Household Air Pollution and Child Lung Function: The Ghana Randomized Air Pollution and Health Study.

Rationale: The impact of a household air pollution (HAP) stove intervention on child lung function has been poorly described. Objectives: To assess the effect of a HAP stove intervention for infants prenatally to age 1 on, and exposure-response associations with, lung function at child age 4. Methods: The Ghana Randomized Air Pollution and Health Study randomized pregnant women to liquefied petroleum gas (LPG), improved biomass, or open-fire (control) stove conditions through child age 1. We quantified HAP exposure by repeated maternal and child personal carbon monoxide (CO) exposure measurements. Children performed oscillometry, an effort-independent lung function measurement, at age 4. We examined associations between Ghana Randomized Air Pollution and Health Study stove assignment and prenatal and infant CO measurements and oscillometry using generalized linear regression models. We used reverse distributed lag models to examine time-varying associations between prenatal CO and oscillometry. Measurements and Main Results: The primary oscillometry measure was reactance at 5 Hz, X5, a measure of elastic and inertial lung properties. Secondary measures included total, large airway, and small airway resistance at 5 Hz, 20 Hz, and the difference in resistance at 5 Hz and 20 Hz (R5, R20, and R5-20, respectively); area of reactance (AX); and resonant frequency. Of the 683 children who attended the lung function visit, 567 (83%) performed acceptable oscillometry. A total of 221, 106, and 240 children were from the LPG, improved biomass, and control arms, respectively. Compared with control, the improved biomass stove condition was associated with lower reactance at 5 Hz (X5 z-score: ß = -0.25; 95% confidence interval [CI] = -0.39, -0.11), higher large airway resistance (R20 z-score: ß = 0.34; 95% CI = 0.23, 0.44), and higher AX (AX z-score: ß = 0.16; 95% CI = 0.06, 0.26), which is suggestive of overall worse lung function. The LPG stove condition was associated with higher X5 (X5 score: ß = 0.16; 95% CI = 0.01, 0.31) and lower small airway resistance (R5-20 z-score: ß = -0.15; 95% CI = -0.30, 0.0), which is suggestive of better small airway function. Higher average prenatal CO exposure was associated with higher R5 and R20, and distributed lag models identified sensitive windows of exposure between CO and X5, R5, R20, and R5-20. Conclusions: These data support the importance of prenatal HAP exposure on child lung function. Clinical trial registered with www.clinicaltrials.gov (NCT01335490).

Did COVID-19 Change the Availability and Use of Clean Energy for Cooking? Evidence From Ghana.

A major part of Ghana's current household energy policy is focused on using a branded cylinder recirculation model (BCRM) to promote the safe use of Liquefied Petroleum Gas (LPG) for primary cooking. The implementation of the BCRM is expected to increase LPG adoption by households to the announced policy goal of 50% of the population by 2030. We investigated the impact of the COVID-19 pandemic on the implementation of the BCRM, availability, and household use of cleaner fuels. This was assessed using existing data on clean fuel use prior to the COVID-19 pandemic. Additional data was collected using questionnaire-based household surveys and qualitative interviews. It was found that the expansion of BCRM was significantly impacted by the COVID-19 pandemic. Planning activities such as baseline data collection and stakeholder engagement were delayed due to the COVID-19 restrictions. Changes in household incomes during the pandemic had the biggest percentage effect on household choice of cooking fuel, causing a regression in some cases, to polluting fuel use. This study provides insights that could be valuable in future understanding of the interactions between pandemic control measures and economic disruptions that may affect household energy choices for cooking.

Geospatial determinants of maternal and child exposure to fine particulate matter in Kintampo, Ghana: Levels within the household and community, by surrounding building density and near roadways.

BACKGROUND: Personal exposure to fine particulate matter (PM2.5) from household air pollution is well-documented in sub-Saharan Africa, but spatiotemporal patterns of exposure are poorly characterized. OBJECTIVE: We used paired GPS and personal PM2.5 data to evaluate changes in exposure across location-time environments (e.g., household and community, during cooking and non-cooking hours), building density and proximity to roadways. METHODS: Our study included 259 sessions of geolocated, gravimetrically-calibrated one-minute personal PM2.5 measurements from participants in the GRAPHS Child Lung Function Study. The household vicinity was defined using a 50-meter buffer around participants' homes. Community boundaries were developed using a spatial clustering algorithm applied to an open-source dataset of building footprints in Africa. For each GPS location, we estimated building density (500 m buffer) and proximity to roadways (100 m buffer). We estimated changes in PM2.5 exposure by location (household, community), time of day (morning/evening cooking hours, night), building density, and proximity to roadways using linear mixed effect models. RESULTS: Relative to nighttime household exposure, PM2.5 exposure during evening cooking hours was 2.84 (95%CI = 2.70-2.98) and 1.80 (95%CI = 1.54-2.10) times higher in the household and community, respectively. Exposures were elevated in areas with the highest versus lowest quartile of building density (FactorQ1vsQ4 = 1.60, 95%CI = 1.42-1.80). The effect of building density was strongest during evening cooking hours, and influenced levels in both the household and community (31% and 65% relative increase from Q1 to Q4, respectively). Being proximal to a trunk, tertiary or track roadway increased exposure by a factor of 1.16 (95%CI = 1.07-1.25), 1.68 (95%CI = 1.45-1.95) and 1.27 (95%CI = 1.06-1.53), respectively. IMPACT: Household air pollution from cooking with solid fuels in sub-Saharan Africa is a major environmental concern for maternal and child health. Our study advances previous knowledge by quantifying the impact of household cooking activities on air pollution levels in the community, and identifying two geographic features, building density and roadways, that contribute to maternal and child daily exposure. Household cooking contributes to higher air pollution levels in the community especially in areas with greater building density. Findings underscore the need for equitable clean household energy transitions that reach entire communities to reduce health risks from household and outdoor air pollution.

Using time-resolved monitor wearing data to study the effect of clean cooking interventions on personal air pollution exposures.

BACKGROUND: Personal monitoring can estimate individuals' exposures to environmental pollutants; however, accuracy depends on consistent monitor wearing, which is under evaluated. OBJECTIVE: To study the association between device wearing and personal air pollution exposure. METHODS: Using personal device accelerometry data collected in the context of a randomized cooking intervention in Ghana with three study arms (control, improved biomass, and liquified petroleum gas (LPG) arms; N = 1414), we account for device wearing to infer parameters of PM2.5 and CO exposure. RESULTS: Device wearing was positively associated with exposure in the control and improved biomass arms, but weakly in the LPG arm. Inferred community-level air pollution was similar across study arms (~45 µg/m3). The estimated direct contribution of individuals' cooking to PM2.5 exposure was 64 µg/m3 for the control arm, 74 µg/m3 for improved biomass, and 6 µg/m3 for LPG. Arm-specific average PM2.5 exposure at near-maximum wearing was significantly lower in the LPG arm as compared to the improved biomass and control arms. Analysis of personal CO exposure mirrored PM2.5 results. CONCLUSIONS: Personal monitor wearing was positively associated with average air pollution exposure, emphasizing the importance of high device wearing during monitoring periods and directly assessing device wearing for each deployment. SIGNIFICANCE: We demonstrate that personal monitor wearing data can be used to refine exposure estimates and infer unobserved parameters related to the timing and source of environmental exposures. IMPACT STATEMENTS: In a cookstove trial among pregnant women, time-resolved personal air pollution device wearing data were used to refine exposure estimates and infer unobserved exposure parameters, including community-level air pollution, the direct contribution of cooking to personal exposure, and the effect of clean cooking interventions on personal exposure. For example, in the control arm, while average 48 h personal PM2.5 exposure was 77 µg/m3, average predicted exposure at near-maximum daytime device wearing was 108 µg/m3 and 48 µg/m3 at zero daytime device wearing. Wearing-corrected average 48 h personal PM2.5 exposures were 50% lower in the LPG arm than the control and improved biomass and inferred direct cooking contributions to personal PM2.5 from LPG were 90% lower than the other arms. Our recommendation is that studies assessing personal exposures should examine the direct association between device wearing and estimated mean personal exposure.

Prediction of personal exposure to PM2.5 in mother-child pairs in rural Ghana.

BACKGROUND: Air pollution epidemiological studies usually rely on estimates of long-term exposure to air pollutants, which are difficult to ascertain. This problem is accentuated in settings where sources of personal exposure differ from those of ambient concentrations, including household air pollution environments where cooking is an important source. OBJECTIVE: The objective of this study was to assess the feasibility of estimating usual exposure to PM2.5 based on short-term measurements. METHODS: We leveraged three types of short-term measurements from a cohort of mother-child pairs in 26 communities in rural Ghana: (A) personal exposure to PM2.5 in mothers and age four children, ambient PM2.5 concentrations (B) at the community level, and (C) at a central site. Baseline models were linear mixed models with a random intercept for community or for participant. Lowest root-mean-square-error (RMSE) was used to select the best-performing model. RESULTS: We analyzed 240 community-days and 251 participant-days of PM2.5. Medians (IQR) of PM2.5 were 19.5 (36.5) µg/m3 for the central site, 28.7 (41.5) µg/m3 for the communities, 70.6 (56.9) µg/m3 for mothers, and 80.9 (74.1) µg/m3 for children. The ICCs (95% CI) for community ambient and personal exposure were 0.30 (0.17, 0.47) and 0.74 (0.65, 0.81) respectively. The sources of variability differed during the Harmattan season. Children's daily exposure was best predicted by models that used community ambient compared to mother's exposure as a predictor (log-scale RMSE: 0.165 vs 0.325). CONCLUSION: Our results support the feasibility of predicting usual personal exposure to PM2.5 using short-term measurements in settings where household air pollution is an important source of exposure. Our results also suggest that mother's exposure may not be the best proxy for child's exposure at age four.

Characterizing sleep-wake patterns in mothers and children in an agrarian community: results from the Ghana Randomized Air Pollution and Health Study.

STUDY OBJECTIVES: Several studies have examined sleep patterns in rural/indigenous communities, however little is known about sleep characteristics in women of reproductive age, and children within these populations. We investigate sleep-wake patterns in mothers and children (ages 3-5 years) leveraging data from the Ghana Randomized Air Pollution and Health Study (GRAPHS). METHODS: The GRAPHS cohort comprises of rural/agrarian communities in Ghana and collected multiday actigraphy in a subset of women and children to assess objective sleep-wake patterns. Data were scored using the Cole-Kripke and Sadeh algorithms for mothers/children. We report descriptive, baseline characteristics and objective sleep measures, compared by access to electricity/poverty status. RESULTS: We analyzed data for 58 mothers (mean age 33 ± 6.6) and 64 children (mean age 4 ± 0.4). For mothers, mean bedtime was 9:40 pm ± 56 min, risetime 5:46 am ± 40 min, and total sleep time (TST) was 6.3 h ± 46 min. For children, median bedtime was 8:07 pm (interquartile range [IQR]: 7:50,8:43), risetime 6:09 am (IQR: 5:50,6:37), and mean 24-h TST 10.44 h ± 78 min. Children with access to electricity had a reduced TST compared to those without electricity (p = 0.02). Mean bedtime was later for both mothers (p = 0.05) and children (p = 0.08) classified as poor. CONCLUSIONS: Mothers in our cohort demonstrated a shorter TST, and earlier bed/risetimes compared to adults in postindustrialized nations. In contrast, children had a higher TST compared to children in postindustrialized nations, also with earlier sleep-onset and offset times. Investigating objective sleep-wake patterns in rural/indigenous communities can highlight important differences in sleep health related to sex, race/ethnicity, and socioeconomic status, and help estimate the impact of industrialization on sleep in developed countries.

Corrigendum to "Prenatal household air pollutant exposure is associated with reduced size and gestational age at birth among a cohort of Ghanaian infants" [Environ. Int. 155 (2021) 106659].

[This corrects the article PMC8628363.].

The Mental Health Outcomes of Food Insecurity and Insufficiency in West Africa: A Systematic Narrative Review.

(1) Background: Food insufficiency is a global pandemic affecting many people, especially those residing in developing countries. African countries have been affected by food insufficiency, which is mostly caused by drought or wars. Famine or food insufficiency has been reported to have an impact on the psychological health and quality of life of people affected. This review assessed the mental health outcomes of famine and food insufficiency in West Africa. (2) Methods: A search of the published literature was conducted using PubMed, PsycExtra, Medline, and PsycINFO databases. The search was limited to papers published in English between the years 2010 and 2020. Two reviewers independently screened the titles and abstracts of the retrieved papers using pre-defined inclusion and exclusion criteria and a third reviewer resolved conflicts. Data were extracted and appraised using a data extraction form and an appraisal checklist. (3) Results: A total of 81 papers were identified through the journal databases search. Out of the seven papers that met the inclusion criteria, six papers used cross-sectional designs and one paper used an experimental design. The six papers used quantitative approach for data collection, while the one paper used a qualitative technique. The evidence synthesized from this review indicated that exposure to food insecurity or insufficiency is associated with increased psychological distress including anxiety, sleeplessness, intellectual disability, general mental, and emotional instability. (4) Conclusions: This review strongly highlights the need for further research across the sub-region. It further suggests that famine and food insufficiency are associated with significant mental health problems in adults and impacts the cognitive and intellectual development of children. Although there is paucity of literature about famine and its impact on mental health in West Africa, these findings are important for developing social policy initiatives for increasing food supply and mental health interventions for all ages.

Prenatal household air pollutant exposure is associated with reduced size and gestational age at birth among a cohort of Ghanaian infants.

BACKGROUND: Low birth weight and prematurity are important risk factors for death and disability, and may be affected by prenatal exposure to household air pollution (HAP). METHODS: We investigate associations between maternal exposure to carbon monoxide (CO) during pregnancy and birth outcomes (birth weight, birth length, head circumference, gestational age, low birth weight, small for gestational age, and preterm birth) among 1288 live-born infants in the Ghana Randomized Air Pollution and Health Study (GRAPHS). We evaluate whether evidence of malaria during pregnancy, as determined by placental histopathology, modifies these associations. RESULTS: We observed effects of CO on birth weight, birth length, and gestational age that were modified by placental malarial status. Among infants from pregnancies without evidence of placental malaria, each 1 ppm increase in CO was associated with reduced birth weight (-53.4 g [95% CI: -84.8, -21.9 g]), birth length (-0.3 cm [-0.6, -0.1 cm]), gestational age (-1.0 days [-1.8, -0.2 days]), and weight-for-age Z score (-0.08 standard deviations [-0.16, -0.01 standard deviations]). These associations were not observed in pregnancies with evidence of placental malaria. Each 1 ppm increase in maternal exposure to CO was associated with elevated odds of low birth weight (LBW, OR 1.14 [0.97, 1.33]) and small for gestational age (SGA, OR 1.14 [0.98, 1.32]) among all infants. CONCLUSIONS: Even modest reductions in exposure to HAP among pregnant women could yield substantial public health benefits, underscoring a need for interventions to effectively reduce exposure. Adverse associations with HAP were discernible only among those without evidence of placental malaria, a key driver of impaired fetal growth in this malaria-endemic area.

Prenatal Household Air Pollution Exposure, Cord Blood Mononuclear Cell Telomere Length and Age Four Blood Pressure: Evidence from a Ghanaian Pregnancy Cohort.

Associations between prenatal household air pollution exposure (HAP), newborn telomere length and early childhood blood pressure are unknown. Methods: Pregnant women were randomized to liquefied petroleum gas (LPG) stove, improved biomass stove or control (traditional, open fire cook stove). HAP was measured by personal carbon monoxide (CO) (n = 97) and fine particulate matter (PM2.5) (n = 60). At birth, cord blood mononuclear cells (CBMCs) were collected for telomere length (TL) analyses. At child age four years, we measured resting blood pressure (BP) (n = 97). We employed multivariable linear regression to determine associations between prenatal HAP and cookstove arm and assessed CBMC relative to TL separately. We then examined associations between CBMC TL and resting BP. Results: Higher prenatal PM2.5 exposure was associated with reduced TL (ß = -4.9% (95% CI -8.6, -0.4), p = 0.03, per 10 ug/m3 increase in PM2.5). Infants born to mothers randomized to the LPG cookstove had longer TL (ß = 55.3% (95% CI 16.2, 109.6), p < 0.01)) compared with control. In all children, shorter TL was associated with higher systolic BP (SBP) (ß = 0.35 mmHg (95% CI 0.001, 0.71), p = 0.05, per 10% decrease in TL). Increased prenatal HAP exposure is associated with shorter TL at birth. Shorter TL at birth is associated with higher age four BP, suggesting that TL at birth may be a biomarker of HAP-associated disease risk.

A cluster randomised trial of cookstove interventions to improve infant health in Ghana.

INTRODUCTION: Household air pollution from solid fuel combustion for cooking and heating is a leading cause of childhood morbidity and mortality worldwide. We hypothesised that clean cooking interventions delivered during pregnancy would improve child health. METHODS: We conducted a cluster randomised trial in rural Ghana to test whether providing pregnant women liquefied petroleum gas (LPG) cookstoves or improved biomass cookstoves would reduce personal carbon monoxide and fine particulate pollution exposure, increase birth weight and reduce physician-assessed severe pneumonia in the first 12 months of life, compared with control participants who continued to cook with traditional stoves. Primary analyses were intention-to-treat. The trial was registered with ClinicalTrials.gov and follow-up is complete. RESULTS: Enrolment began on 14 April 2014, and ended on 20 August 2015. We enrolled 1414 pregnant women; 361 in the LPG arm, 527 in the improved biomass cookstove arm and 526 controls. We saw no improvement in birth weight (the difference in mean birth weight for LPG arm births was 29 g lighter (95% CI -113 to 56, p=0.51) and for improved biomass arm births was 9 g heavier (95% CI -64 to 82, p=0.81), compared with control newborns) nor severe child pneumonia (the rate ratio for pneumonia in the LPG arm was 0.98 (95% CI 0.58 to 1.70; p=0.95) and for the improved biomass arm was 1.21 (95% CI 0.78 to 1.90; p=0.52), compared with the control arm). Air pollution exposures in the LPG arm remained above WHO health-based targets (LPG median particulate matter less than 2.5 microns in diameter (PM2.5) 45 µg/m³; IQR 32-65 vs control median PM2.5 67 µg/m³, IQR 46-97). CONCLUSIONS: Neither prenatally-introduced LPG nor improved biomass cookstoves improved birth weight or reduced severe pneumonia risk in the first 12 months of life. We hypothesise that this is due to lower-than-expected exposure reductions in the intervention arms. TRIAL REGISTRATION NUMBER: NCT01335490.

Time Use Implication of Clean Cookstoves in Rural Settings in Ghana: A Time Use Study.

Whilst the health benefit of using clean cookstoves and fuels is widely known, there is limited information on the non-health benefit of these stoves, especially in low-middle-income countries. This paper reports the time use implications of using clean cookstoves and fuels by comparing liquified petroleum gas (LPG), an improved biomass cookstove (BioLite), and traditional biomass cookstoves (three-stone fires) in Ghana. Using survey-based time diaries, information on all the activities undertaken by study participants during a 24-h was collected and analyzed. The findings of the study show that LPG users spent significantly less time gathering firewood compared to the users of improved cookstoves and three-stone fires. LPG users spent slightly less time per cooking episode, generally, and there was no significant difference in cooking time across the three cookstoves mostly due to stove stacking. Time spent engaging in economic activities was highest for LPG users and improved biomass cookstove users, at least when compared to three-stone fire users. In this study, we provide evidence on the time use implications of clean cookstoves, highlighting their non-health benefits and supporting efforts towards the adoption and sustained used of clean cookstoves.

Determining the Enablers and Barriers for the Adoption of Clean Cookstoves in the Middle Belt of Ghana-A Qualitative Study.

Despite its benefits and espousal in developed counties, the adoption of clean cookstoves is reportedly low in less developed countries, especially in Sub-Saharan Africa. This qualitative study aimed at exploring and documenting the enablers and barriers for adoption of clean cookstove in the middle belt of Ghana. The findings showed convenience of clean cookstove use, reduced firewood usage, less smoke emission and associated health problems resulting from indoor air pollution and time for firewood gathering and cooking, good smell and taste of food as enabling factors for clean cookstove adoption. Factors such as safety, financial constraint (cost), non-availability of spare parts on the open market to replace faulty stove accessories, stove size and household size were the potential barriers to clean cookstove adoption. These findings help us to understand the factors promoting and inhibiting the adoption of clean cook stoves, especially in rural settings.

Association of Carbon Monoxide exposure with blood pressure among pregnant women in rural Ghana: Evidence from GRAPHS.

BACKGROUND AND OBJECTIVE: The Ghana Randomized Air Pollution and Health Study (GRAPHS) is a community-level randomized-controlled trial of cookstove interventions for pregnant women and their newborns in rural Ghana. Given that household air pollution from biomass burning may be implicated in adverse cardiovascular outcomes, we sought to determine whether exposure to carbon monoxide (CO) from woodsmoke was associated with blood pressure (BP) among 817 adult women. METHODS: Multivariate linear regression models were used to evaluate the association between CO exposure, determined with 72 hour personal monitoring at study enrollment, and BP, also measured at study enrollment. At the time of these assessments, women were in the first or second trimester of pregnancy. RESULTS: A significant positive association was found between CO exposure and diastolic blood pressure (DBP): on average, each 1 ppm increase in exposure to CO was associated with 0.43 mmHg higher DBP [0.01, 0.86]. A non-significant positive trend was also observed for systolic blood pressure (SBP). CONCLUSION: This study is one of very few to have examined the relationship between household air pollution and blood pressure among pregnant women, who are at particular risk for hypertensive complications. The results of this cross-sectional study suggest that household air pollution from wood-burning fires is associated with higher blood pressure, particularly DBP, in pregnant women at early to mid-gestation. The clinical implications of the observed association toward the eventual development of chronic hypertension and/or hypertensive complications of pregnancy remain uncertain, as few of the women were overtly hypertensive at this point in their pregnancies.