Around three billion people in the world, and 90% of the rural households in the low- and middle-income countries utilize solid fuel for cooking and heating using traditional stoves [1
]. Such inefficient cooking and heating practices produce high levels of household air pollution (HAP) including a range of health damaging pollutants, such as small soot particles that penetrate deep into the lungs, and carbon monoxide (CO) with exposures often far exceeding national standards and international guidelines. Exposure to HAP has been associated with a range of adverse health outcomes including chronic obstructive pulmonary disease (COPD), lung cancer, airway infections, tuberculosis and diseases of the eye in adults; low birth weight and, of particular concern, acute lower respiratory infections (ALRI) such as pneumonia amongst children less than five years of age [3
]. Each year, close to 4 million people worldwide die prematurely from illnesses attributable to HAP, which is also responsible for an estimated 3.7% of the overall disease burden in low- and middle-income countries [2
There have been global and local initiates and interventions including The Global Alliance for Clean Cook Stoves, to alleviate the problem of HAP due to solid fuel by supporting adoption of clean and safe household cooking solutions [4
]. However, different research findings indicate the existence of resistance to accept some technologies and/or failure of achieving the desired objective in preventing the health problems in some communities [5
Exposure to HAP and resulting health risks vary greatly in different types of societies because of cultural differences and household behaviors of cooking. It is also affected by age, sex and other socio-economic characteristics of the population under consideration putting the mothers and young children at higher risk in most cultures [3
]. As a result, use of behavior intervention along with cook stove technologies and ventilation options have been used as intervention packages to address the problem of HAP and found to be effective [10
Contextual understanding of the socio-cultural and other determinants of cooking behavior using a qualitative approach is crucial to plan appropriate interventions for the target community. To our knowledge, no prior study explored the existing practice and perceptions by involving men and women in rural Ethiopia. In the study, we sought to answer the following research questions:
How do current traditional cooking practices affect HAP?
What are the barriers for improvements?
What does the community know about the health problems related to HAP?
How strong is the intention of the community towards changing the traditional cooking to reduce HAP?
Like other rural areas in different developing countries, biomass was the only fuel option in the community. Previous studies also reported that nearly all rural communities used biomass fuel for cooking [8
]. However, our finding regarding not using charcoal as a fuel source by the community for either cooking or heating was inconsistent with other findings reporting its continuing use by many in rural communities [19
]. Despite a recent study in 2011 [20
] in the same region claiming no use of improved cook stoves, our evidence shows improvements in the use of locally produced cook stoves by the community. During the discussion, the community members reported that a local NGO, which took the responsibility of distributing the cook stoves, did not sustain the supply while there was demand. This could be considered as a lack of an enabling environment for the community to adopt and sustain the changes.
The community used biomass, mainly wood, regardless of the type of stove. A shortage of firewood and absence of forests in the area could be used as an opportunity to shift the biomass fuel use to cleaner energy options, particularly solar energy in the area. This could be feasible due to Ethiopia being listed as one of the countries with the highest solar resources and in the long run, the cost of investing in such alternatives was confirmed to be of the same order as cooking with conventional fuels [22
]. However, solar cooking in rural area is still a critical and not well-developed technology especially in the developing world. Eswara and Ramakrishnarao noted in their study that high initial cost of investment in the use of solar energy was a hurdle for small-scale food processing [23
The participants reported that more than half the community in the area had a separated kitchen in which to cook food. Obviously, there have been changes in the housing conditions and cooking in separated houses in the last two decades illustrated by comparing with a previous study which reported 95% of the inhabitants in the same rural area had one single room for living and cooking [24
]. Nevertheless, the use of traditional stoves and tukul houses with poor ventilation for cooking in the separated kitchens subjected the mothers to similar risks of developing different health problems as cooking in the main living house. To this end, previous studies identified a higher occurrence of cataracts and different respiratory symptoms, including chronic obstructive pulmonary disease and reduction in the lung function among mothers exposed to biomass smoke [3
]. As expected, mothers and young children, including the infants, were at highest risks whether the household used the main living house or a separated kitchen for cooking [9
Our findings showed that the availability and practice of ventilation in the cooking area was poor, as the participants mentioned either the mothers not opening existing windows regularly or there were no windows at all. A study from China also reported the existence of never opened windows during the winter period, but ventilation was significantly improved after delivery of health education [10
]. It has been recommended that the presence of at least one or more windows in the kitchen area is critical, including adequate size and cross ventilation to facilitate natural ventilation [27
A lack of economic resources was the leading barrier to change the existing tradition of cooking and the housing conditions as stated by the participants of the study. It is obvious the economy of the household could determine the type of house and the possibility to invest in alternative fuels and improved cook stoves. Other studies from Uganda and Nepal also identified financial considerations as the most influential factors related to improved cook stove acquisition and use [11
]. A report from another region in Ethiopia also found that women were willing to change cooking practices but were unable to afford cleaner fuels or improved stoves [29
The absence of prioritizing health benefits over other social and personal needs was noticeable. In our study, some participants linked this with a low level of education and lack of enough awareness regarding the long-term effects of exposure to household air pollution. This was also consistent with responses in the Nepalese study [28
]. The fear of fire hazard and being afraid of thieves were the safety and security reasons for not cooking outside and having open windows. We were unable to find similar reasons in other studies. The tradition of cooking inside a house by considering a smoky indoor air as a natural event was consistent with the Nepalese study [28
The community perceived that wood smoke had benefits for strengthening and preserving the tukul houses, to avoid bad smells from the cows and to control pests. Moreover, they perceived that it was good for the health of a mother and newborn during the postpartum period and had a positive cultural value of keeping the house smoky as a sign of existence of inhabitants and indicating good social status. This could also result in hindering the possibilities of shifting the traditional cooking to cleaner energy in the future. A systematic review showed a similar reason of smoke protecting against insects being a barrier of adoption of cook stove interventions [30
All participants perceived that HAP was risky for the eyes and respiratory health problems. From the discussions, they specifically mentioned almost all respiratory symptoms, pneumonia, tuberculosis, and effects on lungs including asthma. This is consistent with previous findings where mothers were aware of the health effects of wood smoke in the respiratory and eye health problems [28
]. We included and asked the men/husbands in our study whose health they believed to be more affected by the smoke–they believed it is the women’s health.
Overall, we found the community had a positive attitude towards using improved cook stoves and intended changes in spite of the barriers and their perception towards the benefits of the wood smoke. Participants also reported on the shortage of firewood in the area and using the farmland to plant trees to solve it. This could be taken as a missed opportunity to implement large-scale cook stove intervention to address the problem of household air pollution in the area as it could facilitate the acceptance of the intervention by the community [32
]. A qualitative study in Kenya also found that women preferred stoves, which helped them use less fuel [33
This is a qualitative study in a specific ethnic group thus the study cannot be generalized to the national level, as the housing, tradition of cooking and related community beliefs and perceptions are culture specific. However, we included both sexes and health extension workers from different areas of the locality to increase the transferability of the findings. The lead author had repeated exposure to the community in the area and all authors had visited some homes before the data collection, which helped improve understanding of the situation and gain consensus on the meanings.