<p>Traditional cooking using biomass is associated with adverse health consequences, local environmental degradation, and regional climate change. Improved stoves (ICS; liquefied petroleum gas (LPG), biogas, electric, efficient biomass) are heralded as a solution, but their adoption and use remains low. In the first chapter, I report on a series of pilot programs that utilized the marketing mix principles of promotion, product, price and place to increase stove sales in rural Inia. We found that when given a choice amongst products, households strongly preferred an electric stove over improved biomass-burning options. Households clearly identified price as a significant barrier to adoption, while provision of discounts (e.g., rebates given if households used the stove) or payments in installments were related to higher purchase. Collectively, these pilots point to the importance of continued and extensive testing of messages, pricing models, and responses to different stove types prior to scale-up. Thus, a one-size-fits-all approach will be unlikely to boost ICS adoption. </p><p>In the second and third chapters, I analyze the impact of mainly improved stove use on social, environmental, and health outcomes in rural India- first in a sample of biogas stove users in Odisha, India, and next with households in the Himalayan state of Uttarakhand. In both settings, ICS use was associated with reduced use of firewood, substantial time savings for primary cooks, and significant reduction in exposure to particulate matter and polycyclic aromatic hydrocarbons in household air. I find that ICS users in Odisha spend reduced time in the hospital with acute respiratory infection and reduced diastolic blood pressure, but no relationship with other health measurements. </p><p>In the third chapter, I also find significant reduction in exposure to personal air pollution. Using temperature sensors as objective stove use monitors for all stoves and heaters we find that households underreport use of improved and traditional stoves. </p><p>These papers provide encouraging evidence of potential for adoption of clean stove and a suite of benefits from clean stove use; however, in order to achieve recommended levels of air pollution additional policies may be needed.</p> / Dissertation

Current methods for the risk assessment of environmental exposures commonly involve questionnaires, stationary monitoring, and personal air sampling. However, as these approaches do not capture the body's internal response, they lend minimal understanding to the biologic consequence of exposure. In order to address the unmet need of connecting external exposure measurements with signatures of internal exposure, this thesis examines the overarching hypothesis that transcriptomic changes in the human airway epithelium can serve as indicators of physiologic responses to inhaled pollutants. This is an extension of previous work that has demonstrated an airway ''field of injury'' effect where cigarette smoke exposure alters gene-expression in epithelial cells lining the respiratory tract. Specifically, I examine transcriptomic changes and the biologic responses associated with exposure to the following pollutants: environmental tobacco smoke (Aim 1), household air pollution from smoky coal combustion (Aim 2), and electronic cigarette vapor (Aim 3). First, I performed whole-genome transcriptional profiling of the nasal epithelium in children and adults and detected gene-expression changes associated with exposure to environmental tobacco smoke. Next, I employed similar approaches to detect a signature of coal smoke exposure in the buccal epithelium of healthy, non-smoking females exposed to household air pollution Xuanwei, China. The findings from these studies suggest that upper airway gene-expression can reflect the host response to prolific sources of environmental exposures that are major risk factors for chronic lung disease. Lastly, I examine the cellular and physiologic consequences of electronic cigarette (ECIG) aerosol exposure by analyzing transcriptomic profiles of human bronchial epithelial cells that have either been (1) differentiated and exposed in vitro or (2) acquired via bronchoscopy from the airway epithelium of ECIG users. The studies detailed in this dissertation offer valuable insight that will accelerate the efforts to evaluate the health effects of both well-established and emerging types of inhaled exposures in large-scale population studies. Furthermore, the transcriptomic strategies woven throughout the following chapters push for a novel assessment paradigm that may enable the public health community to rapidly characterize the physiologic host response to inhalation exposures of different sources, and to evaluate the biologic consequences of exposure-reduction initiatives. / 2017-05-01T00:00:00Z

Introduction and Rationale: Household Air Pollution (HAP) refers to the pollution of air in the indoor environment, from the combustion of solid fuels such as biomass and coal. The World Health Organization (WHO) estimates that 2.6 billion people today are exposed to HAP daily. Women and children tend to be at a higher risk of exposure due to their increased time spent indoors. This can result in a range of adverse cardio-respiratory outcomes such as asthma, Acute Lower Respiratory Infection (ALRI) and Chronic Obstructive Pulmonary Disease (COPD). This thesis document investigates the association between HAP and the adverse respiratory outcomes, namely lung function, ALRI and asthma in children. Methodology: Systematic Reviews were conducted to synthesize the effect of HAP on lung function, ALRI, and asthma. The lung function outcome was synthesized in a narrative manner, while the pooled estimates for the ALRI and asthma outcomes were synthesized by meta-analysis. Results: Exposure to HAP is associated with decreased lung function growth, and an increased risk of the incidence of ALRI in children. No association was noted between HAP exposure and the incidence of asthma in children. Conclusion: The effect of HAP on childhood growth of lung function and the incidence of ALRI provides evidence justifying the universal transition to cleaner fuels and technologies, such as electricity and natural gas. / Thesis / Master of Science (MSc) / Household Air Pollution (HAP) refers to the pollution of indoor air caused by the combustion of solid fuels, such as biomass, for the purposes of heating and cooking. According to the World Health Organization (WHO), 2.6 billion people are exposed to HAP daily. Women and children are especially at high risk of exposure, due to the time spent indoors. This places them at a higher risk of adverse respiratory outcomes, such as Acute Lower Respiratory Tract Infection (ALRI), asthma, Chronic Obstructive Pulmonary Disease (COPD) and reduced lung function. This thesis document investigates the association between HAP and the adverse respiratory outcomes, namely lung function, ALRI and asthma in children. It was found that HAP is associated with a decrease in childhood lung function growth, and an increased risk of the incidence of ALRI. However, there was no clear association between the incidence of asthma and HAP. The results of the systematic reviews justify a transition from the use of solid fuels to clean fuels and technologies.

Household air pollution contributes to the premature death of more than 4 million people annually. Improved cookstoves are one technological intervention that can potentially reduce exposure to household air pollution. However, improved cookstove implementation programs need to consider measures to increase sustainability and promote long-term adoption. The objectives of this research were 1) to develop and implement a new ferrocement cookstove for Peña Blanca, a rural indigenous community in the Ngäbe-Bugle region of Panama, 2) to evaluate its potential sustainability in comparison to the most common cooking technologies observed in the community, 3) to prepare a construction manual for the stove to promote future development, and 4) to provide guidelines for applying a holistic approach to improved cookstove projects. A bottom-up, community-driven approach to development focused on integration and capacity building was used to design and implement a ferrocement improved cookstove. A survey was administered to 26 households to understand the familial and environmental health of the community as well as knowledge, opinions, and needs related to cooking practices and improved stoves. Finally, the ferrocement stove developed for this study, along with the three stone fire, the ecojusta stove model, and a gas stove were evaluated both quantitatively and qualitatively using a sustainability assessment framework developed specifically for improved cookstoves. The results of this study suggest that design and implementation of an improved cookstove in the field that incorporates community feedback and provides educational opportunities may produce solutions that are more likely to be sustainable and meet users’ needs. The process allows for design flexibility to reduce smoke and fuel use while incorporating community preferences such as simplicity and ease of use, ability to control heat, stove features and size. Results from conducting household surveys emphasize the importance of a community-based development process that focuses on meeting community-specific challenges and needs. Conditions such as extreme poverty and lack of support structures pose significant challenges and shape community opinions regarding cooking technology and practices. In fact, the community’s desires in this study differ greatly from that found in the established literature. Specifically, 84% of rural Panamanians from this study felt that reducing smoke indoors was important to them. Sustainability evaluations of improved cookstove implementation programs in Panama highlighted common strengths in the needs assessment and implementation project life stages. These programs excelled at involving the community in identifying project needs and participating in the construction of stoves. On the other hand, the post-implementation and follow-up life stages were assessed to be weaker as these programs generally do not perform evaluation and monitoring of stove use and adoption after the implementation stage or continue user education. Additional qualitative analysis from this study suggest that the traditional stove may be the most sustainable and appropriate stove technology at this time for the community if combined with improving education related to family health, the environment, and stove use that results in behavior change. This approach may have the potential to fulfill the goals of improved cookstove programs globally through education and behavior change as an alternative approach to implementing an inappropriate technology. Moreover, an improved stove that is developed in the community that uses local materials and provides educational opportunities that focus on caring for resources and improving stove operator skill is more likely to be sustainable than other options. General guidelines and lessons learned for applying a holistic approach to improved cookstove development in the field include enhancing community understanding through involvement of local leaders, empowering the community in the decision-making process, providing educational opportunities or facilitating the implementation of a technology that is affordable, effective, and that meets users’ diverse needs, or both. As well as evaluating sustainability likelihood by utilizing comprehensive tools such as surveys, stove testing, program assessment frameworks, life cycle assessments, and incorporating results from post-project monitoring and evaluation iteratively until needs are met and exposure to household air pollution and deforestation rates are reduced. The implications of this work are that 1) technology implementation may not be the best solution, similar investments made in education and behavior change may result in equal or greater sustainability early on, 2) the design and implementation of an improved cookstove in the field with high standards for technical design, that reduce emissions, and with flexibility for elements that do not affect performance can result in meeting users’ needs better with higher adoption rates, and 3) a more holistic approach to development using available tools is suspected to result in improved cookstove programs that improve human and environmental health while meeting users’ needs for the long-term.

Background Birth defects are a significant cause of neonatal mortality and morbidity globally. Environmental and genetic factors may be the risk factors for birth defects. Thus, this study aims to evaluate the association between the type of household cooking fuel and birth defects in Nepal, as well as investigate whether air ventilation usage had a modifying effect on the possible association. Methods This cross-sectional study used secondary data from Nepal Perinatal Quality Improvement Projectfrom 2017 to 2018. The study sample was 66,713 women with a newborn, whose information was available in hospital records and exit interviews. The association between cooking fuel type usage and birth defects was investigated with adjusted multivariable logistic regression. To investigate the air ventilation usage, a stratified multivariable logistic regression analysis was performed. Results This study found a significant association between cooking fuel type usage and birth defects. Mothers using polluted fuels had higher odds (aOR 1.48 [95% CI 1.15-1.90]) of having a child with a birth defect compared to mothers using clean fuels. Women not using air ventilation while cooking had even higher odds of having a child with birth defects (aOR 1.56 [95% CI 1.20-2.03]), whereas the association was not significant among women using air ventilation. Conclusion The usage of polluted cooking fuels is an important factor related to birth defects. Air ventilation in turn may be important in decreasing its effects. Hence, future studies and interventions are needed to reduce neonatal mortality and life-long morbidity.

Child mortality in sub-Saharan Africa is reducing but the levels remain high with subnational within-country variations. Birth weight is a key predictor of child survival and monitoring birth weight outcomes, in particular, prevalence of low birth weights, is important for resource allocation to improve child survival outcomes. Past research in sub-Saharan Africa has found that different individual-level factors are associated with birth weight including BMI of mother, sex of baby, educational level of mother, and wealth index of household. Some environmental factors are found to be associated with birth outcomes. However, past findings regarding the association of birth weight with household air pollution (HAP) resulting from cooking fuels are non-conclusive. In this study, we analyze variability in birth weights subnationally for Ghana and assess its association with household air pollution resulting from cooking fuels, accounting for variation due to other factors including maternal and household predictors, as well as geographical location. The analysis was based on birth weights for 1310 births, obtained from data collected in 2014 in the Demographic and Health Survey (DHS). We use Bayesian spatial regression models to estimate associations and capture spatial variation. Spatial variation was captured with a conditional autoregressive (CAR) model. Based on various models, we do not find evidence to suggest that cooking fuel is associated with birth weight. After accounting for covariates, the average birth weights per district ranged from 2823g (95% CI: 2613g, 3171g) in Ketu district to 3243g (95% CI: 3083g, 3358g) in Ashanti Akim North district. Across Ghana, difference in birth weight attributable to district spatial effects range from -33g in Lawra district in Upper West region of Ghana to 11g in Ho in the Volta region.

Cooking stove technologies are crucial for meeting household energy needs, yet many lack access to clean solutions, leading to Household Air Pollution (HAP) and associated health risks. There is an urgent need to understand and mitigate environmental and health challenges posed by traditional stoves burning solid fuels like fuelwood. This thesis examines the environmental and human health impacts of different cooking fuel options using a Life Cycle Assessment (LCA) approach. A case study is developed in the state of Tamil Nadu in India, considering different cooking fuel mix scenarios and sustainable transition in the sector. Key impact categories such as Global Warming Potential (GWP), Fine Particulate Matter Formation, and Human Health are examined. Findings reveal persistent challenges, particularly with solid fuels like firewood, contributing to HAP and adverse health effects. Transitioning to renewable energy sources such as Biogas and Electricity is crucial for mitigating environmental impacts and improving public health outcomes. Eliminating firewood in the Sustainable scenario fuel mix could result in a 43% reduction in GWP, an 87.5% reduction in delicate particulate matter, and a 75% improvement in human health. This study provides insights for policymakers to develop interventions promoting sustainable cooking practices and enhancing community well-being in Tamil Nadu and beyond. / Köksspis-teknologier är avgörande för att tillgodose hushållens matbehov, men miljontals saknar tillgång till rena matlagningslösningar, vilket leder till hushållsluftföroreningar (HAP) och associerade hälsorisker. Det finns ett brådskande behov av att förstå och mildra miljö- och hälsoutmaningar som traditionella spisar, som använder fasta bränslen såsom ved, innebär. Denna avhandling undersöker miljö- och hälsoeffekterna av olika alternativ för matlagningsbränsle med en livscykelanalys (LCA)-ansats. En fallstudie har utvecklats i delstaten Tamil Nadu i Indien, där olika scenarier för blandning av matlagningsbränslen och en hållbar övergång inom sektorn övervägs. Viktiga faktorer som global uppvärmningspotential (GWP), bildning av fint partikulärt material och människors hälsa undersöks noggrant. Resultaten avslöjar ihållande utmaningar, särskilt med fasta bränslen som ved, som bidrar till HAP och negativa hälsoeffekter. Övergången till förnybara energikällor som biogas och elektricitet är avgörande för att mildra miljöpåverkan och förbättra folkhälsan. Att eliminera ved i bränslemixen i det hållbara scenariet kan leda till en 43 % minskning av GWP, en 87,5 % minskning av fintpartikulärt material, och en 75 % förbättring i mänsklig hälsa. Genom att utnyttja insikterna från denna studie kan beslutsfattare och intressenter utveckla riktade insatser för att främja hållbara matlagningspraxis och förbättra välbefinnandet för samhällen i Tamil Nadu och vidare.