Background
Household air pollution
Stove technologies exist, but there is a gap in understanding stove use behaviors
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Exposures to other sources of air pollution, such as outdoor fires to cook animal fodder, use of kerosene lamps for lighting, visits to neighboring homes where open cooking fires are used, trash burning near the home, and the continued use of the traditional stove [29, 30] dilute the impact of an introduced clean fuel stove, such as gas or electric stoves.
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‘De-implementation’ efforts to discourage the use of the traditional stove and fuel sources, such as incentivizing families to remove the stove from the home, have not been well integrated into intervention studies.
Stove research in Guatemala
Implementation science and new stove adoption
Methods
Participants and setting
Ethics approval and consent to participate
Study procedures
Focus groups
NACER II study
Stove use monitoring
Data analysis
Results
Thematic analysis of focus group discussions
Enabler | Barrier | Enabler or barrier | |
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Free gathered wood | X | ||
Affordable wood delivered to home | X | ||
Shame of being different than neighbors if own new stove | X | ||
Worried neighbors will envy them if own new stove | X | ||
Plancha stove meets most cooking demands | X | ||
Plancha heats the room, providing warmth | X | ||
Older women are accustomed to using the plancha and afraid of gas | X | ||
Older women are afraid of gas | X | ||
Inorganic refuse needs to be burned in outdoor open fires | X | ||
Animal food needs long cooking times over open fire to not “waste gas” | X | ||
Difficult to access gas tank refills | X | ||
Explosion danger from gas stove | X | ||
Newly married women are financially constrained | X | ||
Younger women are not the decision-makers in the household | X | ||
Uncured or wet wood during rainy season is smoky | X | ||
During cold weather windows are closed, increasing smoke | X | ||
Burn danger to child if near open fire | X | ||
Knowledge about climate change | X | ||
Knowledge about health impacts of breathing smoke | X | ||
Clean kitchens, cooking pots and clothes | X | ||
Young women want to be “modern” and use gas stoves | X | ||
Cost of wood versus gas fuel is unknown | X | ||
Men provide money for stove repair costs | X | ||
Men are in charge of constructing doors/windows/kitchens | X | ||
Smoldering fire is bothersome, but people learn to adapt | X |
NACER II study
Maternal characteristics | |
Maternal age, years, mean (range) | 25.4 (18.4–38.8) |
Maternal education, n (%) (n = 49) | |
None | 13 (27) |
Completed elementary school | 13 (27) |
Completed middle school | 7 (14) |
Completed high school | 16 (32) |
Principal source of income in the home | |
Tenant farmers/works the land of others | 25 (50) |
Employee in public/private sector | 13 (26) |
Construction | 4 (8) |
Small business owner | 3 (6) |
Cultivates own land; weaves; sells animals | 3 (6) |
Maternal ethnicity, n (%) | |
Mam-speaking, or indigenous | 42 (86) |
Spanish-speaking, or ladino | 3 (6) |
Both | 4 (8) |
First pregnancy, n (%) | 7 (14) |
Prior pregnancies, mean (range) | 3.4 (2–10) |
Gestational age at baseline, weeks (mean, range) | 13.1 (6.7–19.7) |
Household characteristics | |
Socioeconomic status | |
Crowdinga, mean (range)) | 4.9 (1.3–12) |
Economic supportb, mean (range) | 2.3 (1–6) |
Dependency ratioc, mean (range) | 3.8 (1.4–10) |
Access to latrine, n (%) | 49 (98) |
Main water source during dry season, n (%) | |
Piped water to home | 33 (66) |
Well water | 9 (18) |
Natural well (spring) | 8 (16) |
Main house structure materials, n (%) | |
Roof | |
Aluminum | 44 (88) |
Tile/Cement | 6 (12) |
Walls | |
Adobe | 29 (58) |
Cinderblock/brick | 16 (32) |
Wood/Other | 7 (14) |
Floor | |
Cement | 28 (56) |
Dirt | 21 (42) |
Tile | 1 (2) |
Exposure to air pollution | |
Primary lighting source, n (%) | |
Candles | 2 (4) |
Electricity | 48 (96) |
Primary heating source, n (%) | |
None | 43 (86) |
Open fire | 2 (4) |
Wood chimney stove | 5 (10) |
Primary stove type | |
Open fire | 10 (20) |
Plancha stove (no chimney or deteriorated) | 40 (80) |
Stove qualityd | |
Fair | 4 (8) |
Moderate | 35 (70) |
Poor | 11 (22) |
Cooking fuel type, n (%) | |
Wood only | 7 (14) |
Wood and crop residue | 22 (44) |
Wood and plastic | 2 (4) |
Wood, crop residue and plastic | 19 (38) |
Traditional steam bath | |
Usage per week, median minutes (IQR) | 60 (30, 67) |
Symptoms associated to cooking, n (%) | |
Eyes irritated | 42 (84) |
Throat irritated/Causes coughing | 35 (70) |
Headache | 30 (60) |
Household decision-making | |
Large purchase items | |
Participant | 2 (4) |
Spouse | 22 (44) |
Both participant and spouse together | 8 (16) |
In-laws | 12 (24) |
Other family member | 6 (12) |
Small daily purchases | |
Participant | 6 (12) |
Spouse | 7 (14) |
Both participant and spouse together | 19 (38) |
In-laws | 12 (24) |
Other family member | 6 (12) |
Visiting relatives | |
Participant | 5 (10) |
Spouse only | 17 (34) |
Both participant and spouse together | 23 (46) |
In-laws | 4 (8) |
Other family members | 1 (2) |
Phase 1 and Phase 2 activities
Objectives | Learning strategies | |
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Class 1 | Discuss “simple or easy” ways of preventing exposure to smoke from burning wood and other solid fuels | Photos used to generate discussion. Images include proper ventilation, well-maintained stove, children close to open fire |
Demonstrate use of gas cookstoves and discuss benefits and barriers to use | Facilitator cooks atol (corn-based beverage) over gas stove. Stove technician reinforces proper stove use and maintenance. Participants return-demonstrate lighting and cleaning stove | |
Class 2 | Discuss options that exist for the reduction in exposure to smoke produced by burning wood to cook, in women and children | Women each receive photo representing 9 strategies to reduce smoke exposure. When moderator reads the strategy out loud, the woman with the photo attaches the photo to the wall |
Women work in groups to form puzzles with strategies to reduce smoke in the home | ||
Discuss maternal and child illnesses associated with exposure to smoke | Group discussion of personal/known experiences with illnesses such as pneumonia and low birth weight and relationship to HAP | |
Discuss frequently mentioned barrier “food tastes better cooked on wood” compared to gas stoves | Blind taste test of beans prepared in identical manner, on wood and gas stove. Discussion of which food is better, and why | |
Class 3 | Investigate perceptions regarding financial savings or costs related to gas stove that influence its use | Open discussion using flip chart to tally responses |
Discuss decision-making processes in the home that influences the sustained use of gas stoves and fuel | Small group role play “we are out of gas, what do we do now?”, followed by discussion of decision making in the home and how to improve communication | |
Compare differences in cooking time when using wood versus gas fuels and discuss time savings/leisure time | Cook off: half of group cooks atol over an open wood fire, the other half cooks over a gas stove. Compare time saved, taste of food, and discuss how women might spend time if not using wood fires. |
Intensive behavioral intervention approach in phase 2: The diagnosis
Theoretical Domains Framework | ||
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Domains | Constructs | General assessment questions for women in target households |
Capability-Physical (COM-B) | ||
Skills | Skills Skills development | - Can women light the flame using a match and can they regulate the flame? - Can women connect the tank to the stove? - Can women turn gas on and off at the tank valve? - Can women detect and respond to a gas leak? - Can women lift and transport the tanks? - Can women keep children out of the way of the tanks when cooking or when not cooking? |
Capability-Psychological (COM-B) | ||
Knowledge | Procedural knowledge | - Do women know the sequence of steps for use of the stove on a daily basis? - Do women know how to determine the tank is empty and how to turn stove off and attach a new tank? - Do women know how to get the tank refilled and delivered to their home? |
Knowledge (related to gas stove benefits) | Household Benefits - Do women know that using the gas stove makes a cleaner kitchen? - Do women understand the economic and time-saving aspects of the stoves? Health Benefits - Do women understand the health benefits of avoiding wood smoke for them and their children? Community or Ecological Benefits - Do women know that using a gas stove reduces deforestation/saves ecologic resources? Concerns - Do women have concerns about the stove, (e.g. based on collective myth about explosion risk or other concerns)? | |
Knowledge of task environment | - Do women have the interpersonal skills to promote gas stove use within their families? | |
Memory, attention, and decision processes | Attention | - Can women remember how to use stove and tank, and can they demonstrate the steps involved? |
Decision making | - Can women recall a time when they were trying to cook and something happened to trigger them to stop using the gas stove and switch to the wood stove? | |
Cognitive overload | - Can women concentrate on using the gas stove in different types of situations (e.g. when children are under foot, when mother in law is directing in the kitchen, when guests are present)? | |
Behavioral regulation | Self-monitoring | - Do women have any symptoms that prompt them to avoid smoke exposures (headache, eye irritation, cough)? |
Action planning | - Are there some unavoidable situations where women must use wood? What are they? - Can women plan ahead to use gas for parties with large amounts of food? - Can women plan ahead to cook the animal food early on when the tank is full? | |
Motivation-Reflective (COM-B) | ||
Social/Professional Identity | Identity (within household) | - How do women feel being the owner of the gas stove? How has the stove changed how they spend their day? - Does using the gas stove resonate with view of self as good cook and wife? - What have other family members said about the stove? |
Social identity | - Do women know others who use a gas stove? - Have women seen anyone else cooking with a gas stove outside their family? - How is the women perceived by friends and family perceive her using the gas stove? | |
Group identity | - Is there a community group that women could work together with to promote gas stove use? - Would being part of a group of women who were using gas stoves enhance women’s roles in the community? - Would this strengthen women’s view of themselves? | |
Beliefs about capability | Self-confidence | - Do women feel confident they can use the gas stove for cooking most meals? Can women avoid using wood for cooking meals? Can women avoid using wood for other tasks? |
Perceived behavioral control | - Can women describe a time that they were not able to use the stove because others did not want them to? How confident were women about continuing to use the gas stove when this happens? - What things do women do to influence the health of their family? | |
Self-esteem Empowerment | - Do women believe that their actions are important for changing their family’s health? - What things do women do to influence the health of their family? - How do women think that using a gas stove can help their family’s health? | |
Optimism | Optimism Pessimism | - Do women think that their actions can positively affect their children’s health? - Do women think that no matter what they do, they cannot make a difference in children’s health? In their health? |
Identity | - Do women see themselves in charge of children and the cooking realm in the home? | |
Beliefs about consequences | Beliefs | - Do women believe that changing to gas stoves will reduce the risk of illness to their children? To self? To others? |
Outcome expectations | - Do women believe that illnesses can be controlled/avoided by their own actions? | |
Consequences | - What do women think will happen if they do not use the gas stove? - What will happen if women start using the gas stove? If they don’t like the gas stove, will they be able to change back to the wood stove easily? - What will happen if women stop using a wood stove? - What do women gain or lose from switching stoves? - What will happen if the woman tells their family that they are switching to a gas stove? | |
Intentions | Stability of intentions | - What are women’s intentions for purchasing wood in the future? - What are women’s intentions for purchasing refillable gas tanks in the future? - What are women’s intentions for repairing the gas stove if it breaks in the future? |
Goals | Goals | - What are women’s goals for preventing respiratory illnesses in the family? - What are women’s goals for using a gas stove? Using a wood stove? - How much do they want to use a gas stove? |
Motivation-Automatic (COM-B) | ||
Reinforcement | Rewards | - Are there any good reasons to use the gas stove over the wood stove? What are those reasons? |
Consequences | - Do women think that using the stove change has had other impacts in their home? Good or bad? | |
Emotion | Fear | - How afraid are women when they use the gas stove? - What makes women afraid of the stove? (probe on valve, gas leak, lighting, explosion, playing with knobs) - How afraid are women about their children getting too close to the gas stove? - What can women do to overcome these fears? - What are women afraid may happen if they use it? - Are others in the home afraid of the stove? What are they afraid of? - Do women have fears about the wood stove? What are those fears? |
Positive/negative affect | - How happy or proud are women about using the stove? - Have women’s interest in using this stove increased, or decreased or stayed the same over time? | |
Opportunity- Physical (COM-B) | ||
Environmental context and resources | Environmental stressors | - During certain seasons, is it harder to use a gas or a wood stove? What might make it easier to use the gas stove? - Have price fluctuations in the cost of tank refills affected the household? How? |
Resources/material resources | - How does the family procure gas tank refills? - Who does the stove repairs in the house? In the community? - What if the stove broke? What would the woman do? Would she be able to afford to repair it? - If she had to buy a new stove would she be able to do so? Would she have to borrow money? Can she buy a new stove on credit from a store? | |
Barriers and facilitators | - Is it hard to get gas tank refills? Why? Discuss how she would go about refilling the tank when it is empty - Is it hard to make repairs to the gas stove? Why? Discuss a time when she had to repair her stove and what she did | |
Opportunity- Social (COM-B) | ||
Social influences | Social pressure | - Do family/friends pressure women to use either the wood or the gas stove? Why does she think that happens? What if women don’t agree to use the wood stove? Can she describe an instance where this happened? |
Social supports | - Do husbands provide support for tank refills and stove repairs? How? What kind of support? - Do other friends and family provide support? How? What kind of support? | |
Group norms | - Do women think that other women similar to them are starting to use gas stoves? - Do women see themselves as setting an example for other women by using a gas stove? How does that make women feel? |
Intensive behavioral intervention approach in phase 2: The intervention functions
Behavior Targeted | Intervention function | Example | Method for assessing whether intervention function was achieved |
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Initiation of stove use and safety checking | Training | With another cook in home (preferably mother-in-law), demonstrate sequence of lighting stove, changing fuel tank and checking for leaks | At next visit, other cook return-demonstrates steps for one of these sequences. |
Recognize and avoid smoke exposures in family members, including children | Education | With other adult family members in home, discuss signs and symptoms of low birth weight, pneumonia and chronic obstructive pulmonary disease. Explain why smoke from cooking fires exacerbates conditions. Ask if they have seen conditions and what they can do to avoid smoke. | At next visit, household member states two health conditions or diseases caused or exacerbated by HAP and names one action they have done to avoid smoke exposure. |
Cooking with gas stove instead of woodstove | Persuasion | Show video of several women cooking together in smoke-free clean kitchen, with testimony from mother-in-law about how she likes her kitchen clean and free of smoke. Ask if this reflects the reality in their home. | At next visit, praise them if they have used their gas stove more frequently (measured by days from last tank refill). If they have not, ask them what they remembered about video they saw last time. |
Cooking with gas stove instead of woodstove | Incentivization | Tell family that they will receive a prize if they use their stove two times a day for one week. | At next visit, reward the family with small bag of beans and rice if they adhered to stove use for 1 week |
Cooking with gas stove instead of woodstove saves time | Modelling | Fieldworker discusses her use of gas stove and how this has benefitted her daughters-in-law who live with her, including their ability to earn more income performing other tasks, like raising animals to sell. | Ask woman if she remembers the conversation with the fieldworker from the previous visit. Ask her what things she could do with more time freed up from cooking. |
Initiate tank refill before field team’s next visit (family level) | Enablement | Ask tank delivery service to visit home with fieldworker to provide contact information and discuss future deliveries. | Within one month after end of study, family has elicited LPG tank refill and the tank was delivered to the home. |
Attempted/successful trouble shooting discussion with others in home of kitchen smoke risks (family level) | Environmental Restructuring | Discuss material costs for modifying kitchen to include an extra window with husband. Show a video of a man discussing the benefits to his family after he made this change. Trouble-shoot barriers and enablers to making structural changes in the home. | At the end of the study, reassess if any household modifications have been done that improves ventilation in the kitchen, such as new window or added door, or new kitchen where gas stove is located. |