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Abstract
Background
Household air pollution from biomass fuels burning in traditional cookstoves currently
appeared as one of the most serious threats to public health with a recent burden
estimate of 2.6 million premature deaths every year worldwide, ranking highest among
environmental risk factors and one of the major risk factors of any type globally.
Improved cookstove interventions have been widely practiced as potential solutions.
However, studies on the effect of improved cookstove interventions are limited and
heterogeneous which suggested the need for further research.
Methods
A cluster randomized controlled trial study was conducted to assess the effect of
biomass-fuelled improved cookstove intervention on the concentration of household
air pollution compared with the continuation of an open burning traditional cookstove.
A total of 36 clusters were randomly allocated to both arms at a 1:1 ratio, and improved
cookstove intervention was delivered to all households allocated into the treatment
arm. All households in the included clusters were biomass fuel users and relatively
homogenous in terms of basic socio-demographic and cooking-related characteristics.
Household air pollution was determined by measuring the concentration of indoor fine
particulate, and the effect of the intervention was estimated using the Generalized
Estimating Equation.
Results
A total of 2031 household was enrolled in the study across 36 randomly selected clusters
in both arms, among which data were obtained from a total of 1977 households for at
least one follow-up visit which establishes the intention-to-treat population dataset
for analysis. The improved cookstove intervention significantly reduces the concentration
of household air pollution by about 343 μg/m
3 (
Ḃ = − 343, 95% CI − 350, − 336) compared to the traditional cookstove method. The overall
reduction was found to be about 46% from the baseline value of 859 (95% CI 837–881)
to 465 (95% CI 458–472) in the intervention arm compared to only about 5% reduction
from 850 (95% CI 828–872) to 805 (95% CI 794–817) in the control arm.
Conclusions
The biomass-fuelled improved cookstove intervention significantly reduces the concentration
of household air pollution compared to the traditional method. This suggests that
the implementation of these cookstove technologies may be necessary to achieve household
air pollution exposure reductions.
Trial registration
The trial project was retrospectively registered on August 2, 2018, at the clinical
trials.gov registry database (
https://clinicaltrials.gov/) with the
NCT03612362 registration identifier number.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12199-020-00923-z.
Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face to face panel meeting. The resultant 12 item TIDieR checklist (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with an explanation and elaboration for each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.
Summary Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk–outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk–outcome pairs, and new data on risk exposure levels and risk–outcome associations. Methods We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk–outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings In 2017, 34·1 million (95% uncertainty interval [UI] 33·3–35·0) deaths and 1·21 billion (1·14–1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6–62·4) of deaths and 48·3% (46·3–50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39–11·5) deaths and 218 million (198–237) DALYs, followed by smoking (7·10 million [6·83–7·37] deaths and 182 million [173–193] DALYs), high fasting plasma glucose (6·53 million [5·23–8·23] deaths and 171 million [144–201] DALYs), high body-mass index (BMI; 4·72 million [2·99–6·70] deaths and 148 million [98·6–202] DALYs), and short gestation for birthweight (1·43 million [1·36–1·51] deaths and 139 million [131–147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3–6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning. Funding Bill & Melinda Gates Foundation.
Title:
Environmental Health and Preventive Medicine
Publisher:
BioMed Central
(London
)
ISSN
(Print):
1342-078X
ISSN
(Electronic):
1347-4715
Publication date
(Electronic):
4
January
2021
Publication date PMC-release: 4
January
2021
Publication date
(Print):
2021
Volume: 26
Electronic Location Identifier: 1
Affiliations
[1
]GRID grid.442845.b, ISNI 0000 0004 0439 5951, Department of Environmental Health, College of Medicine & Health Sciences, School
of Public Health, , Bahir Dar University, ; Bahir Dar, Ethiopia
[2
]GRID grid.442845.b, ISNI 0000 0004 0439 5951, Department of Epidemiology and Biostatistics, College of Medicine & Health Sciences,
School of Public Health, , Bahir Dar University, ; Bahir Dar, Ethiopia
[3
]GRID grid.411903.e, ISNI 0000 0001 2034 9160, Department of Environmental Health Sciences and Technology, , Jimma University, ; Jimma, Ethiopia
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History
Date
received
: 8
September
2020
Date
accepted
: 6
December
2020
Funding
Funded by: FundRef http://dx.doi.org/10.13039/501100005872, Bahir Dar University;
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