National Institute of Environmental Health Sciences

By Megan Avakian

Exposure to household air pollution (HAP) produced by open fires or traditional biomass cookstoves causes over four million premature deaths each year, mostly among women and children living in low- and middle-income countries (LMICs). Even though stoves and fuels that can reduce HAP are available, people have been slow to adopt these cleaner burning options. To better understand the factors influencing clean stove adoption, Kendra Williams, a doctoral candidate at Johns Hopkins University and a Fogarty International Center (FIC) Global Health Fellow, is working with women enrolled in the Cardiopulmonary Outcomes and Household Air Pollution (CHAP) clean cooking intervention trial in Puno, Peru.

Through her Fogarty Fellowship (see text box), supported in part by NIEHS, Williams is spending one year on the ground in Peru working with a team of research mentors to identify the barriers and motivators for women to use a clean liquified petroleum gas (LPG) stove instead of a traditional biomass stove.

“Just because women receive a clean stove doesn’t mean they are going to use it. Fuel cost and availability, local cooking customs, and taste preferences are just a few of the factors that can affect stove choice among women in rural Peru,” said Williams.

Williams’ team of mentors are part of the UJMT Global Consortium, which is made up of four U.S. universities and Asociación Benéfica PRISMA, a partner non-profit organization in Peru. Although only a few months into her one-year research training in Peru, Williams says she’s already seeing how the Fogarty Fellowship program will enhance her global health research career. “The fact that Fogarty and NIH link trainees with LMIC research institutions is extremely beneficial. I’ve learned so much from the study team in Peru about how to collaborate with local communities, and how to adapt different research strategies to the context.”

Her research is based within the larger CHAP study led by William Checkley, M.D., of the Center for Global Non-Communicable Diseases at Johns Hopkins University. CHAP is enrolling 180 non-pregnant women living in Puno. Half of the women will receive a free LPG stove and free fuel for one year, while the remaining women will continue to cook on a traditional stove. At the end of the first year, women in the intervention group will keep the stove but stop receiving free gas, while women in the control group will receive the stove and a year’s supply of free gas. The study design will allow the researchers to compare health and air quality outcomes between gas and traditional stove users, as well as whether gas use is sustained once women stop receiving free gas.

To monitor stove use, the research team is using temperature sensors attached to both LPG and traditional stoves. A spike in temperature indicates the stove was used. The women will also answer survey questions about their cooking practices, such as the number of hours spent cooking and which stove they used. Comparing the temperature and survey data will allow Williams to evaluate how accurate self-report surveys are as a tool for monitoring stove use.

The research team will also conduct qualitative interviews with households classified as exclusive and non-exclusive users of LPG to identify factors that may drive the decision to use or not use the LPG stove.

Even though the research team is still collecting data, Williams says she’s surprised that so far nearly all participants are exclusively using the LPG stove. The practice of stove stacking, where households use a clean stove but also continue to cook on a traditional stove, is common in rural populations around the world, says Williams.

“The fact that so far we are seeing very little stove stacking in our study is shocking and suggests that fuel cost and availability may be the major barriers to exclusive use of gas stoves in Puno,” said Williams. Research has shown that near exclusive use of clean stoves is needed to reduce HAP to levels that will benefit health.

Though the Peruvian government provides vouchers to reduce the cost of gas, Williams says the remaining investment is still out of reach for many families. Additionally, the voucher program subsidizes the cost of only one LPG tank per month, but Williams is finding that when families use the LPG stove exclusively, they use two tanks per month on average. Williams hopes the government program can support some of the women to continue using the LPG stoves after the project ends. “If we can overcome the financial barrier then we may be able to achieve near exclusive use of gas in Puno, and achieve the many health benefits that may come from that.”