RESUMEN
INTRODUCTION: Switching from polluting (e.g. wood, crop waste, coal) to clean cooking fuels (e.g. gas, electricity) can reduce household air pollution (HAP) exposures and climate-forcing emissions. While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood. METHODS: We examined longitudinal survey data from 24,172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology (PURE) study. We assessed household-level primary cooking fuel switching during a median of 10 years of follow up (~2005-2015). We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching. RESULTS: One-half of study households (12,369) reported changing their primary cooking fuels between baseline and follow up surveys. Of these, 61% (7,582) switched from polluting (wood, dung, agricultural waste, charcoal, coal, kerosene) to clean (gas, electricity) fuels, 26% (3,109) switched between different polluting fuels, 10% (1,164) switched from clean to polluting fuels and 3% (522) switched between different clean fuels. Among the 17,830 households using polluting cooking fuels at baseline, household-level factors (e.g. larger household size, higher wealth, higher education level) were most strongly associated with switching from polluting to clean fuels in India; in all other countries, community-level factors (e.g. larger population density in 2010, larger increase in population density between 2005-2015) were the strongest predictors of polluting-to-clean fuel switching. CONCLUSIONS: The importance of community and sub-national factors relative to household characteristics in determining polluting-to-clean fuel switching varied dramatically across the nine countries examined. This highlights the potential importance of national and other contextual factors in shaping large-scale clean cooking transitions among rural communities in low- and middle-income countries.