Pay-as-you-go liquefied petroleum gas supports sustainable clean cooking in Kenyan informal urban settlement during COVID-19 lockdown.

Approximately 2.8 billion people rely on polluting fuels (e.g. wood, kerosene) for cooking. With affordability being a key access barrier to clean cooking fuels, such as liquefied petroleum gas (LPG), pay-as-you-go (PAYG) LPG smart meter technology may help resource-poor households adopt LPG by allowing incremental fuel payments. To understand the potential for PAYG LPG to facilitate clean cooking, objective evaluations of customers' cooking and spending patterns are needed. This study uses novel smart meter data collected between January 2018-June 2020, spanning COVID-19 lockdown, from 426 PAYG LPG customers living in an informal settlement in Nairobi, Kenya to evaluate stove usage (e.g. cooking events/day, cooking event length). Seven semi-structured interviews were conducted in August 2020 to provide context for potential changes in cooking behaviours during lockdown. Using stove monitoring data, objective comparisons of cooking patterns are made with households using purchased 6 kg cylinder LPG in peri-urban Eldoret, Kenya. In Nairobi, 95% of study households continued using PAYG LPG during COVID-19 lockdown, with consumption increasing from 0.97 to 1.22 kg/capita/month. Daily cooking event frequency also increased by 60% (1.07 to 1.72 events/day). In contrast, average days/month using LPG declined by 75% during lockdown (17 to four days) among seven households purchasing 6 kg cylinder LPG in Eldoret. Interviewed customers reported benefits of PAYG LPG beyond fuel affordability, including safety, time savings and cylinder delivery. In the first study assessing PAYG LPG cooking patterns, LPG use was sustained despite a COVID-19 lockdown, illustrating how PAYG smart meter technology may help foster clean cooking access.

Evaluating Housing Health Hazards: Prevalence, Practices and Priorities in Delhi's Informal Settlements.

Housing quality is crucially linked to health and sustainability goals, yet there is limited research on informal housing and settlements where housing quality is poor, and the health risks are expected to be greatest. This paper describes the investigation of housing conditions in a low-income resettlement colony in Delhi. A novel transdisciplinary methodology to evaluate multiple housing health hazards and establish intervention priorities in participation with the community was developed. Findings from housing surveys and indoor environmental monitoring were contrasted with a participatory self-assessment-revealing the widespread prevalence of hazards and suboptimal housing conditions as well as substantial differences in priorities, and thus perspectives, between participants and researchers. Focus group discussions explored the findings and built consensus on priorities. Our findings uncovered how poor housing conditions affect daily practices and thus are likely to adversely affect socio-economic development and gender equality. We highlight limitations in current frameworks to assess housing hazards and argue that a transdisciplinary approach is vital to provide a holistic understanding and to develop effective interventions. These insights are crucial to inform inclusive solutions for adequate housing and human settlements that can support improved health and help achieve the sustainable development goals.

Getting to effective housing policy for health: a thematic synthesis of policy development and implementation.

Impacts of housing on health are well-recognised. Despite this, housing standards have been neglected and there are gaps in healthy housing policies, particularly in low and middle-income countries. Given the recent publication of the WHO Housing and health guidelines, and the need to implement these into policy at all scales, we carried out a focused search and thematic synthesis of available literature on the barriers and enablers to recent housing and health policy. We aimed to generate lessons of what works to support healthy housing policy development and implementation elsewhere. Twenty-three studies representing four countries were eligible for inclusion and covered housing-related risks of air quality, lead, accessible design, and housing conditions. Findings demonstrated that policy development and implementation were facilitated through awareness of housing and health, evidence of existing housing conditions and health impacts, collaborations across sectors and between residents and decision-makers and effective enforcement systems that employed incentives, tools such as certificates for compliance, and housing inspections. Concerns about economic viability and tensions between housing rights and responsibilities limited healthy housing policy for the 'common good'. Despite limitations in the diversity of available evidence, this thematic synthesis provides a starting point for healthy and equitable housing for all.

Estimated health effects from domestic use of gaseous fuels for cooking and heating in high-income, middle-income, and low-income countries: a systematic review and meta-analyses.

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.

Burden of headaches, eye irritation and respiratory symptoms among females stacking LPG with polluting cooking fuels: Modelling from peri-urban Cameroon, Ghana & Kenya.

Introduction: Liquefied petroleum gas (LPG) is a clean cooking fuel that emits less household air pollution (HAP) than polluting cooking fuels (e.g. charcoal, wood). While switching from polluting fuels to LPG can reduce HAP and improve health, the impact of 'stacking' (concurrent use of polluting fuels and LPG) on adverse health symptoms (e.g. headaches, eye irritation, cough) among female cooks is uncertain. Methods: Survey data from the CLEAN-Air(Africa) study was collected on cooking patterns and health symptoms over the last 12 months (cough, wheezing, chest tightness, shortness of breath, eye irritation, headaches) from approximately 400 female primary cooks in each of three peri­urban communities in sub-Saharan Africa: Mbalmayo, Cameroon; Obuasi, Ghana; and Eldoret, Kenya. Random effects Poisson regression, adjusted for socioeconomic and health-related covariates, assessed the relationship between primary and secondary cooking fuel type and self-reported health symptoms. Results: Among 1,147 participants, 10 % (n = 118) exclusively cooked with LPG, 45 % (n = 509) stacked LPG and polluting fuels and 45 % (n = 520) exclusively cooked with polluting fuels. Female cooks stacking LPG and polluting fuels had significantly higher odds of shortness of breath (OR 2.16, 95 %CI:1.04-4.48) compared with those exclusively using LPG. In two communities, headache prevalence was 30 % higher among women stacking LPG with polluting fuels (Mbalmayo:82 %; Eldoret:65 %) compared with those exclusively using LPG (Mbalmayo:53 %; Eldoret:33 %). Women stacking LPG and polluting fuels (OR 2.45, 95 %CI:1.29-4.67) had significantly higher odds of eye irritation than women cooking exclusively with LPG. Second-hand smoke exposure was significantly associated with higher odds of chest tightness (OR 1.92, 95 % CI:1.19-3.11), wheezing (OR 1.76, 95 % CI:1.06-2.91) and cough (OR 1.78, 95 %CI:1.13-2.80). Conclusions: In peri­urban sub-Saharan Africa, women exclusively cooking with LPG had lower odds of several health symptoms than those stacking LPG and polluting fuels. Promoting a complete transition to LPG in these communities may likely generate short-term health benefits for primary cooks.

Household concentrations and female and child exposures to air pollution in peri-urban sub-Saharan Africa: measurements from the CLEAN-Air(Africa) study.

BACKGROUND: Relatively clean cooking fuels such as liquefied petroleum gas (LPG) emit less fine particulate matter (PM2·5) and carbon monoxide (CO) than polluting fuels (eg, wood, charcoal). Yet, some clean cooking interventions have not achieved substantial exposure reductions. This study evaluates determinants of between-community variability in exposures to household air pollution (HAP) across sub-Saharan Africa. METHODS: In this measurement study, we recruited households cooking primarily with LPG or exclusively with wood or charcoal in peri-urban Cameroon, Ghana, and Kenya from previously surveyed households. In 2019-20, we conducted monitoring of 24 h PM2·5 and CO kitchen concentrations (n=256) and female cook (n=248) and child (n=124) exposures. PM2·5 measurements used gravimetric and light scattering methods. Stove use monitoring and surveys on cooking characteristics and ambient air pollution exposure (eg, walking time to main road) were also administered. FINDINGS: The mean PM2·5 kitchen concentration was five times higher among households cooking with charcoal than those using LPG in the Kenyan community (297 µg/m3, 95% CI 216-406, vs 61 µg/m3, 49-76), but only 4 µg/m3 higher in the Ghanaian community (56 µg/m3, 45-70, vs 52 µg/m3, 40-68). The mean CO kitchen concentration in charcoal-using households was double the WHO guideline (6·11 parts per million [ppm]) in the Kenyan community (15·81 ppm, 95% CI 8·71-28·72), but below the guideline in the Ghanaian setting (1·77 ppm, 1·04-2·99). In all communities, mean PM2·5 cook exposures only met the WHO interim-1 target (35 µg/m3) among LPG users staying indoors and living more than 10 min walk from a road. INTERPRETATION: Community-level variation in the relative difference in HAP exposures between LPG and polluting cooking fuel users in peri-urban sub-Saharan Africa might be attributed to differences in ambient air pollution levels. Thus, mitigation of indoor and outdoor PM2·5 sources will probably be critical for obtaining significant exposure reductions in rapidly urbanising settings of sub-Saharan Africa. FUNDING: UK National Institute for Health and Care Research.

Contrast-Induced encephalopathy following diagnostic coronary angiography.

Contrast-induced encephalopathy (CIE) is a rare, reversible complication of coronary angiography that can mimic acute strokes. This case illustrates the diagnostic challenges for a patient presenting with confusion following coronary angiography and raises awareness for CIE as diagnosis of exclusion.

COVID-19 & informal settlements: is 'Stay Home' safe?

The disproportional burden of coronavirus (COVID-19) and vulnerability to containment measures in informal settlements have been recognised; however, the role of poor housing conditions in propagating these remains neglected. Poor housing conditions makes it difficult to effectively implement social distancing measures. With increased time spent in cramped, dark and uncomfortable indoor environments, water and sanitation outside the home, and no outdoor space, higher exposure to existing health hazards and high levels of stress, with women and children being most vulnerable, are anticipated. Through this commentary paper, we reflect on these interconnections and recommend immediate measures and the long-term need for adequate housing for health and well-being.

Complex dynamics in sustaining clean cooking and food access through a pandemic: A COVID-19 impact study in peri-urban Cameroon.

Access to clean energy for cooking is central to achieving Sustainable Development Goal 7. Latest predictions suggest that this goal will not be met by 2030, with further setbacks due to the COVID-19 pandemic. We investigated the impacts of COVID-19 restrictions on household cooking fuel, practices and dietary behaviours in a peri-urban community in Central Cameroon. Using surveys (n = 333) and qualitative semi-structured interviews (n = 12), we found negative financial impacts and high levels of food insecurity, with 83 % and 56 % of households reporting reduced income and insufficient food, respectively. Households reduced food intake and cooking frequency and relied more heavily on local sources (e.g., farmland) to feed their families. Changes in primary cooking fuel were less pronounced and fuel choice was inherently linked to cooking behaviours, with some households utilising LPG more often for simple tasks, such as reheating food. Local systems were key in sustaining food and fuel access and households demonstrated resilience by employing numerous mechanisms to overcome challenges. Our findings underline the vulnerability of households in maintaining sufficient food intake and sustaining clean cooking, highlighting how policy needs to take a nuanced approach considering food-energy dynamics and strengthening local systems to ensure access to clean energy is resistant to system shocks.

Multiple aspects of energy poverty are associated with lower mental health-related quality of life: A modelling study in three peri-urban African communities.

Objective: Over 900 million people in sub-Saharan Africa (SSA) live in energy poverty, relying on cooking polluting fuels (e.g. wood, charcoal). The association between energy poverty and mental/physical health-related quality of life (HRQoL) among women in SSA, who are primarily tasked with cooking, is unknown. Methods: Females (n â€‹= â€‹1,150) from peri-urban Cameroon, Kenya and Ghana were surveyed on their household energy use and mental/physical health status using the standardized Short-Form 36 (SF-36) questionnaire. Random effects linear regression linked household energy factors to SF-36 mental (MCS) and physical component summary (PCS) scores. A binary outcome of 'likely depression' was derived based on participants' MCS score. Random effects Poisson regression with robust error variance assessed the relationship between household energy factors and odds of likely depression. Results: The prevalence of likely depression varied by a factor of four among communities (36%-Mbalmayo, Cameroon; 20%-Eldoret, Kenya; 9%-Obuasi, Ghana). In the Poisson model (coefficient of determination (R2) â€‹= â€‹0.28), females sustaining 2 or more cooking-related burns during the previous year had 2.7 (95%CI:[1.8,4.1]) times the odds of likely depression as those not burned. Females cooking primarily with charcoal and wood had 1.6 times (95%CI:[0.9,2.7]) and 1.5 times (95%CI:[0.8,3.0]) the odds of likely depression, respectively, as those primarily using liquefied petroleum gas. Women without electricity access had 1.4 (95%CI:[1.1,1.9]) times the odds of likely depression as those with access. In the MCS model (R2 â€‹= â€‹0.23), longer time spent cooking was associated with a lower average MCS score in a monotonically increasing manner. In the PCS model (R2 â€‹= â€‹0.32), women injured during cooking fuel collection had significantly lower (-4.8 95%CI:[-8.1,-1.4]) PCS scores. Conclusion: The burden of energy poverty in peri-urban communities in SSA extends beyond physical conditions. Experiencing cooking-related burns, using polluting fuels for cooking or lighting and spending more time cooking are potential risk factors for lower mental HRQoL among women.

COVID-19 impacts on household energy & food security in a Kenyan informal settlement: The need for integrated approaches to the SDGs.

This longitudinal study presents the joint effects of a COVID-19 community lockdown on household energy and food security in an informal settlement in Nairobi, Kenya. Randomly administered surveys were completed from December 2019-March 2020 before community lockdown (n = 474) and repeated in April 2020 during lockdown (n = 194). Nearly universal (95%) income decline occurred during the lockdown and led to 88% of households reporting food insecurity. During lockdown, a quarter of households (n = 17) using liquefied petroleum gas (LPG), a cleaner cooking fuel typically available in pre-set quantities (e.g. 6 kg cylinders), switched to polluting cooking fuels (kerosene, wood), which could be purchased in smaller amounts or gathered for free. Household size increases during lockdown also led to participants' altering their cooking fuel, and changing their cooking behaviors and foods consumed. Further, households more likely to switch away from LPG had lower consumption prior to lockdown and had suffered greater income loss, compared with households that continued to use LPG. Thus, inequities in clean cooking fuel access may have been exacerbated by COVID-19 lockdown. These findings demonstrate the complex relationship between household demographics, financial strain, diet and cooking patterns, and present the opportunity for a food-energy nexus approach to address multiple Sustainable Development Goals (SDGs): achieving zero hunger (SDG 2) and universal affordable, modern and clean energy access (SDG 7) by 2030. Ensuring that LPG is affordable, accessible and meets the dietary and cooking needs of families should be a policy priority for helping improve food and energy security among the urban poor.

Housing, health and energy: a characterisation of risks and priorities across Delhi's diverse settlements.

Improved housing has the potential to advance health and contribute to the Sustainable Development Goals. Research examining housing, health and energy use in low-income countries is limited; understanding these connections is vital to inform interventions for healthy sustainable human settlements. This paper investigates the low-income setting of Delhi, where rapid urbanisation, a varied climate, high pollution levels, and a wide variation in housing quality could result in significant energy use and health risks. Drawing on approaches from health and the built environment and existing data and literature, a characterisation of energy use and health risks for Delhi's housing stock is completed. Four broad settlement types were used to classify Delhi housing and energy use calculations and health risk assessment were performed for each variant. Energy use is estimated to be nearly two times higher per household among planned housing compared with other settlement types. Health risks, however, are found to be largest within informal slum settlements, with important contributions from heat and particulate matter across all settlements. This paper highlights intervention priorities and outlines the need for extensive further research, particularly through data gathering, to establish evidence to accelerate achieving healthy, sustainable and equitable housing in Delhi.

COVID-19 and informal settlements - implications for water, sanitation and health in India and Indonesia.

Informal settlements are home to over 1 billion people worldwide and are characterised by high population densities and poor environmental conditions. The authors identify the impact of COVID-19 on existing water and sanitation practices and potential pathways for the transmission of COVID-19 in informal settlements in India and Indonesia. In the short term, there is an urgent need for mobile and contactless hand washing, washing/bathing facilities and toilets. In the long term, COVID-19 provides an opportunity to invest in centralised water and sanitation networked solutions appropriate for high-density settings to integrate those settlements into cities and improve environmental conditions and health in these cities.

Participatory Action Research as a Framework for Transdisciplinary Collaboration: A Pilot Study on Healthy, Sustainable, Low-Income Housing in Delhi, India.

To tackle global challenges, research collaborations need to integrate multiple disciplinary perspectives and connect with local practices to find solutions that are sustainable and impactful. This paper discusses how participatory action research (PAR) is used as a framework for transdisciplinary collaboration to integrate different disciplines and identify healthy and sustainable housing solutions appropriate for local development practices and policy. By analyzing a transdisciplinary research collaboration investigating housing interventions for low-income settlements in Delhi, reflections and recommendations are provided for other projects wishing to use a similar methodology. It is found that the PAR framework has successfully guided the integration of contrasting methods and improved the impact of research outcomes, resulting in the emergence of new shared practices. However, it proves to be challenging and requires heightened communication and engagement to achieve understanding between all disciplines and practices. It is recommended that focus is given to developing relationships and effective communication channels and that time should be preallocated for reflection. The work provides insights for integrating academic disciplines, the community, and relevant stakeholders in the cocreation of evidence that is paramount to formulate effective solutions to global challenges.

HUMAN CAPITAL GROWTH AND POVERTY: EVIDENCE FROM ETHIOPIA AND PERU.

In this paper we use high quality data from two developing countries, Ethiopia and Peru, to estimate the production functions of human capital from age 1 to age 15. We characterize the nature of persistence and dynamic complementarities between two components of human capital: health and cognition. We also explore the implications of different functional form assumptions for the production functions. We find that more able and higher income parents invest more, particularly at younger ages when investments have the greatest impacts. These differences in investments by parental income lead to large gaps in inequality by age 8 that persist through age 15.