Household air pollution and under-five mortality in India (1992–2006)
Naz et al. Environmental Health
Household air pollution and under-five mortality in India (1992-2006)
Sabrina Naz 0
Andrew Page 0
Kingsley Emwinyore Agho 1
0 Centre of Health Research, School of Medicine, Western Sydney University , Building 3, Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2571 , Australia
1 School of Science and Health, Western Sydney University , Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2571 , Australia
Background: Household air pollution (HAP) - predominantly from cooking fuel is a major public health hazard and one of the leading causes of respiratory illness and deaths among children under-five years in India. This study investigates the association between HAP from cooking fuel and under-five mortality using India's National Family and Health Survey (NFHS) datasets over the period 1992-2006 (total of 166,382 children), and the extent to which the association differed by environmental and behavioral factors affecting level of exposure. Methods: The association between HAP and under-five mortality of three age-groups (neonatal age between 0-28 days, post-neonatal age between 1-11 months and children aged between 12-59 months) was examined using multi-level logistic regression models. Results: HAP was associated with mortality among children aged under-five (OR = 1.30, 95%CI = 1.18-1.43, P < 0.001) and was more strongly associated in sub-group analyses of post-neonatal mortality (OR = 1.42, 95%CI = 1.19-1.71, P < 0.001) and child mortality (OR = 1.42, 95%CI = 1.05-1.91, P = 0.021) than neonatal mortality (OR = 1.23, 95%CI = 1.09-1.39, P = 0.001). The association was stronger for households in rural areas and for households without a separate kitchen using polluting fuel, and in women who had never breastfed for all age-groups. Conclusion: Use of cooking fuel in the household is associated with increased risk of mortality in children aged under-five years. Factors relating to access to clean fuels, improvements in infrastructure and household design and behavioral factors are discussed, and can result in further declines in under-five mortality in India.
Household air pollution; Under-five mortality; Child mortality; Cooking fuel; India
India is the second most populous and seventh largest
country by area in the world located in South Asia, and
currently is one of the ten fastest growing economies in
the world [
]. In the last five decades in India, there has
been extensive improvement in poverty reduction,
literacy, health standards and human development, however,
there remains significant population challenges in relating
to health and sanitation [
]. More than 90 % of the rural
population and 31 % of the urban population in India still
rely primarily on solid fuels as a domestic source of energy
]. Household air pollution (HAP) from solid fuels
(such as wood, animal dung, crop residues, charcoal and
coal) for cooking and heating is a substantial cause of
respiratory illness and death, due to a range health
damaging pollutants such as fine particles, carbon
monoxide (CO2), nitrogen oxides (NO2), sulphur dioxide
(SO2), benzene, butadiene, formaldehyde, polyaromatic
hydro-carbons and a number of other chemicals, [
and remains a major public health concern in the
developing world [
]. A recent study from India
indicated that 56 % of children aged under-five remained
with their mother at all times during cooking [
], and that
proximity to smoke from solid fuel use is associated with
an increase in the risk of health problems among young
According to World Health Organization (WHO), 3.5 %
of the total burden of disease in India country has been
attributable to HAP [
] and a previous study from
India has indicated that solid fuel use was responsible
for 20 % of deaths among children <5 years [
addition, 24 % of total deaths among children under
five in India was associated with acute respiratory illness
] which has also been identified as the
leading cause of death of children less than five by the 2010
Global Burden of disease (GBD) study [
underfive mortality in India declined from 125 per 1,000 live
births in 1990 to 74.6 per 1,000 live births in 2005–06
], and despite projections that it will further decline to
70 per 1,000 live births by 2015, this still does not achieve
the Millennium Development Goal 4 (MDG4) target of 42
per 1,000 live births to reduce mortality among children
under five by two-thirds [
A number of previous studies in India have reported
the effects of HAP on respiratory diseases among young
] and associations between HAP and
under-five mortality with other health outcomes (e.g., low
birth weight, respiratory illnesses among young children)
]. However, those studies have been limited to
surveys of limited geographic areas, or hospital based data
sources for specific regional populations or focused on all
types of HAP (for example, including tobacco use), and
not exclusively cooking fuel [
]. To date, no studies
in India have examined changes in the association
between HAP and under-five mortality over time, or
investigated the role of environmental and behavioural factors
that might affect the level of exposure to HAP (for
example, place of residence, location of kitchen, and
breastfeeding status). Accordingly, the objective of this study
was to investigate trends in the association between HAP
from cooking fuel and under-five mortality for three
consecutive age groups (neonatal, post-neonatal and child),
and to assess how this is affected by key environmental
and behavioral factors using large-scale nationally
representative data over the period 1992–2006.
The data in this study were extracted from India’s
National Family and Health Survey (NFHS) datasets
for the years 1992–93 (NFHS-1), 1998–99 (NFHS-2)
and 2005–06 (NFHS-3). The NFHS are nationwide surveys
based on a representative sample of households
throughout the country under the authority of the Ministry of
Health and Family Welfare (MOHFW), Government of
India, and implemented by the International Institute for
Population Sciences (IIPS), Mumbai with technical
assistance from Macro International of Calverton, Maryland,
USA, as a part of its Demographic and Health Surveys
1, 30, 31
]. To date, the three NFHS surveys
(NFHS-1, NFHS-2 & NFHS-3) have collected
demographic and health data by interviewing ever-married
women (aged 15–49 years) and men (aged 15–54 years)
using a stratified sample of households based on a
twostage cluster design [
1, 30, 31
]. NFHS-3 covered all 29
states of India, which includes more than 99 % of
India’s population [
A total of 303,361 ever-married women of reproductive
age (112,357 from urban and 191,009 from rural areas)
were included in the three datasets with a response rate of
95.4 % in women across the three datasets (NFHS-1,
NFHS-2 and NFHS-3). This study was based on
information relating to 166,382 singleton live-born children,
of whom 11,311 died in the 5-years prior to the survey.
An index period of five years was to minimize recall
bias of child birth and death information self-reported
by the mother.
The analysis for under-five mortality was carried out for
three successive age groups: neonatal, post-neonatal and
child mortality, using the following definitions:
Neonatal mortality: The number of deaths during
the first 28 days of life (0–28 days). Defined as,
Number of neonatal deaths/Total number of live
Post-neonatal mortality: The number of deaths
between one month and the first birthday (1–11
months). Defined as, Number of post-neonatal
deaths/Total number of live births
Child mortality: The number of deaths between exact
ages one and five (12–59 months). Defined as, Number
of child deaths/Total number of live births
The outcome variables were considered dichotomous
for the analysis, where age at death was either yes (=1)
denoting death occurred during these any three periods
of age or no (=0) denoting the child survived during the
Exposure to cooking fuel
The main exposure variable was type of cooking fuel
used in the household. The respondents were asked,
“What type of fuel does your household mainly use for
cooking?” and in response 12 types of cooking fuel were
reported. In the analysis, these fuels were grouped into
two categories on the basis of exposure to cooking smoke:
“clean fuels” (electricity, liquid petroleum gas (LPG),
natural gas and biogas) and “polluting fuels” (kerosene,
coal/lignite, charcoal, wood, straw/shrubs/grass, agricultural
crop waste and dung cakes). NFHS analyses have previously
classified cooking fuel as “solid” and “non-solid” fuels,
where kerosene was categorised in the non-exposed
(i.e. “clean fuel”) group [
1, 30, 31
]. However, some
previous studies have reported kerosene as a polluting fuel
and have found significant associations between
underfive mortality or respiratory illness among children and
kerosene fuel use [
21, 32, 33
]. For this reason, kerosene
was categorised in the polluting fuels group.
Place of residence (categorized as “urban” or “rural”),
household wealth index (categorized as “high income”,
“middle income” or “low income”), mother’s education
(categorized as “secondary or higher”, “primary” or “no
education”), mother’s working status (categorized as
“working” or “not working”) and type of house (categorized
as “pucca”, “semi-pucca” or “kachha”) were included as
markers of socio-economic status, and have previously
been identified as potential confounders of the association
between HAP and under-five mortality [
11, 21–23, 33–38
The household wealth index was constructed using
principal components analysis, with weights for the wealth index
calculated by giving scores to the asset variables such as
ownership of transport, durable goods and facilities in the
1, 30, 31, 39
]. “Low income” referred to the
bottom 40 % of households, “middle income” referred to
the middle 40 % of households, and “high income” referred
to the top 20 % of households, based on the approach
described by Filmer and Pritchett [
]. Mother’s age
(categorized as <20, 20–29, 30–39 and 40–49 years)
and sex of the child (categorized as “female” or “male”)
were also considered as potential confounders of the
association between HAP and under-five mortality.
Breastfeeding status of mother (categorized as ever
breastfed “yes” or “no”) and location of kitchen (categorized
as separate room used as kitchen “yes” or “no”) were also
considered a priori factors that may indicate different levels
of exposure to polluting fuels. No separate kitchen
used for cooking in the household as an indicator of
proximity to polluting fuel use has also been presented
to be an significant factor associated with high
exposure to HAP [
24, 26–28, 36, 37, 40
breastfeeding has been shown to be a protective factor
for under-five mortality, generally in neonatal and infancy
33, 34, 41–44
] which may reduce the greater risk
of exposure associated with HAP. Hence, analyses sought
to determine whether the magnitude of the association
between HAP and under-five mortality differed by past
The association between type of cooking fuels and
under-five mortality was investigated using a series of
multilevel logistic regression models adjusted for the
potential confounders of household wealth, place of
residence, mother’s age, mother’s education, mother’s
working status, sex of child, breastfeeding status, kitchen
location and type of house. Changes in neonatal, post
neonatal and child mortality incidences from HAP over
time were also investigated using a trend analysis across
1992–93, 1998–99 and 2005–06 NFHS data by
specifying ‘period’ as a continuous variable. To identify the
overall effect of HAP from cooking fuels with neonatal,
post-neonatal and child mortality, pooled analyses were
also conducted. The extent of divergence or convergence
between the slopes of period specific trends within each
variable over the study period (1992–2006) was assessed
by testing the interaction between period and a given
confounding variable using likelihood ratio tests.
Stratified analyses were also conducted by breastfeeding
status and by location of kitchen to determine whether
the magnitude of the effect of the exposure on outcomes
differed across levels of these variables. Breastfeeding
status (ever breastfed “yes” or “no”) and location of
kitchen (separate room used as kitchen “yes” or “no”) were
each also combined with type of cooking fuel as
composite ordinal variables to investigate different level of
exposure to HAP for under-five mortality outcomes.
The “Svy” command was used for calculating weighted
cumulative incidence estimates of mortality to adjust for
the cluster sampling survey design. Random effects
multilevel logistic regression models were conducted by using
the “xtlogit” command and for likelihood ratio test for
interaction “lrtest” command was used. Adjusted risk
differences were also estimated from logistic regression
model using the “margins” command. All analyses were
carried out in STATA version 13.1 (Stata Corp: College
Station, TX, USA).
The Demography and Health Survey (DHS) project sought
and obtained the required ethical approvals from ethics
committees in India before the surveys were conducted.
Informed consent was obtained from study participants
before their participation in the surveys. Publicly
available, de-identified datasets were used in this study
following approval from The DHS Program.
The overall under-five mortality incidence proportion in
India decreased from 8.7 % per year in 1992 to 6.6 % per
year in 2006 for those using polluting fuels for cooking.
Decreasing trends were also evident for each age group,
where the neonatal mortality incidence proportion declined
from 4.5 % in 1992 to 3.9 % in 2006, post-neonatal
mortality incidence proportion from 2.7 % in 1992 to
1.7 % in 2006 and child mortality incidence proportion
from 1.5 % in 1992 to 0.9 % in 2006 (Fig. 1). Use of
polluting fuels (kerosene, coal/lignite, charcoal, wood, straw/
shrubs/grass, agricultural crop waste and dung cakes) for
cooking was associated with a higher risk of post-neonatal
(OR = 1.42, 95%CI = 1.19-1.71, P < 0.001) and child
mortality (OR = 1.42, 95%CI = 1.05-1.91, P = 0.021) than
neonatal mortality (OR = 1.23, 95%CI = 1.09-1.39, P = 0.001)
after adjusting for household wealth, place of residence,
mother’s age, mother’s education, mother’s working
status, sex of child, breastfeeding status, kitchen location
and type of house (Table 1). Use of polluting fuels and
under-five mortality showed statistically significant
association (OR = 1.30, 95%CI = 1.18-1.43, P < 0.001) after
adjusting for confounders (Fig. 2). Corresponding risk
differences between use of clean fuel and polluting fuel
were found (0.68 %, 95%CI = 0.33 %-1.03 %) for neonatal,
(0.61 %, 95%CI = 0.35 %-0.87 %) for post-neonatal,
(0.34 %, 95%CI = 0.28 %-0.40 %) for child mortality and
(1.50 %, 95%CI = 1.01 %-1.99 %) for overall under-five
Stratified analyses to examine different levels of
exposure to HAP showed more than 5-fold greater risk of
mortality in women who never breastfeed and who used
polluting fuels for cooking (compared to breastfeeding
women who used clean fuels), with robust associations
evident for child (OR = 10.47 95%CI = 7.13-15.37, P <
0.001) and post-neonatal (OR = 8.87 95%CI = 6.94-11.33,
P < 0.001) mortality than neonatal (OR = 5.36 95%CI =
4.65-6.19, P < 0.001) mortality (Table 2). In addition, the
risk of under-five mortality was also higher for the
women who ever breastfed but used polluting fuel for
cooking (Table 2).
Analyses combining location of kitchen (separate room
used as kitchen or not) and use of cooking fuels, showed
strong evidence of an association between households
using polluting fuels and no separate kitchen (compared
to households with a separate kitchen who used clean
fuel for cooking), with stronger associations for child
mortality (OR = 7.37, 95%CI = 5.56-9.76, P < 0.001) than
post-neonatal (OR = 4.03, 95%CI = 3.40-4.78, P < 0.001)
and neonatal mortality (OR = 2.34, 95%CI = 2.11-2.59, P <
0.001) (Table 2). There was also an indication of
association between use of polluting fuels in a separate kitchen
and neonatal, post-neonatal and child mortality (Table 2).
A sensitivity analysis was conducted including kerosene as
a “clean fuel” group which did not change results
substantially (only 6.94 % of women reported the use of kerosene
for cooking in three survey years) (data not shown).
Under-five mortality in India has declined substantially
over time, however, the association between household
use of polluting fuels for cooking and under-five
mortality has not changed significantly over time. The risk
of death was higher in post-neonatal and child age
groups than the neonatal age-group, and were generally
consistent with previous studies in India and Nigeria
11, 21–23, 34
]. Findings are also consistent with
proposed biological mechanisms relating to key pollutants
such as fine particles, carbon monoxide (CO) and a
number of other chemicals present in solid cooking fuels
Table 1 HAP associated with neonatal, post neonatal and child mortality in India: a pooled analysis for 1992–2006
Neonatal Post neonatal Child
ne n (%)f ne n (%)f ne
compared to clean cooking fuels. Under-five mortality in
all consecutive age groups was higher in rural areas
compared to urban and in households without a separate
kitchen (compared to separate kitchen) for cooking their
meals. There was also a lower risk of mortality in mothers
who had ever breastfed compared to never breastfed
which was consistent with its previously reported role in
respiratory outcomes [
41, 43, 44
] and which appeared to
attenuate the effects of polluting fuel use, with a higher
risk of under-five mortality among never breastfeeding
(compared to ever breastfeeding) mothers using polluting
This study found rural children were at greater risk of
death than children from rural areas which was consistent
with previous studies in India [
11, 21, 22
90 % of rural households in India depend on solid fuels
as a domestic source of energy and the only option for
cooking, whereas cleaner fuels (natural gas/LPG) were
more common in urban areas [
]. Other socioeconomic
factors associated factors (for example, kachha (poor)
house, mother’s with no education, and lower income)
are also likely influences of the use of polluting fuels in
The location of kitchen has previously been shown to
be an important factor in studies of HAP and under-five
mortality in developing country settings (such as, African
countries and Bangladesh) [
], and are also consistent
with observed associations between HAP and under-five
mortality in the present study which have not been shown
before for India using nationally representative data
sources. Analyses that incorporated the location of
kitchen found a higher risk of neonatal, post-neonatal
and child mortality when mothers reported no separate
kitchen and used polluting fuels for cooking. Moreover,
ne n (%)f
Table 2 Risk of mortality by breastfeeding status and kitchen location
ne n (%)f ORb 95 %(CI)
Study Factors P value ORb 95 %(CI) P value n (%)f ORb 95 %(CI) P value
Combined Association of Breastfeeding
Status and Use of Cooking fuel
Ever breastfed & used clean fuelsa, c 203 1.5 1.00 67 0.6 1.00 27 0.2 1.00
Ever breastfed & used polluting fuelsd 2285 2.6 1.58 (1.37-1.83) <0.001 1322 1.4 2.76 (2.16-3.53) <0.001 919 1.0 4.72 (3.22-6.92) <0.001
Never breastfed & used clean fuelsc 362 2.7 1.73 (1.46-2.06) <0.001 149 1.0 2.15 (1.61-2.87) <0.001 42 0.3 1.49 (0.92-2.41) 0.109
Never breastfed & used polluting fuelsd 3232 8.2 5.36 (4.65-6.19) <0.001 1816 4.4 8.87 (6.94-11.33) <0.001 887 2.2 10.47 (7.13-15.37) <0.001
Linear trend 1.83 (1.78-1.88) <0.001 1.84 (1.78-1.91) <0.001 1.57 (1.50-1.64) <0.001
Combined Association of Kitchen
Location and Use of Cooking fuel
Separate kitchen used clean fuelsa, c 419 2.1 1.00 146 0.7 1.00 51 0.3 1.00
Separate kitchen used polluting fuelsd 2182 3.8 1.83 (1.65-2.04) <0.001 1175 1.9 2.81 (2.36-3.34) <0.001 559 0.9 3.79 (2.84-5.05) <0.001
No separate kitchen used clean fuelsc 131 2.3 1.30 (1.06-1.58) 0.010 66 1.3 1.88 (1.40-2.51) <0.001 17 0.2 1.38 (0.80-2.39) 0.249
No separate kitchen used polluting fuelsd 2912 4.6 2.34 (2.11-2.59) <0.001 1761 2.6 4.03 (3.40-4.78) <0.001 1136 1.7 7.37 (5.56-9.76) <0.001
Linear trend 1.21 (1.18-1.24) <0.001 1.32 (1.28-1.37) <0.001 1.54 (1.47-1.61) <0.001
Note: aReference category, bodds ratio, cclean fuels: electricity, LPG, natural gas, biogas, dPolluting fuels: kerosene, coal/lignite, charcoal, wood, straw/shrubs/grass, agricultural crop and animal dung, en = number of
mortality cases of children for neonatal, post-neonatal and child age-group, fpercentage of mortality cases
this study found that households using polluting fuels
in indoor kitchen without partitions were at higher risk
of death of their children under-five than household
with separate kitchen both in urban and rural areas.
Findings suggest that a separate kitchen in the household
could reduce the death of young children even where
polluting fuels were used for cooking. This is because
households without a separate kitchen have higher
concentrations of particles and children mainly less than
five year of age were exposed to higher level of smoke
as they spent many hours indoors [
Breastfeeding has previously been shown to protect
infants against infection and has been reported as a
protective factor for reducing risk of respiratory illness
among infants [
], and thus was a behaviour that
was investigated to determine whether breastfeeding
status might attenuate the association between HAP and
under-five mortality. Analyses showed substantial
differences in the association between HAP and under-five
mortality between women who did or did not breastfeed.
The strong effect of the breastfeeding status of mother
was examined in the neonatal and post-neonatal period
compared to older children who reported using polluting
fuels, but who also breastfed their children. Therefore,
breastfeeding in the first one year of life was found to be a
protective factor for lower risk of mortality among young
children associated with HAP, consistent with previous
similar studies in Nigeria [
], but not previously shown
in a South Asian context.
There are a number of methodological considerations
to be taken into account when interpreting these
findings. This study was based on a series of cross-sectional
secondary datasets, with a number of potential sources
of bias including selection, misclassification and recall
bias. Firstly, the classification of cooking fuel may be a
source of misclassification bias, as some households use
a combination of polluting and clean fuels. Moreover,
the DHS survey only collected information of primary
fuel use, and there was no data for secondary fuel use.
For example, one recent study on India indicated that
dwellings reporting kerosene as their primary fuel
frequently shift to cooking with biomass fuel (such as wood)
which may cause higher concentrations of HAP [
and attenuate associations between HAP and under-five
mortality. In addition, this study did not account for past
exposure to HAP or recent changes in cooking methods
because of its cross-sectional design.
Secondly, information on birth and death of children
was self-reported by mothers, which may be a source of
recall bias. The present study constrained analyses to
those children born within a five year period prior to the
survey date in order to minimise the likelihood of recall
bias (and maximise the study sample size). Thirdly, this
study used cross-sectional data for analysis, and it is
difficult to clearly define temporal relationships between
the exposure and outcome when collected at the same
point of time.
Furthermore, we considered all-cause mortality for our
analysis of the association between HAP and under-five
mortality. Cause of death information was not available
in the NFHS dataset used for this study. Verbal autopsy
questionnaires are employed for identifying cause of death
in developing countries, including India; however this
information is often of variable quality and was not collected
for India NFHS data. Not only pneumonia and acute
respiratory infections but also other factors, such as preterm
birth complications, low birth weight, nutritional
conditions and diarrhoea also affect mortality among under-five
children but we could not measure cause-specific death
due to lack of data. The 2010 GBD study indicated that
acute lower respiratory infections was the second leading
cause of death (after preterm birth complications) in
under-five children in India [
]. HAP from cooking fuel
is a primary cause for respiratory infections among
underfive children and thus can be associated with the deaths
caused by those illnesses. However, including all-cause
mortality will also include mortality outcomes not
associated with HAP, which is likely to be a source of
ascertainment bias in the outcome, and lead to an underestimation
of the association between HAP and the cause-specific
outcomes noted above.
This study also did not measure actual levels and
patterns of exposure to emission from cooking smoke due
to the absence of such information in DHS data. Proxy
environmental and behavioural measures were defined
to examine the effects of level of exposure. Location of
kitchen was used as a proxy measure to investigate the
effects of different level of exposure associated with HAP
and under-five mortality and several studies in India
noted a significant association between HAP and kitchen
18, 45, 47, 48
]. Other proxy measures such as
'presence of window', and 'cooking under a chimney' were
available at NFHS-3; however this information were not
collected in previous surveys.
Despite these methodological concerns, this present study
used large-scale nationally representative DHS data with a
very high response rate of 95.4 %, and was the first study to
pool datasets over a long period (1992–2006), a period in
India characterised by rapid socio-economic development.
No previous studies have investigated trends and
differentials in the association between HAP and under-five
mortality in India over this long period, or assessed the role of
environmental and behavioural factors that may be points of
intervention and health promotion at the national level in
the Indian context to further contribute to declines in
under-five mortality in the post-MDG period.
The magnitude of the association between HAP and
under-five mortality remained consistent over time in all
age-groups and higher exposure to cooking fuel can
substantially increase the risk of respiratory illness and child
deaths in developing countries like India. According to
NFHS-3, only 0.4 % of the households had access to
electricity and 24.7 % of households used LPG/natural
gas, with the remainder still relying on polluting fuels in
both urban and rural areas [
]. Despite the potentially
small relative risk of under-five mortality associated with
HAP, it remains a common exposure in the population
and therefore the population attributable risk - of this
preventable risk factor - remains a public health priority
Raising awareness about the health risk related with
HAP and the use of polluting fuel is needed in rural and
low income urban areas. Radio and television have been
identified as useful media to raise awareness and to reach
poorer sub-groups of the population [
]. The most
important intervention to reduce exposure to polluting
fuel is ready access to clean fuels such as LPG/natural gas,
biogas and electricity [
18, 19, 22
]. Many countries like
Brazil, Bolivia, Ecuador have decreased exposure to
pollution from cooking fuel by promoting liquid fuel
supported by government policy [
]. Switching to
clean fuel is advisable, however, it is not an affordable
option for many poor families in India and supplying
cleaner fuel to rural household is expensive, and thus
requires long term intervention because of poor
infrastructure in India [
18, 19, 22
Behavioral change interventions also have potential,
and are shorter term alternatives in India to reduce child
exposure from HAP [
18, 19, 22
]. Studies from India
suggested that improvements in natural household ventilation,
particularly windows and improved stoves (stoves with
chimney) might lead to a reduction in HAP [
18, 19, 22
Cooking stoves with a chimney also have health
advantages, via reductions in carbon monoxide emissions and
incidence of respiratory infections [
]. Studies showed
that India has distributed ten millions of improved cooking
stoves since 1980 and plans to distribute 150 million in the
next decade [
]. Findings from this study suggests
that, behavioral interventions are likely to play a key role in
decreasing childhood deaths in India by promoting the use
of improved cooking stoves, raising awareness for cooking
in a separate kitchen and removing children from the
cooking area while cooking, increasing natural ventilation
in household and implementing concerted health
promotion campaigns to inform people about public health
hazard relating to HAP.
The overall under-five mortality rates in India have
decreased substantially over the study period (1992–2006).
While HAP was associated with a modest increase in
risk of mortality in children under five, the ubiquitous
use of polluting fuel in India and associated population
attributable risk, confirms that HAP remains an
important public health problem. Cooking fuel is a modifiable
risk factor that can be changed by improvements in
house design, health system policies, infrastructure,
behavioural intervention and economic development of the
HAP: Household Air Pollution; NFHS: National Family and Health Survey;
WHO: World Health Organization; ARI: Acute Respiratory Infection;
GBD: Global Burden of Disease; MDG: Millennium Development Goal;
MOHFW: Ministry of Health and Family Welfare; IIPS: International Institute for
Population Sciences; LPG: Liquid Petroleum Gas; DHS: Demography and
The authors declare that they have no competing interests.
SN and AP contributed to the conception and design of this study. SN
performed the literature review and analysis and drafted the manuscript. AP
and KEA contributed to the interpretation, and critical revisions of the
manuscript. All authors read and approved the final manuscript.
This study was part of the first author’s thesis for a doctoral dissertation with
the School of Medicine at the Western Sydney University, Australia. We are
grateful to The DHS Program, ORC Macro, Calverton, Maryland, USA for
providing the Indian DHS data sets for this analysis.
1. International Institute for Population Science and Macro International. National Family Health Survey (NFHS-3) , 2005 - 06 : India: Volume I. Mumbai: IIPS. 2007 . https://dhsprogram.com/pubs/pdf/FRIND3/FRIND3-Vol1AndVol2. pdf. Accessed 16 Dec 2015 .
2. Chakraborty D , Mondal NK , Datta JK . Indoor pollution from solid biomass fuel and rural health damage: A micro-environmental study in rural area of Burdwan, West Bengal . International Journal of Sustainable Built Environment . 2014 ; 3 ( 2 ): 262 - 71 .
3. Sinha SN , Kulkarni P , Shah S , Desai N , Patel G , Mansuri M , Saiyed H . Environmental monitoring of benzene and toluene produced in indoor air due to combustion of solid biomass fuels . Sci Total Environ . 2006 ; 357 ( 1 ): 280 - 7 .
4. Naeher LP , Brauer M , Lipsett M , Zelikoff JT , Simpson CD , Koenig JQ , Smith KR . Woodsmoke health effects: a review . Inhal Toxicol . 2007 ; 19 ( 1 ): 67 - 106 .
5. WHO: Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide: global update 2005: summary of risk assessment . http://apps.who.int/iris/bitstream/10665/69477/1/WHO_ SDE_PHE_OEH_ 06 .02_eng. pdf. Accessed 16 Dec 2015 .
6. Fullerton DG , Bruce N , Gordon SB . Indoor air pollution from biomass fuel smoke is a major health concern in the developing world . Trans R Soc Trop Med Hyg . 2008 ; 102 ( 9 ): 843 - 51 .
7. Smith KR , Mehta S. The burden of disease from indoor air pollution in developing countries: comparison of estimates . Int J Hyg Environ Health . 2003 ; 206 ( 4-5 ): 279 - 89 .
8. Martin II WJ , Hollingsworth JW , Ramanathan V . Household air pollution from cookstoves: impacts on health and climate . In: Global Climate Change and Public Health . Springer; 2014 . p. 237 - 55 .
9. Rehfuess E , Bruce N , Smith K. Solid Fuel Use: Health Effect . In: Nriagu JO (ed.) Encyclopedia of Environmental Health, v 5 , pp. 150161 Burlington: Elsevier, 2011 . Environmental Health 2011 ; 5 : 150161 .
10. WHO: Indoor air pollution: national burden of disease estimates . http:// www.who.int/indoorair/publications/indoor_air_national_burden_estimate _ revised.pdf. Accessed 16 Dec 2015 .
11. Bassani DG , Jha P , Dhingra N , Kumar R . Child mortality from solid-fuel use in India: a nationally-representative case-control study . BMC Public Health . 2010 ; 10 ( 1 ): 491 .
12. Upadhyay AK , Singh A , Kumar K , Singh A . Impact of indoor air pollution from the use of solid fuels on the incidence of life threatening respiratory illnesses in children in India . BMC Public Health . 2015 ; 15 ( 1 ): 300 .
13. WHO: Causes of child mortality, by country , 2000 - 2010 . http://www.who.int/ gho/child_health/mortality/mortality_causes_text/en/. Accessed 16 Dec 2015 .
14. Institute for Health Metrics and Evaluation (IHME) : GBD PROFILE: India . http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ ihme_gbd_ country_report_india.pdf. Accessed 16 Dec 2015 .
15. Patel I , Chang J , Srivastava J , Balkrishnan R . India's Progress towards the health related Millennium Development Goals-Child Mortality . Indian Jornal of Pharmacy Practice 2011 ; 4 ( 4 ).
16. Broor S , Pandey RM , Ghosh M , Maitreyi RS , Lodha R , Singhal T , Kabra SK . Risk factors for severe acute lower respiratory tract infection in under-five children . Indian Pediatr . 2001 ; 38 ( 12 ): 1361 - 9 .
17. Mahalanabis D , Gupta S , Paul D , Gupta A , Lahiri M , Khaled M . Risk factors for pneumonia in infants and young children and the role of solid fuel for cooking: a case-control study . Epidemiol Infect . 2002 ; 129 ( 01 ): 65 - 71 .
18. Mishra V , Smith KR , Retherford RD . Effects of cooking smoke and environmental tobacco smoke on acute respiratory infections in young Indian children . Popul Environ . 2005 ; 26 ( 5 ): 375 - 96 .
19. Ramesh Bhat Y , Manjunath N , Sanjay D , Dhanya Y. Association of indoor air pollution with acute lower respiratory tract infections in children under 5 years of age . Paediatr Int Child Health . 2012 ; 32 ( 3 ): 132 - 5 .
20. Sharma S , Sethi GR , Rohtagi A , Chaudhary A , Shankar R , Bapna JS , Joshi V , Sapir DG . Indoor air quality and acute lower respiratory infection in Indian urban slums . Environ Health Perspect . 1998 ; 106 ( 5 ): 291 .
21. Epstein MB , Bates MN , Arora NK , Balakrishnan K , Jack DW , Smith KR . Household fuels, low birth weight, and neonatal death in India: the separate impacts of biomass, kerosene, and coal . Int J Hyg Environ Health . 2013 ; 216 ( 5 ): 523 - 32 .
22. Pandey S , Lin Y. Adjusted effects of domestic violence, tobacco use, and indoor Air pollution from use of solid fuel on child mortality . Matern Child Health J . 2013 ; 17 ( 8 ): 1499 - 507 .
23. Tielsch JM , Katz J , Thulasiraj RD , Coles CL , Sheeladevi S , Yanik EL , Rahmathullah L . Exposure to indoor biomass fuel and tobacco smoke and risk of adverse reproductive outcomes, mortality, respiratory morbidity and growth among newborn infants in south India . Int J Epidemiol . 2009 ; 38 ( 5 ): 1351 - 63 .
24. Gurley E , Homaira N , Salje H , Ram P , Haque R , Petri W , Bresee J , Moss W , Breysse P , Luby S. Indoor exposure to particulate matter and the incidence of acute lower respiratory infections among children: A birth cohort study in urban Bangladesh . Indoor Air . 2013 ; 23 ( 5 ): 379 - 86 .
25. Gurley ES , Salje H , Homaira N , Ram PK , Haque R , Petri Jr WA , Bresee J , Moss WJ , Luby SP , Breysse P , et al. Seasonal concentrations and determinants of indoor particulate matter in a low-income community in Dhaka, Bangladesh . Environ Res . 2013 ; 121 : 11 - 6 .
26. Khalequzzaman M , Kamijima M , Sakai K , Chowdhury NA , Hamajima N , Nakajima T. Indoor air pollution and its impact on children under five years old in Bangladesh . Indoor Air . 2007 ; 17 ( 4 ): 297 - 304 .
27. Khalequzzaman M , Kamijima M , Sakai K , Ebara T , Hoque BA , Nakajima T. Indoor air pollution and health of children in biomass fuel-using households of Bangladesh: comparison between urban and rural areas . Environ Health Prev Med . 2011 ; 16 ( 6 ): 375 - 83 .
28. Khalequzzaman M , Kamijima M , Sakai K , Hoque BA , Nakajima T. Indoor air pollution and the health of children in biomass-and fossil-fuel users of Bangladesh: situation in two different seasons . Environ Health Prev Med . 2010 ; 15 ( 4 ): 236 - 43 .
29. Murray E , Brondi L , Kleinbaum D , McGowan J , Van Mels C , Brooks W , Goswami D , Ryan P , Klein M , Bridges C . Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study . Indoor Air . 2012 ; 22 ( 2 ): 132 - 9 .
30. International Institute for Population Science (IIPS). National Family Health Survey (MCH and Family Planing) , India 1992 - 93 . Mumbai: IIPS. 1995 . http://www.dhsprogram.com/pubs/pdf/FRIND1/FRIND1.pdf. Accessed 16 Dec 2015. Accessed 16 Dec 2015 .
31. International Institute for Population Science (IIPS) and ORC Macro . National Family Health Survey (NFHS-2) , 1998 - 99 : India. Mumbai: IIPS. 2000 . http://www.dhsprogram.com/pubs/pdf/FRIND2/FRIND2.pdf. Accessed 16 Dec 2015 .
32. Choi J-Y, Baumgartner J , Harnden S , Alexander BH , Town RJ , D'Souza G , Ramachandran G . Increased risk of respiratory illness associated with kerosene fuel use among women and children in urban Bangalore, India . Occup Environ Med . 2015 ; 72 ( 2 ): 114 - 22 .
33. Wichmann J , Voyi K. Influence of cooking and heating fuel use on 1-59 month old mortality in South Africa . Matern Child Health J . 2006 ; 10 ( 6 ): 553 - 61 .
34. Ezeh OK , Agho KE , Dibley MJ , Hall JJ , Page AN . The effect of solid fuel use on childhood mortality in Nigeria: evidence from the 2013 cross-sectional household survey . Environ Health . 2014 ; 13 ( 1 ): 113 .
35. Kashima S , Yorifuji T , Tsuda T , Ibrahim J , Doi H. Effects of traffic-related outdoor air pollution on respiratory illness and mortality in children, taking into account indoor air pollution , in Indonesia. J Occup Environ Med . 2010 ; 52 ( 3 ): 340 - 5 .
36. Naz S , Page A , Agho KE . Household Air Pollution and Under-Five Mortality in Bangladesh ( 2004 - 2011 ). Int J Environ Res Public Health . 2015 ; 12 ( 10 ): 12847 - 62 .
37. Rehfuess EA , Tzala L , Best N , Briggs DJ , Joffe M. Solid fuel use and cooking practices as a major risk factor for ALRI mortality among African children . J Epidemiol Community Health . 2009 ; 63 ( 11 ): 887 - 92 .
38. Rinne ST , Rodas EJ , Rinne ML , Simpson JM , Glickman LT . Use of biomass fuel is associated with infant mortality and child health in trend analysis . Am J Trop Med Hyg . 2007 ; 76 ( 3 ): 585 - 91 .
39. Filmer D , Pritchett LH . Estimating wealth effects without expenditure data-or tears: an application to educational enrollments in states of India . Demography. 2001 ; 38 ( 1 ): 115 - 32 .
40. Dasgupta S , Huq M , Khaliquzzaman M , Pandey K , Wheeler D. Indoor air quality for poor families: new evidence from Bangladesh . Indoor Air . 2006 ; 16 ( 6 ): 426 - 44 .
41. Arifeen S , Black RE , Antelman G , Baqui A , Caulfield L , Becker S. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums . Pediatrics . 2001 ; 108 ( 4 ): e67 - e67 .
42. Black RESSJ . Where and why are 10 million children dying every year? Lancet . 2003 ; 361 ( 9376 ): 2226 .
43. Cushing AH , Samet JM , Lambert WE , Skipper BJ , Hunt WC , Young SA , McLaren LC . Breastfeeding reduces risk of respiratory illness in infants . Am J Epidemiol . 1998 ; 147 ( 9 ): 863 - 70 .
44. Heinig MJ . Host defense benefits of breastfeeding for the infant: effect of breastfeeding duration and exclusivity . Pediatr Clin North Am . 2001 ; 48 ( 1 ): 105 - 23 .
45. Prasad R , Singh A , Garg R , Hosmane GB . Biomass fuel exposure and respiratory diseases in India . Drug Discoveries & Therapeutics 2012 , 6 ( 5 ): 219 - 28 .
46. Balakrishnan K , Ramaswamy P , Sambandam S , Thangavel G , Ghosh S , Johnson P , et al. Air pollution from household solid fuel combustion in India: an overview of exposure and health related information to inform health research priorities . Glob Health Action . 2011 ; 4 .
47. Agrawal S. Effect of indoor air pollution from biomass and solid fuel combustion on prevalence of self-reported asthma among adult men and women in India: findings from a nationwide large-scale cross-sectional survey . J Asthma . 2012 ; 49 ( 4 ): 355 - 65 .
48. Mishra VK , Retherford RD . Cooking smoke increases the risk of acute respiratory infection in children . 1997 . http://www.eastwestcenter.org/ fileadmin/stored/pdfs/NFHSbull008.pdf. Accessed 16 Dec 2015 .
49. Ahmed LA . Women's roles in addressing indoor air pollution issues in Bangladesh: Knowledge and attitude . Providence, RI, United States: Brown University; 2003 .
50. Rouse J . Indoor air pollution: issues for Bangladesh. UK-Water, Engineering and Development Centre (WEDC ): Loughborough University; 2000 . Accessed 16 Dec 2015 .
51. Polsky D , Ly C. The health consequences of indoor air pollution: A review of the solutions and challenges . White paper Philadelphia: University of Pennsylvania Retrieved October 2012 , 8 : 2012 .
52. Chengappa C , Edwards R , Bajpai R , Shields KN , Smith KR . Impact of improved cookstoves on indoor air quality in the Bundelkhand region in India . Energy Sustain Dev . 2007 ; 11 ( 2 ): 33 - 44 .
53. Roden CA , Bond TC , Conway S , Pinel ABO , MacCarty N , Still D . Laboratory and field investigations of particulate and carbon monoxide emissions from traditional and improved cookstoves . Atmos Environ . 2009 ; 43 ( 6 ): 1170 - 81 .
54. Kishore V , Ramana P . Improved cookstoves in rural India: how improved are they?: A critique of the perceived benefits from the National Programme on Improved Chulhas (NPIC) . Energy . 2002 ; 27 ( 1 ): 47 - 63 .
55. Wilkinson P , Smith KR , Davies M , Adair H , Armstrong BG , Barrett M , Bruce N , Haines A , Hamilton I , Oreszczyn T. Public health benefits of strategies to reduce greenhouse-gas emissions: household energy . Lancet . 2009 ; 374 ( 9705 ): 1917 - 29 .