Systems Science Approaches for Global Environmental Health Research: Enhancing Intervention Design and Implementation for Household Air Pollution (HAP) and Water, Sanitation, and Hygiene (WASH) Programs.

BACKGROUND: Two of the most important causes of global disease fall in the realm of environmental health: household air pollution (HAP) and poor water, sanitation, and hygiene (WASH) conditions. Interventions, such as clean cookstoves, household water treatment, and improved sanitation facilities, have great potential to yield reductions in disease burden. However, in recent trials and implementation efforts, interventions to improve HAP and WASH conditions have shown few of the desired health gains, raising fundamental questions about current approaches. OBJECTIVES: We describe how the failure to consider the complex systems that characterize diverse real-world conditions may doom promising new approaches prematurely. We provide examples of the application of systems approaches, including system dynamics, network analysis, and agent-based modeling, to the global environmental health priorities of HAP and WASH research and programs. Finally, we offer suggestions on how to approach systems science. METHODS: Systems science applied to environmental health can address major challenges by a) enhancing understanding of existing system structures and behaviors that accelerate or impede aims; b) developing understanding and agreement on a problem among stakeholders; and c) guiding intervention and policy formulation. When employed in participatory processes that engage study populations, policy makers, and implementers, systems science helps ensure that research is responsive to local priorities and reflect real-world conditions. Systems approaches also help interpret unexpected outcomes by revealing emergent properties of the system due to interactions among variables, yielding complex behaviors and sometimes counterintuitive results. DISCUSSION: Systems science offers powerful and underused tools to accelerate our ability to identify barriers and facilitators to success in environmental health interventions. This approach is especially useful in the context of implementation research because it explicitly accounts for the interaction of processes occurring at multiple scales, across social and environmental dimensions, with a particular emphasis on linkages and feedback among these processes. https://doi.org/10.1289/EHP7010.

Adoption and sustained use of cleaner cooking fuels in rural India: a case control study protocol to understand household, network, and organizational drivers.

BACKGROUND: Implementing efficient stoves and clean fuels in low and middle-income countries are critical for improving health of poor women and children and improve the environment. Cleaner biomass stoves, however, perform poorly against the World Health Organization's indoor air quality guidelines. This has shifted the focus to systematic dissemination and implementation of cleaner cooking systems such as liquefied petroleum gas (LPG) among poor communities. Even when there is some uptake of LPG by poor communities, its sustained use has been low. Concurrent use of LPG with traditional biomass cookstoves compromises reductions in household air pollution and limits health and environmental dividends. Therefore understanding key drivers of adoption and sustained implementation of clean fuels among the poor is critical. There is a significant gap, however, in the research to understand determinants and sustained exclusive use of clean fuels in rural poor communities. METHODS/DESIGN: Using a case control study design, this study will explore the impact of affordability, accessibility, and awareness on adoption and sustained use of LPG among rural poor communities of India. The study uses a multistage random sampling to collect primary data from 510 households. Case group or LPG adopters constitute 255 households while control group or non-LPG adopters constitute the remaining 255 households. The study will deploy sophisticated stove use monitoring sensors in each of the stoves in 100 case group households to monitor stove use and stacking behavior (using clean and traditional systems of cooking) of participants for 12 months. Moreover, this will be the first study to explore the impact of personal social networks striated by gender on LPG adoption. This study is guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) implementation science evaluation framework. DISCUSSION: Lessons from this study will feed into a larger discussion on developing a pro-poor strategy to foster uptake and sustained use of cleaner cooking systems such as LPG. Understanding the determinants of adoption and sustained use of cleaner cooking systems through the RE-AIM framework will expand our insights on implementation of cleaner cooking systems among poor communities and will advance implementation science in the clean cooking sector. A thorough study of such implementation strategies is crucial to realize multiple UN Sustainable Development Goals on global health, climate change, and energy security.

Dynamics of sustained use and abandonment of clean cooking systems: study protocol for community-based system dynamics modeling.

BACKGROUND: More than 3 billion of the world's population are affected by household air pollution from relying on unprocessed solid fuels for heating and cooking. Household air pollution is harmful to human health, climate, and environment. Sustained uptake and use of cleaner cooking technologies and fuels are proposed as solutions to this problem. In this paper, we present our study protocol aimed at understanding multiple interacting feedback mechanisms involved in the dynamic behavior between social, ecological, and technological systems driving sustained use or abandonment of cleaner cooking technologies among the rural poor in India. METHODS/DESIGN: This study uses a comparative case study design to understand the dynamics of sustained use or abandonment of cleaner cooking technologies and fuels in four rural communities of Rajasthan, India. The study adopts a community based system dynamics modeling approach. We describe our approach of using community based system dynamics with rural communities to delineate the feedback mechanisms involved in the uptake and sustainment of clean cooking technologies. We develop a reference mode with communities showing the trend over time of use or abandonment of cleaner cooking technologies and fuels in these communities. Subsequently, the study develops a system dynamics model with communities to understand the complex sub-systems driving the behavior in these communities as reflected in the reference mode. We use group model building techniques to facilitate participation of relevant stakeholders in the four communities and elicit a narrative describing the feedback mechanisms underlying sustained adoption or abandonment of cleaner cooking technologies. DISCUSSION: In understanding the dynamics of feedback mechanisms in the uptake and exclusive use of cleaner cooking systems, we increase the likelihood of dissemination and implementation of efficacious interventions into everyday settings to improve the health and wellbeing of women and children most affected by household air pollution. The challenge is not confined to developing robust technical solutions to reduce household air pollution and exposure to improve respiratory health, and prevent associated diseases. The bigger challenge is to disseminate and implement cleaner cooking technologies and fuels in the context of various social, behavioral, and economic constraints faced by poor households and communities. TRIAL REGISTRATION: The Institutional Review Board of Washington University in St. Louis has exempted community based system dynamics modeling from review.

Social, economic, and resource predictors of variability in household air pollution from cookstove emissions.

We examine if social and economic factors, fuelwood availability, market and media access are associated with owning a modified stove and variation in household emissions from biomass combustion, a significant environmental and health concern in rural India. We analyze cross-sectional household socio-economic data, and PM(2.5) and particulate surface area concentration in household emissions from cookstoves (n=100). This data set combines household social and economic variables with particle emissions indexes associated with the household stove. The data are from the Foundation for Ecological Society, India, from a field study of household emissions. In our analysis, we find that less access to ready and free fuelwood and higher wealth are associated with owning a replacement/modified stove. We also find that additional kitchen ventilation is associated with a 12% reduction in particulate emissions concentration (p<0.05), after we account for the type of stove used. We did not find a significant association between replacement/modified stove on household emissions when controlling for additional ventilation. Higher wealth and education are associated with having additional ventilation. Social caste, market and media access did not have any effect on the presence of replacement or modified stoves or additional ventilation. While the data available to us does not allow an examination of direct health outcomes from emissions variations, adverse environmental and health impacts of toxic household emissions are well established elsewhere in the literature. The value of this study is in its further examination of the role of social and economic factors and available fuelwood from commons in type of stove use, and additional ventilation, and their effect on household emissions. These associations are important since the two direct routes to improving household air quality among the poor are stove type and better ventilation.

Evaluation of mass and surface area concentration of particle emissions and development of emissions indices for cookstoves in rural India.

Mass-based dose parameters (for example, PM(2.5)) are most often used to characterize cookstove particulate matter emissions. Particle surface area deposition in the tracheobronchial (TB) and alveolar (A) regions of the human lung is also an important metric with respect to health effects, though very little research has investigated this dose parameter for cookstove emissions. Field sampling of cookstove emissions was performed in two regions of rural India, wherein PM(2.5), particulate surface area concentration in both TB and A regions, and carbon monoxide (CO) were measured in 120 households and two roadside restaurants. Novel indices were developed and used to compare the emissions and efficiency of several types of household and commercial cookstoves, as well as to compare mass-based (PM(2.5)) and surface area-based measurements of particle concentration. The correlation between PM(2.5) and surface area concentration was low to moderate: Pearson's correlation coefficient (R) for PM(2.5) vs surface area concentration in TB region is 0.38 and for PM(2.5) vs surface area concentration in A region is 0.47, indicating that PM(2.5) is not a sufficient proxy for particle surface area concentration. The indices will also help communicate results of cookstove studies to decision makers more easily.