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Air pollution is a critical global public health and environmental concern, leading to over 6.7 million premature deaths annually, disproportionately affecting low- and middle-income countries (LMICs), where the use of polluting fuels for cooking remains widespread. Incorporating perceptions of air pollution is argued as vital for developing effective intervention strategies. However, this has seldom been given focus in the development of clean cooking interventions. The use of firewood in Kenyan schools is commonplace and the transition to clean cooking methods in school settings is gaining international attention. We investigated how air pollution is perceived and understood by staff in three schools from an informal settlement in Nairobi, Kenya which predominately use firewood or charcoal for school catering. We conducted focus group discussions and in-depth interviews and used thematic analysis to explore perceptions of air pollution in the schools and how these differed between different staff groups. Perceptions of air pollution were dominated by external environmental factors from the surrounding informal settlement. While the impacts of air pollution from firewood on catering staff and teaching activities were recognised, understandings of the long-term health impacts were often blurred and dislocated from the school setting. Responsibilities for addressing air pollution were said to be with external stakeholders, but the school staff cited a lack of government interventions to address underlying poverty and multiple pollution sources. Effective strategies to tackle air pollution must involve careful engagement with stakeholders and community members to incorporate local perceptions of air pollution and address broader systemic issues that increase exposure. Clean cooking interventions focused solely on reducing air pollution may face challenges due to competing financial demands and a tendency to shift responsibilities for tackling such an issue. Broader benefits, such as economic and environmental improvements, might be more compelling drivers for successful implementation., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Exposure to household air pollution from polluting domestic fuel (solid fuel and kerosene) represents a substantial global public health burden and there is an urgent need for rapid transition to clean domestic fuels. Gas for cooking and heating might possibly affect child asthma, wheezing, and respiratory health. The aim of this review was to synthesise the evidence on the health effects of gaseous fuels to inform policies for scalable clean household energy., Methods: In this systematic review and meta-analysis, we summarised the health effects from cooking or heating with gas compared with polluting fuels (eg, wood or charcoal) and clean energy (eg, electricity and solar energy). We searched PubMed, Scopus, Web of Science, MEDLINE, Cochrane Library (CENTRAL), Environment Complete, GreenFile, Google Scholar, Wanfang DATA, and CNKI for articles published between Dec 16, 2020, and Feb 6, 2021. Studies eligible for inclusion had to compare gas for cooking or heating with polluting fuels (eg, wood or charcoal) or clean energy (eg, electricity or solar energy) and present data for health outcomes in general populations. Studies that reported health outcomes that were exacerbations of existing underlying conditions were excluded. Several of our reviewers were involved in screening studies, data extraction, and quality assessment (including risk of bias) of included studies; 20% of studies were independently screened, extracted and quality assessed by another reviewer. Disagreements were reconciled through discussion with the wider review team. Included studies were appraised for quality using the Liverpool Quality Assessment Tools. Key health outcomes were grouped for meta-analysis and analysed using Cochrane's RevMan software. Primary outcomes were health effects (eg, acute lower respiratory infections) and secondary outcomes were health symptoms (eg, respiratory symptoms such as wheeze, cough, or breathlessness). This study is registered with PROSPERO, CRD42021227092., Findings: 116 studies were included in the meta-analysis (two [2%] randomised controlled trials, 13 [11%] case-control studies, 23 [20%] cohort studies, and 78 [67%] cross-sectional studies), contributing 215 effect estimates for five grouped health outcomes. Compared with polluting fuels, use of gas significantly lowered the risk of pneumonia (OR 0·54, 95% CI 0·38-0·77; p=0·00080), wheeze (OR 0·42, 0·30-0·59; p<0·0001), cough (OR 0·44, 0·32-0·62; p<0·0001), breathlessness (OR 0·40, 0·21-0·76; p=0·0052), chronic obstructive pulmonary disease (OR 0·37, 0·23-0·60; p<0·0001), bronchitis (OR 0·60, 0·43-0·82; p=0·0015), pulmonary function deficit (OR 0·27, 0·17-0·44; p<0·0001), severe respiratory illness or death (OR 0·27, 0·11-0·63; p=0·0024), preterm birth (OR 0·66, 0·45-0·97; p=0·033), and low birth weight (OR 0·70, 0·53-0·93; p=0·015). Non-statistically significant effects were observed for asthma in children (OR 1·04, 0·70-1·55; p=0·84), asthma in adults (OR 0·65, 0·43-1·00; p=0·052), and small for gestational age (OR 1·04, 0·89-1·21; p=0·62). Compared with electricity, use of gas significantly increased risk of pneumonia (OR 1·26, 1·03-1·53; p=0·025) and chronic obstructive pulmonary disease (OR 1·15, 1·06-1·25; p=0·0011), although smaller non-significant effects were observed for higher-quality studies. In addition, a small increased risk of asthma in children was not significant (OR 1·09, 0·99-1·19; p=0·071) and no significant associations were found for adult asthma, wheeze, cough, and breathlessness (p>0·05). A significant decreased risk of bronchitis was observed (OR 0·87, 0·81-0·93; p<0·0001)., Interpretation: Switching from polluting fuels to gaseous household fuels could lower health risk and associated morbidity and mortality in resource-poor countries where reliance on polluting fuels is greatest. Although gas fuel use was associated with a slightly higher risk for some health outcomes compared with electricity, gas is an important transitional option for health in countries where access to reliable electricity supply for cooking or heating is not feasible in the near term., Funding: WHO., Competing Interests: Declaration of interests We declare no competing interests., (Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Background: Access to, and sustained adoption of, clean household fuels at scale remains an aspirational goal to achieve sufficient reductions in household air pollution (HAP) in order to impact on the substantial global health burden caused by reliance on solid fuels., Aim and Objectives: To systematically appraise the current evidence base to identify: (i) which factors enable or limit adoption and sustained use of clean fuels (namely liquefied petroleum gas (LPG), biogas, solar cooking and alcohol fuels) in low- and middle-income countries; (ii) lessons learnt concerning equitable scaling-up of programmes of cleaner cooking fuels in relation to poverty, urban-rural settings and gender., Methods: A mixed-methods systematic review was conducted using established review methodology and extensive searches of published and grey literature sources. Data extraction and quality appraisal of quantitative, qualitative and case studies meeting inclusion criteria were conducted using standardised methods with reliability checking., Findings: Forty-four studies from Africa, Asia and Latin America met the inclusion criteria (17 on biogas, 12 on LPG, 9 on solar, 6 on alcohol fuels). A broad range of inter-related enabling and limiting factors were identified for all four types of intervention, operating across seven pre-specified domains (i.e. fuel and technology characteristics, household and setting characteristics, knowledge and perceptions, financial, tax and subsidy aspects, market development, regulation, legislation and standards, and programme and policy mechanisms) and multiple levels (i.e. household, community, national). All domains matter and the majority of factors are common to all clean fuels interventions reviewed although some are fuel and technology-specific. All factors should therefore be taken into account and carefully assessed during planning and implementation of any small- and large-scale initiative aiming at promoting clean fuels for household cooking., Conclusions: Despite limitations in quantity and quality of the evidence this systematic review provides a useful starting point for the design, delivery and evaluation of programmes to ensure more effective adoption and use of LPG, biogas, alcohol fuels and solar cooking., Funding: This review was funded by the Department for International Development (DfID) of the United Kingdom. The authors would also like to thank the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) for their technical support., (Copyright © 2016 Elsevier Inc. All rights reserved.)