Assessment of the association between health problems and cooking fuel type, and barriers towards clean cooking among rural household people in Bangladesh

In low- and middle-income countries, household cooking primarily relies on solid fuels such as wood, charcoal, dung, agricultural residues, and coal [1]. However, their use has raised significant public health concerns and garnered considerable attention. Traditional open-fire cooking methods are highly inefficient and release harmful particulates and gaseous substances into the household air, causing approximately 4 million premature deaths annually [2], with women and children being particularly vulnerable [3]. Literature indicates that the combustion of solid fuels in inefficient stoves produces hazardous substances, including suspended particulate matter (PM), carbon monoxide, poly-aromatic hydrocarbons, poly-organic matter, and formaldehyde, resulting in severe health consequences [4]. These adverse effects are associated with public health hazards such as reduced lung function, respiratory illnesses, asthma, pneumonia, tuberculosis, eye disorders, pregnancy complications, cardiovascular disease, and cancer [5]. Furthermore, traditional domestic energy methods also have detrimental effects on health, safety, and overall well-being [6].

Compared to solid fuels, cleaner alternatives like electricity and gases are often considered healthier and less detrimental to human health [7]. Cooking with clean fuel supports women’s empowerment, provides public health benefits, and reduces health damage from indoor air pollution [8]. Recognizing the extensive negative consequences of polluting solid cooking fuels, one of the Sustainable Development Goals (SDGs) prioritizes universal access to clean cooking (part of SDG target 7.1) [9]. This target has been directly linked to achieving various other SDG targets as well [10]. While clean cooking fuels or gases are prevalent in cities, biomass fuels continue to be widely used in rural areas. Current projections suggest that a third of the world’s population will still rely on polluting fuels in 2030 [2]. Efforts have been made over time to elucidate the factors contributing to this outcome.

Bangladesh, a lower-middle-income country, has the lowest access to clean cooking fuels. Approximately 94% of rural Bangladeshi households cook and heat using solid fuels like wood, coal, and animal dung [11]. Previous studies in Bangladesh have demonstrated the negative association of cooking with solid fuels with respiratory and eye health [12], cardiovascular health [13], under-five mortality [14], and adverse obstetric outcomes among women exposed to biomass fuel [15]. Solid fuel users, in comparison to clean fuel users, exhibited significantly higher blood pressure [16]. Furthermore, household air pollution (HAP) from solid fuel cooking has emerged as a significant contributor to fatalities and disabilities in many developing countries, including Bangladesh [17].

There exists a significant barrier or gap hindering the widespread acceptance and usage of clean cooking fuels in Bangladesh and globally, which poses a notable challenge [18]. Researchers attribute this barrier to a range of factors, including socio-cultural, economic, political, and institutional challenges [19]. Without addressing and dismantling these barriers through the implementation of integrated economic and social policies, the realization of various Sustainable Development Goal (SDG) targets remains an aspirational goal with limited chances of success [20].

This study aims to contribute to the existing literature by highlighting the comparison between health issues and cooking fuel categories, along with barriers to adopting clean cooking. The fuel categories are broadly classified into two groups. Initially, we assessed the predominant fuel types used by participants, categorizing them into: solid fuel and clean fuel, in alignment with findings from prior research [21, 22]. Given that the outcome or dependent variable in our study is binary, we opted for binary logistic regression, consistent with established practices outlined in the existing literature [23, 24]. The study investigates and compares health problems associated with these cooking fuels, specifically analyzing the frequency of health issues experienced by rural individuals when using solid fuels compared to clean fuels. Subsequently, the research delves into identifying barriers towards clean cooking in rural settings, despite the numerous health benefits associated with it.

Our study introduces two novel aspects. Firstly, unlike previous studies that primarily concentrate on the health effects of solid fuels within limited regions, we compare the health effects across different fuel categories, encompassing a large geographical area in rural Bangladesh with a substantial sample size. Secondly, despite some global studies addressing clean cooking barriers, none specifically focus on these barriers in Bangladesh. Our study offers valuable insights into the challenges of adopting clean cooking practices in rural Bangladesh. The transition to clean energy sources is a topic under consideration by regional governments, yet little has been explored regarding the potential health effects of such a shift. Our findings can provide valuable information for policymakers dealing with this specific population.

The socio-demographic characteristics of the participants are introduced in Table 1. A total number of 1240 participants were included in this study, the majority of whom were female (83.4%) and fell within the age range of ≥ 40 years (42%). The majority of the participants (75.7%) were housewife where largest proportion of the respondent from lower socioeconomic status (59.8%). Additionally, Majority of respondents (41.8%) were from Chattogram division followed by Dhaka (28.3%), Rajshahi (16.9%), Mymensingh (13%) and largest proportion of people are living there over 5 years (85.9%). Solid fuels are used for cooking in majority households (73.3%) compared to clean fuel (26.7%). In terms of health-related information, a notable number of respondents had respiratory-related symptoms (cough 11.1%, Pressure in chest while breathing 11% etc.), eye related problems (Itching or burning in eyes 16.9%, Discomfort in eyes 17.9% etc.), diabetes (12.4%), hypertension (21.1%), and allergy (32.6%).

Table 2 shows identified factors associated with cooking fuel type. The adjusted models contained the variables shown to be significant in the binary logistic regression analysis. In the adjusted model, participants who had no educational qualification, primary and secondary level education were 8.53 times, 7.60 times and 4.69 times more likely to have solid fuel user (AOR [Adjusted odds ratio] = 8.53, 95% CI [Confidence interval] = 3.22 – 22.61, p < 0.001, AOR = 7.60, 95% CI = 3.33 – 17.34, p < 0.001 and AOR = 4.69, 95% CI = 2.19 – 10.05, p < 0.001, respectively) compared to participants who had studied university or above. Participants from lower socioeconomic status were 13.27 times and 5.25 times more likely to solid fuel use (AOR = 13.27, 95% CI = 6.82 – 25.85, p < 0.001 and AOR = 5.25, 95% CI = 2.87 – 9.60, p < 0.001, respectively) compared to participants who had higher socioeconomic status. Respondents who lived in Chattogram and Rajshahi division were 6% and 10% less likely to have solid fuel user (AOR = 0.06, 95% CI = 0.04–0.12, p < 0.001 and AOR = 0.10, 95% CI = 0.05–0.20, p < 0.001, respectively) compared to respondents who lived in Dhaka division. People who were living for 2 to 5 years in their location were 25% less likely to have solid fuel use compared to people who were living for less than 2 years (AOR = 0.25, 95% CI = 0.07 – 0.84, p = 0.024).

Table 3 shows identified health problems associated with cooking fuel type. The variables ascertained to be significant in the binary logistic regression analysis were added in the adjusted models. The adjusted model revealed that people who had cough related problems were 2.06 times more likely to have solid fuel use compared to people who had no cough related problems (AOR = 1.41, 95% CI = 0.80 – 2.92, p = 0.030). Participants who had pressure in chest while breathing were 2.52 times more likely have solid fuel user compared to those who had no pressure in chest while breathing (AOR = 2.52, 95% CI = 1.15 – 5.53, p = 0.021). Again, people who had discomfort in eyes were 2.31 times more likely to have solid fuel use compared to those who had no discomfort in eyes (AOR = 2.31, 95% CI = 1.18 – 4.55, p = 0.015). The adjusted model also revealed that participants who had no diabetes and didn’t know whether they had diabetes were 2.40 times and 9.54 times more likely to have solid fuel use (AOR = 2.40, 95% CI = 1.45 – 3.10, p < 0.001, AOR = 9.54, 95% CI = 4.06 – 22.41, p < 0.001, respectively) in comparison with those who had diabetes. People who didn’t know that they had asthma were 3.69 times more likely to have solid fuel user compared to those who had asthma (AOR = 3.69, 95% CI = 1.36 – 10.01, p = 0.011). Finally, the participants who didn’t know whether they had allergies were 35% less likely to have solid fuel use compared to participants who had allergies (AOR = 0.35, 95% CI = 0.14 – 0.87, p = 0.024).

Figure 3 illustrates the barriers to clean cooking adoption. The data revealed that a higher percentage of participants (46.96%) cited economic problems as the primary reason for not using clean cooking fuel. Additionally, 8.63% of respondents identified a lack of awareness as a barrier, while 8.09% mentioned socio-cultural norms, customs, and practices. Furthermore, 6.22% of participants expressed concerns about losing the taste of food when cooking with clean fuel. Other barriers included social factors (7%), insufficient information about clean fuel (6.92%), maintenance issues with clean fuel (4.43%), a shortage of clean fuel or its unavailability (4.28%), attitudes towards technology (3.34%), problems related to the distribution of clean fuel (2.96%), and miscellaneous factors (1.17%), all contributing to obstacles in adopting clean cooking practices.

The use of solid fuel is a significant contributor to health problems in many low and middle-income countries, including Bangladesh. This study, to the best of our knowledge, is the first of its kind, covering four different divisions or regions in Bangladesh, aiming to investigate the association between health problems and cooking fuel type, along with barriers towards clean cooking. The findings revealed that approximately three-fourths of the participants used solid fuel for cooking. In the adjusted multivariate logistic model, the use of solid fuels was strongly associated with factors such as education, monthly family income, divisions/regions, and duration of living. Consequently, health problems such as cough, chest pressure while breathing, eye discomfort, diabetes, asthma, and allergies were strongly associated with solid fuel use. Economic problems were identified as the main barrier among others towards clean cooking.

Our study showed that 73.3% of rural households use solid fuel for cooking. While this finding is slightly more satisfactory than a previous study conducted in rural Bangladesh, which reported 94% of households using solid fuels for cooking [11], it still highlights a significant reliance on solid fuels. The government of Bangladesh has taken noteworthy initiatives for clean cookstoves to minimize solid fuel use [46]. Worldwide studies on the status of solid fuel use show diverse data, with around 80.5% of rural households in India using solid fuels [47], 95% in rural Pakistan [48], 95% in rural Myanmar [49], and 75% in rural China reported solid fuel use [50]. Factors associated with solid fuel use include economic problems, lack of awareness of the risks of solid fuels, and socio-demographic and socio-cultural influences [19].

A significant association was observed between illiteracy and the use of solid fuel, consistent with a previous cross-sectional study in Bangladesh that noted a higher prevalence of solid fuel use among individuals without formal education [39]. Similar patterns have been documented in other regions globally, such as in India [51] and Pakistan [52]. The likely causes contributing to this observation may include a lower awareness and a knowledge gap regarding the health risks associated with the use of solid fuel [18].

In the current study, a lower socioeconomic status (less than 15,000 BDT monthly) was significantly linked to the use of solid fuel. This finding aligns with a study in China, which reported that regions with low per capita household income are more reliant on solid fuel [50]. The prevalence of solid fuels in rural areas and the high prices of cleaner fuels compel households in rural Bangladesh to resort to cooking with solid fuel.

Our study revealed a significant association between cough, chest pressure while breathing, and eye discomfort with the use of solid fuel, consistent with similar findings in a study conducted in Bogura district, Bangladesh [31]. Comparable results have been reported in various parts of the world, including Nigeria [53], Uganda [54], China [55], and Nepal [12]. Moreover, diabetes, asthma, and allergies were also found to be significantly related to the use of solid fuel. Although a similar comprehensive study is lacking in Bangladesh, various global studies have addressed these issues. A cross-sectional study in China, for instance, established a strong connection between the use of household solid fuels and an elevated risk of diabetes [56]. Another study in India identified significant associations between asthma, allergies, and the use of solid fuel [57, 58].

Household members, particularly women and children, are highly exposed to household air pollutants such as respirable and fine particulate matter (PM2.5, PM10) and other gaseous substances released by solid fuels [26, 59]. These harmful air pollutants contribute to the development of asthma and allergy-related health problems in household members [60]. Additionally, PM pollution, particularly PM2.5, has a significant impact on blood glucose levels [61]. PM exposure elevates blood glucose levels through an increase in glucocorticoids [62]. Moreover, the majority of women who used solid cooking fuel experienced a negative impact on their blood pressure, a critical risk factor for diabetes mellitus [13]. Another study conducted in India reported that exposure to biomass fuel smoke significantly accelerates the prevalence of symptoms related to respiratory and eye problems [63]. Additionally, our findings indicate that economic problems are the main barriers to adopting clean cooking practices, consistent with results from a systematic literature review [19]. Furthermore, the tendency to lose food taste with clean fuels was identified as one of the significant barriers in Bangladesh.

Overall, this study provides valuable insights into the complex interplay of socio-demographic factors, health outcomes, and barriers influencing cooking fuel choices in rural Bangladesh. Addressing these factors is essential for promoting clean cooking practices, mitigating health risks, and contributing to sustainable development goals related to health and environmental sustainability.

In conclusion, this study underscores the substantial health risks associated with the persistent use of solid fuels for cooking in rural households in Bangladesh. Solid fuel use is linked to severe health consequences, including respiratory problems, eye ailments, diabetes, asthma, and allergies, compared to those using clean fuels. The findings emphasize the importance of considering cooking fuels as a significant factor in national-level policies and programs aimed at minimizing adverse health effects. Bangladesh’s ongoing efforts to achieve the SDGs, particularly the target of universal access to clean cooking energies, should prioritize addressing the implications of cooking fuel choices. Neglecting the development and implementation of technology for clean cooking compromises the attainment of other SDGs. This study contributes to policymaking by advocating for the adoption of clean fuels and raising awareness about the detrimental impacts of solid fuels. Collaborative efforts involving policymakers, local communities, and stakeholders, aimed at reducing barriers, can lead to meaningful improvements in clean cooking practices and overall well-being in rural areas. Future research, especially employing a qualitative approach, will further enhance our understanding of the current issues.