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National Institute of Environmental Health Sciences

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Implementation Science to Scale-Up Clean Cooking and Improve Health

By Megan Avakian

Exposure to household air pollution (HAP) produced by open fires or traditional biomass cookstoves causes three to four million premature deaths each year, mostly among women and children living in low- and middle-income countries. HAP exposures also impact rural communities in the U.S. where woodstoves may be used for residential heating. Developing clean technologies that reduce HAP exposures enough to improve health is just the first step in tackling this global health problem. The second step is achieving successful adoption and continued use of new technologies. To better understand the factors that contribute to sustainable uptake of cookstove interventions, the Clean Cooking Implementation Science Network (ISN) is bringing implementation science to the household energy research community.

Implementation science is a research discipline that attempts to understand and predict the variables that lead to the success or failure of a medical or public health intervention. Fuel cost and availability, environmental conditions, and cooking behaviors are just a few of the factors that can affect whether a clean cooking intervention will be successful, according to Josh Rosenthal, Ph.D., a senior scientist in the Division of Epidemiology and Population Studies at Fogarty International Center who coordinates the ISN working group.

Karnataka stove prep

A woman uses her new stove, powered by the cleaner burning liquefied petroleum gas (LPG) in Karnataka, India. Understanding both the uptake of clean fuels and the degree to which they displace more polluting open fires are key objectives of the ISN.
(Photo courtesy of Josh Rosenthal)

“As cookstove researchers work to improve stove technologies, the ISN has a parallel effort to build a knowledge base that will advance our understanding of how to implement cleaner fuels and technologies to achieve health benefits on a population scale,” said Rosenthal. A recent article from the ISN serves as a starting point to build this knowledge base by introducing the clean cooking community to the implementation science approach and some of the frameworks that can be used to plan, execute, and evaluate intervention programs in the field.

The ISN is also providing advice to researchers in the Household Air Pollution (HAP) Health Outcomes Trial, a large-scale, multi-country clean cooking trial funded by several components of the NIH, including the NIEHS, and the Bill and Melinda Gates Foundation. “The ISN members have expertise in anthropology, economics, epidemiology, energy, and policy and can advise HAP Trial researchers on issues such as program design, behavior change, fuel provision, and related issues,” explained Rosenthal. “Likewise, the ISN learns from what researchers are observing in the field.”

Karnataka interview

A researcher (left) interviews a community member in Karnataka, India as part of a long term epidemiological study to understand diet and cooking patterns in relation to household air pollution and various health endpoints. Such background information is crucial to understand local context in any implementation research project.
(Photo courtesy of Josh Rosenthal)

To further advance implementation science to improve sustained use and scale-up of clean cooking technology, the ISN is developing four research projects (one each in Ghana and Cameroon and two in India) to understand economic incentives and the dynamics of household decisions. The ISN is also launching a series of 10-12 case studies on clean fuel programs around the world. While results from each case study will be context-specific, collectively they are expected to provide insight into generalizable factors that contribute to the success or failure of an intervention, including those related to the technology, setting, perceptions, finances, markets, regulations, and programmatic features.

One way the case studies will accomplish this is by monitoring and documenting the process of program implementation. According to Rosenthal, cookstove intervention trials have historically focused on basic and easily assessed outputs, such as the number of households receiving clean fuels or stoves. An implementation research analysis of a program during or after its roll out helps the research community understand why an intervention did not work or had unexpected results, and when it does work, why it did and how it might be optimized.

“Potentially important medical and public health interventions, such as vaccines, cleaner burning stoves, bed nets, and water filtration devices regularly fail to make an impact in the real world for a wide variety of reasons. Understanding these dynamics is an important part of the research process,” explained Rosenthal. “The lessons we aim to generate from the ISN will provide guidance to both the research and implementation communities to ensure that basic and clinical research has the best shot at making a real difference to public health.”

A Collaborative Effort

The Clean Cooking Implementation Science Network (ISN) is a partnership between the Fogarty International Center (FIC), NIEHS, other NIH institutes, as well as the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), Environmental Protection Agency (EPA), and the Global Alliance for Clean Cookstoves (GACC). The ISN is hosted by the Center for Global Health Studies (CGHS) at Fogarty, and supported by the NIH Common Fund.