fuels are being implemented to improve HAP effects.MethodsA literature review was conducted for household air pollution related to biomass cookstoves in resource limited countries. In January 2018, we electronically searched the PubMed database for the term cookstoves with no date restrictions. We included cohort, case-control, cross-sectional studies, conference abstracts, editorials, and reviews; studies that assessed the emissions related to cookstove and factors affecting HAP emissions.ResultsTwenty-three articles met the objectives of the review. Fine particulate matter with aerodynamic diameter <2.5 µm (PM_2.5), carbon monoxide (CO) and polycyclic aromatic hydrocarbons (PAH) are the major HAP emissions. Emission factors are based on the stove and fuel used while the activity is based on cooking practices. Changes in composition and sources of PM_2.5 causes modification to its resulting toxicity. Many PAHs and their metabolites released by HAP have carcinogenic, teratogenic and mutagenic potential. Improving ventilation decreases concentrations of PM_2.5 and CO in the household air. Few standard tools are available to measure ventilation and continued IC efficacy in long term.ConclusionUnavailability of tools to measure ventilation and continued IC efficacy in long term affect uniformity and comparability of IC study results. Community education about the health effects of HAP and importance of ventilation in decreasing HAP is an important aspect of public health policy to prevent HAP effects.     

The Association of Women’s Empowerment with Stillbirths in Nepal

Introduction

Globally, 2.6 million stillbirths occur each year. Empowering women can improve their overall reproductive health and help reduce stillbirths. Women empowerment has been defined as women’s ability to make choices in economic decision-making, household and health care decision-making. In this paper, we aimed to evaluate if women’s empowerment is associated with stillbirths.

Methods

Data from 2016 Nepal Demographic Health Surveys (NDHS) were analysed to evaluate the association between women’s empowerment and stillbirths. Equiplots were generated to assess the distribution of stillbirths by wealth quintile, place of residence and level of maternal education using data from NHDS 1996, 2001, 2006, 2011 and 2016 data. For the association of women empowerment factors and stillbirths, univariate and multivariate analyses were conducted.

Results

A total of 88 stillbirths were reported during the survey. Univariate analysis showed age of mother, education of mother, age of husband, wealth index, head of household, decision on healthcare and decision on household purchases had significant association with stillbirths (p < 0.05). In multivariate analysis, only maternal age 35 years and above was significant (aOR 2.42; 1.22–4.80). Education of mother (aOR 1.48; 0.94–2.33), age of husband (aOR 1.54; 0.86–2.76), household head (aOR 1.51; 0.88–2.59), poor wealth index (aOR 1.62; 0.98–2.68), middle wealth index (aOR 1.37; 0.76–2.47), decision making for healthcare (aOR 1.36; 0.84–2.21) and household purchases (aOR 1.01; 0.61–1.66) had no any significant association with stillbirths.

Conclusions

There are various factors linked with stillbirths. It is important to track stillbirths to improve health outcomes of mothers and newborn. Further studies are necessary to analyse women empowerment factors to understand the linkages between empowerment and stillbirths.

     

Control of household air pollution for child survival: estimates for intervention impacts

Background

Exposure to household air pollution (HAP) from cooking with solid fuels affects 2.8 billion people in developing countries, including children and pregnant women. The aim of this review is to propose intervention estimates for child survival outcomes linked to HAP.

Methods

Systematic reviews with meta-analysis were conducted for ages 0-59 months, for child pneumonia, adverse pregnancy outcomes, stunting and all-cause mortality. Evidence for each outcome was assessed against Bradford-Hill viewpoints, and GRADE used for certainty about intervention effect size for which all odds ratios (OR) are presented as protective effects.

Results

Reviews found evidence linking HAP exposure with child ALRI, low birth weight (LBW), stillbirth, preterm birth, stunting and all-cause mortality. Most studies were observational and rated low/very low in GRADE despite strong causal evidence for some outcomes; only one randomised trial was eligible.Intervention effect (OR) estimates of 0.64 (95% CI: 0.55, 0.75) for ALRI, 0.71 (0.65, 0.79) for LBW and 0.66 (0.54, 0.81) for stillbirth are proposed, specific outcomes for which causal evidence was sufficient. Exposure-response evidence suggests this is a conservative estimate for ALRI risk reduction expected with sustained, low exposure. Statistically significant protective ORs were also found for stunting [OR=0.79 (0.70, 0.89)], and in one study of pre-term birth [OR=0.70 (0.54, 0.90)], indicating these outcomes would also likely be reduced. Five studies of all-cause mortality had an OR of 0.79 (0.70, 0.89), but heterogenity precludes a reliable estimate for mortality impact. Although interventions including clean fuels and improved solid fuel stoves are available and can deliver low exposure levels, significant challenges remain in achieving sustained use at scale among low-income households.

Conclusions

Reducing exposure to HAP could substantially reduce the risk of several child survival outcomes, including fatal pneumonia, and the proposed effects could be achieved by interventions delivering low exposures. Larger impacts are anticipated if WHO air quality guidelines are met. To achieve these benefits, clean fuels should be adopted where possible, and for other households the most effective solid fuel stoves promoted. To strengthen evidence, new studies with thorough exposure assessment are required, along with evaluation of the longer-term acceptance and impacts of interventions.

     

Estimating the Number of Low-Income Americans Exposed to Household Air Pollution from Burning Solid Fuels

Background: Exposure to household air pollution (HAP) from inefficient biomass and coal stoves kills nearly 4 million people every year worldwide. HAP is an environmental risk associated with poverty that affects an estimated 3 billion people mostly in low- and middle-income countries.Objectives: Our goal was to estimate the number of low-income Americans exposed to potentially health-damaging concentrations of HAP.Methods: We mapped county-level data for the percentage of households using wood, coal, and/or coke as their primary heating fuel along with percent of the population below the federal poverty level. Using U.S. Census data and the likelihood of fugitive emissions as reported in the literature, we estimated the number of low-income Americans potentially exposed to HAP.Results: Solid fuel is the primary heating source for > 2.5 million U.S. households, or 6.5 million people. The mapping exercise showed several rural areas, primarily in the northern and western regions, that have high levels of solid-fuel use and poverty. We then identified 117 counties with high co-incident poverty and solid-fuel use as high-priority counties for research into potential health risks from HAP. We estimate that between 500,000 and 600,000 low-income people in the United States are likely exposed to HAP from burning solid fuels within their homes.Conclusion: HAP occurs within the United States and should be further investigated for adverse health risks, especially among those living in areas with rural poverty.Citation: Rogalsky DK, Mendola P, Metts TA, Martin WJ II. 2014. Estimating the number of low-income Americans exposed to household air pollution from burning solid fuels. Environ Health Perspect 122:806–810; http://dx.doi.org/10.1289/ehp.1306709     

Household fuels,low birth weight,and neonatal death in India: The separate impacts of biomass,kerosene, and coal

We examined the impact of maternal use of different household cooking fuels in India on low birth weight (LBW < 2500 g), and neonatal mortality (death within 28 days of birth). Using cross-sectional data from India's National Family Health Survey (NFHS-3), we separately analyzed the prevalence of these two outcomes in households utilizing three types of high-pollution fuels for cooking – biomass, coal, and kerosene – using low-pollution fuels (gas and biogas) as the comparison “control” group. Taking socioeconomic and child-specific factors into account, we employed logistic regression to examine the impact of fuel use on fetal and infant health. The results indicate that household use of high-pollution fuels is significantly associated with increased odds of LBW and neonatal death. Compared to households using cleaner fuels (in which the mean birth weight is 2901 g), the primary use of coal, kerosene, and biomass fuels is associated with significant decreases in mean birth weight (of −110 g for coal, −107 g for kerosene, and −78 g for biomass). Kerosene and biomass fuel use are also associated with increased risk of LBW (p < 0.05). Results suggest that increased risk of neonatal death is strongly associated with household use of coal (OR 18.54; 95% CI: 6.31–54.45), and perhaps with kerosene (OR 2.30; 95% CI: 0.95–5.55). Biomass is associated with increased risk of neonatal death among infants born to women with no more than primary education (OR 7.56; 95% CI: 2.40–23.80). These results are consistent with a growing literature showing health impacts of household air pollution from these fuels.     

Does biofuel smoke contribute to anaemia and stunting in early childhood?

BACKGROUND: Reliance on biomass fuels for cooking and heating exposes many women and young children in developing countries to high levels of air pollution indoors. Exposure to biomass smoke has been linked to reduced birth weight, acute respiratory infections, and childhood mortality. This study examines the association between household use of biofuels (wood, dung, and crop residues) for cooking and heating and prevalence of anaemia and stunting in children. METHODS: Data are from a 1998-99 national family health survey in India, which measured height, weight, and blood haemoglobin of 29 768 children aged 0-35 months in 92 486 households. Multinomial logistic regression is used to estimate the effects of biofuel use on prevalence of anaemia and stunting, controlling for exposure to tobacco smoke, recent episodes of illness, maternal education and nutrition, and other potentially confounding factors. RESULTS: Analysis shows that prevalence of moderate-to-severe anaemia was significantly higher among children in households using biofuels than among children in households using cleaner fuels (RRR = 1.58; 95% CI: 1.28, 1.94), independent of other factors. Prevalence of severe stunting was also significantly higher among children in biofuel-using households (RRR = 1.84; 95% CI: 1.44, 2.36). Thirty-one per cent of moderate-to-severe anaemia and 37% of severe stunting among children aged 6-35 months in India may be attributable to exposure to biofuel smoke. Effects on mild anaemia and moderate stunting were smaller, but positive and statistically significant. Effects of exposure to tobacco smoke on anaemia and stunting were small and not significant. CONCLUSIONS: The study provides a first evidence of the strong association between biofuel use and risks of anaemia and stunting in children, suggesting that exposure to biofuel smoke may contribute to chronic nutritional deficiencies in young children.     

Solid Fuel Use for Household Cooking: Country and Regional Estimates for 1980–2010

Background: Exposure to household air pollution from cooking with solid fuels in simple stoves is a major health risk. Modeling reliable estimates of solid fuel use is needed for monitoring trends and informing policy.Objectives: In order to revise the disease burden attributed to household air pollution for the Global Burden of Disease 2010 project and for international reporting purposes, we estimated annual trends in the world population using solid fuels.Methods: We developed a multilevel model based on national survey data on primary cooking fuel.Results: The proportion of households relying mainly on solid fuels for cooking has decreased from 62% (95% CI: 58, 66%) to 41% (95% CI: 37, 44%) between 1980 and 2010. Yet because of population growth, the actual number of persons exposed has remained stable at around 2.8 billion during three decades. Solid fuel use is most prevalent in Africa and Southeast Asia where > 60% of households cook with solid fuels. In other regions, primary solid fuel use ranges from 46% in the Western Pacific, to 35% in the Eastern Mediterranean and < 20% in the Americas and Europe.Conclusion: Multilevel modeling is a suitable technique for deriving reliable solid-fuel use estimates. Worldwide, the proportion of households cooking mainly with solid fuels is decreasing. The absolute number of persons using solid fuels, however, has remained steady globally and is increasing in some regions. Surveys require enhancement to better capture the health implications of new technologies and multiple fuel use.     

Out of Pocket Expenditure for Sick Newborn Care in Referral Hospitals of Nepal

Background

Almost all preventable neonatal deaths take place in low- and middle-income countries and affect the poorest who have the least access to high quality health services. Cost of health care is one of the factors preventing access to quality health services and universal health coverage. In Nepal, the majority of expenses related to newborn care are borne by the caregiver, regardless of socioeconomic status. We conducted a study to assess the out of pocket expenditure (OOPE) for sick newborn care in hospitals in Nepal.

Methods

This cross-sectional study of hospital care for newborns was conducted in 11 hospitals in Nepal and explored OOPE incurred by caregivers for sick newborn care. Data were collected from the caregivers of the sick newborn on the topics of cost of travel, accommodation, treatment (drugs, diagnosis) and documented on a sick newborn case record form.

Results

Data were collected from 814 caregivers. Cost of caregivers’ stay accounted for more than 40% of the OOPE for sick newborn care, followed by cost of travel, and the baby’s stay and treatment. The overall OOPE ranged from 13.6 to 226.1 US dollars (USD). The median OOPE was highest for preterm complications ($33.2 USD; CI 14.0–226.1), followed by hyperbilirubinemia ($31.9 USD; CI 14.0–60.7), respiratory distress syndrome ($26.9 USD; 15.3–121.5), neonatal sepsis ($ 25.8 USD; CI 13.6–139.8) and hypoxic ischemic encephalopathy ($23.4 USD; CI 13.6–97.7).

Discussion for practice

In Nepal, OOPE for sick newborn care in hospitals varied by neonatal morbidity and duration of stay. The largest proportion of OOPE were for accommodation and travel. Affordable and accessible health care will substantially reduce the OOPE for sick newborn care in hospitals.

     

Effect of indoor air pollution from biomass combustion on prevalence of asthma in the elderly

In this study I examined the effect of cooking smoke on the reported prevalence of asthma among elderly men and women greater than or equal to 60 years old). The analysis is based on 38,595 elderly persons included in India's second National Family Health Survey conducted in 1998-1999. Effects of exposure to cooking smoke, ascertained by type of fuel used for cooking (biomass fuels, cleaner fuels, or a mix of biomass and cleaner fuels), on the reported prevalence of asthma were estimated using logistic regression. Because the effects of cooking smoke are likely to be confounded with effects of age, tobacco smoking, education, living standard, and other such factors, the analysis was carried out after statistically controlling for such factors. Results indicate that elderly men and women living in households using biomass fuels have a significantly higher prevalence of asthma than do those living in households using cleaner fuels [odds ratio (OR) = 1.59; 95% confidence interval (95% CI), 1.30-1.94], even after controlling for the effects of a number of potentially confounding factors. Active tobacco smoking was also associated with higher asthma prevalence in the elderly, but not environmental tobacco smoke. Availability of a separate kitchen in the house and a higher living standard of the household were associated with lower asthma prevalence. The adjusted effect of cooking smoke on asthma was greater among women (OR = 1.83; 95% CI, 1.32-2.53) than among men (OR = 1.46; 95% CI, 1.14-1.88). The findings have important program and policy implications for countries such as India, where large proportions of the population rely on polluting biomass fuels for cooking and space heating. More epidemiologic research with better measures of smoke exposure and clinical measures of asthma is needed to validate the findings.     

Variations in perinatal mortality associated with different polluting fuel types and kitchen location in Bangladesh

This study examines the association between household air pollution from use of polluting cooking fuels and perinatal mortality in Bangladesh. We analysed the data from the Bangladesh Demographic and Health Surveys (BDHS) 2004, 2007, 2011, and 2014. The two outcome variables were stillbirth and early neonatal mortality. The exposure variable was type of primary cooking fuel used in the household (clean vs. polluting). Bivariate and multivariable analyses were conducted to obtain the crude and adjusted odds ratio (aOR), respectively. In the adjusted model, the exposure to polluting fuels was associated with early neonatal mortality (aOR: 1.46, 95% confidence interval [CI]: 1.01–2.10), but not with stillbirth (aOR: 1.25, 95% CI: 0.85–1.84). The effect of cooking with agricultural crop waste was greater for stillbirth (aOR: 1.76, 95% CI: 1.10–2.80) and for early neonatal mortality (aOR: 1.78, 95% CI: 1.13–2.80) which was also associated with wood as the main fuel (aOR: 1.52, 95% CI: 1.04–2.21). Using polluting fuels in an indoor kitchen was associated with an increased odds of stillbirth (aOR: 4.12, 95% CI: 1.49–11.41). Cooking with polluting fuels is associated with perinatal mortality. The combined association of polluting cooking fuels and indoor kitchen location was greater for stillbirth. This effect and the effect of different fuel types need further investigation. Although this is a large sample, there are some limitations with the BDHS data in both recording the exposure and the outcomes. A large prospective trial is needed to determine the precise effect size.