Abstract
Indoor air pollution (IAP) has adverse effects on the health of people, globally. The objective of this systematic review was to present the range of health problems studied in association with indoor air pollutants in South Asian countries. We searched five databases, including PubMed, Web of Science, Scopus, Google Scholar, and CAB Direct for articles published between the years 2000 and 2020. We retrieved 5,810 articles, out of which we included 90 articles in our review. Among South Asian countries, only five countries have published results related to relationship between indoor air pollutants and adverse health conditions. All studies have shown adversity of indoor air pollutants on human’s health. We found indoor solid fuel burning as a key source of indoor air pollution in the included studies, while women and children were most affected by their exposure to solid fuel burning. More than half of the studies accounted particulate matter responsible for indoor air pollution bearing negative health effects. In the included studies, eyes and lungs were the most commonly affected body organs, exhibiting common symptoms like cough, breathing difficulty and wheezing. This might have developed into common conditions like respiratory tract infection, chronic obstructive pulmonary diseases and eye cataract. In addition to promote research in South Asian countries, future research should focus on novel digital ways of capturing effects of indoor air pollutants among vulnerable segments of the population. As a result of this new knowledge, public health agencies should develop and test interventions to reduce people’s exposure levels and prevent them to develop adverse health outcomes.
Introduction
Despite indoor air pollution is a constant threat, humans are more exposed to indoor air than outdoor air as they spend more than half of their lives indoors as compared to outdoor [1]. Consequently, the origin of most of air pollution-related diseases is based on people’s exposure to their indoor environment [2]. Indoor air pollutants are the eighth-most significant risk factor that accounts for 2.7% of the global burden of disease [3]. The activities that serve as a potential source of indoor air pollution (IAP) are biomass burning and tobacco smoking while other sources are aerosols, building material, and outdoor pollution [4].
Although effects of indoor air pollution are global, the prevalence of public health concerns due to indoor air pollution is higher in Lower- and Middle-Income Countries (LMICs) such as South Asian countries. As conventional fuels, such as biomass, wood, coal and charcoal, and kerosene are cheaper to buy [5, 6] in these countries, they are primarily for the purpose of cooking and heating activities.
The burning of these conventional fuels (solid fuels and kerosene) release numerous toxic pollutants and gaseous emissions which are hazardous to health. These pollutants and gaseous chemicals include carbon compounds (e.g., carbon monoxide (CO)), sulfur compounds (SOx), nitrogen compounds (NOx), ozone, and aerosols or particulate matter (PM2.5 and PM10). The indoor air pollution of particulate matter in the LMICs accounts for around 76% of the global air pollution. On average concentration of particulate matter (PM) in South Asia is much higher from the standards set by the WHO and ranges from 300 to 3,000 μg/m3 [5], [6], [7], [8]. For instance, biomass burning results in emission of over 200 types of volatile and particulate matter [9, 10].
Various studies have reported issues related to respiratory disorders [11], [12], [13], [14], cardiovascular diseases [15], cataracts [16] and birth [17] in relationship with exposure to indoor air pollution. Indoor air pollution is responsible for 4.3 million deaths in a year. Among these death, common causes of death were stroke, ischemic heart disease, chronic obstructive pulmonary diseases pneumonia and lung cancer [15, 18].
Despite the huge burden of morbidity and mortality caused by exposure to indoor air pollutants, little attention has been given to research and studying relationship between health effects and indoor air pollutants in the South Asian countries. In this context, no systematic review has been conducted to present the range of health problems studied in association with indoor air pollutants. This review has specifically identified; (a) commonly studied indoor air pollutants; (b) health problems (disease or symptom) they have caused and (c) household members most affected by these pollutants. Findings of this review can be used to plan future studies and to develop interventions to reduce exposure and their negative health effects.
Methods
This systematic review was conducted in accordance with the Preferred Reporting and Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The review question was formulated by using the population-exposure-outcome (PEO) framework. The elements of the PEO framework were defined as; population (any household member), exposure (indoor air pollutants, including particulate matter, carbon compounds, nitrogen compounds, sulfur compounds, metal ions, and ozone), and outcome (any health outcome, including symptom and disease). Based on the PEO framework, our review question was “What are the health impacts on people exposed to indoor air pollution in South Asia?”
Search strategy
The literature search was performed in August 2020 using five electronic databases, including PubMed, Web of Science, Scopus, Google Scholar, and CAB Direct by using predefined search terms. Reason for considering Google Scholar was to ensure coverage and comprehensiveness in our search strategy. With the use of Boolean operators (AND, OR) and truncation, the search string included a combination of keywords such as “indoor air pollutants”, “household air pollutants”, “solid fuel”, “biomass burning”, “tobacco smoke”, “second-hand smoke”, “particulate matter”, “paint”, “health effects”, “health risks”, “health consequences”, “health impacts”, “adverse health outcomes”, “health problems”, “disease”, “infection”, “irritation” in combination with Boolean logic search methods. The search strategy for PubMed is given in Table 1, however, the same was modified based on each database’s requirements.
Search strategy in PubMed.
| Search strategy |
|---|
| ((((((Household pollut*) OR (indoor air pollut*)) OR (indoor air pollution[MeSH Terms])) AND ((ffrft[Filter]) AND (humans[Filter]) AND (english[Filter]) AND (2000:2020[pdat])) AND ((ffrft[Filter]) AND (humans[Filter]) AND (english[Filter]))) AND (((((((health effect) OR (health consequence)) OR (adverse health outcome)) OR (health problem)) OR (disease*)) OR (infection*)) OR (health risk) AND ((ffrft[Filter]) AND (humans[Filter]) AND (english[Filter]) AND (2000:2020[pdat])) |
Screening of articles
Two reviewers (LR and SHZN) searched the databases and checked records for their eligibility, independently. Titles, abstracts, and full texts were screened in order by applying the inclusion and exclusion criteria. The reason for articles exclusion was also recorded if they failed to meet the eligibility criteria during full-text screening. Any discrepancy in screening results was discussed among the two reviewers during regular debriefing meetings and help from the third reviewer (SMA) was sought to achieve agreement if needed.
Quality appraisal
Two reviewers (LR and SHZN) appraised all eligible studies for their quality. All eligible studies, regardless of their quality, were included in this review. We have used Critical Appraisal Skills Programme (CASP) checklists for cohort and case-control studies and Joanna Briggs Institute (JBI) checklist for cross-sectional studies to apprise the quality of studies. Reviewers assigned score to each quality indicator, where 0 referred to ‘not meeting criterion’ or 1 referred to ‘meeting criterion’. Results of quality appraisal were presented as mean.
Data extraction
Before starting the screening process, a list of extraction items was developed and piloted by two reviewers (LR and SHZN) to ensure consistency in comprehension and data extraction. Table 1 in Supplementary Material shows the names of extraction items, their description, and possible response/extraction categories. The pollutant and health outcome categories are also summarized in Tables 2 and 3 in the Supplementary Material, respectively.
Eligibility criteria
All the empirical studies in the English language related to health effects of household-level air pollution conducted in any of the South Asian countries (India, Pakistan, Bangladesh, Nepal, Bhutan, Afghanistan, Sri Lanka, and the Maldives) between the years 2000 and 2020 were included in this systematic review.
All non-English literature, non-empirical publication types, such as systematic reviews, editorials, protocols, conference abstracts, and commentaries were excluded. Case studies and secondary analysis of datasets, such as demographic health surveys were also excluded. Except for households, other indoor locations such as cars, schools, and hospitals were excluded. Effects of changes, due to the exposure to indoor air pollutants, at the molecular level were excluded, e.g., changes in the DNA structure of lymphocytes. The studies that were related to household air pollution but did not discuss its health effects were also excluded from this review.
Results
Study selection
A total of 5,810 records were screened, out of which 4,940 were excluded based on eligibility criteria. The abstracts of 870 articles were screened, of which 429 were excluded, and the remaining 441 articles qualified for full-text screening. After the full-text screening, 351 articles were excluded, and 90 unique studies were considered eligible for data extraction and were included in this review (Figure 1). The mean quality score for all eligible studies were 8 (out of 10), however, mean quality scores for cross-sectional, cohort and case-control studies were 7, 8 and 9, respectively.
PRISMA diagram.
The eligible studies comprised 59 studies from India, 10 from Bangladesh, nine from Nepal, nine from Pakistan, and three from Sri Lanka, and no records were found for Afghanistan, Bhutan, and Maldives. By study design, 68 studies were cross-sectional, nine were cohort, eight were case-control, and five were experimental studies.
Source of indoor air pollutants
We found that most of the studies have focused on cooking fuel-related indoor air pollution and the health effects associated with it. Out of 90 studies, 88% of the studies have discussed the health effects of indoor air pollution due to solid fuel burning and out of this, 70% of the studies have found negative health outcomes of indoor air pollution due to biomass burning.
Pollutants
Combustion of solid fuels resulted in emissions of various indoor air pollutants. In 49 studies, indoor air pollution and its health effects studied were related to levels of particulate matter emissions. In addition to particulate matter, carbon compounds emissions (n=39), nitrogenous compounds emissions (n=12), sulfur compounds (n=7), metal ions emissions (n=2) and ozone emissions (n=1) were also studied in relationship with indoor air pollution. Figure 2 gives the health outcomes associated with different indoor air pollutants.
Health outcomes associated with different indoor air pollutants.
Health outcomes
A list of 13 health outcomes and 12 symptoms was recorded from all the 90 eligible studies. We have presented common outcomes and symptoms studied or examined in five countries graphically in Figures 3 and 4, respectively. Almost all of the studies (85 out of 90) found that indoor air pollution had a major impact on the lungs of human beings, 20 studies reported the eyes as an affected organ and other affected organs mentioned were skin, heart, and nose.
Common diseases studied or examined in five countries.
Common symptoms studied or examined in five countries.
Outcomes in targeted population
Indoor air pollution had negative effects on the health of all men, women, and children but the most affected were women followed by children and men [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Table 2 gives the details of negative health outcomes in the context of the population of interest, and Table 3 shows relationship between health outcomes, types of pollutants and their sources.
Health outcomes associated with the population of interest.
| Population of interest | Adverse outcomes | Number of studies |
|---|---|---|
| Women | Respiratory | 48 |
| Cardiovascular | 12 | |
| Ophthalmic | 4 | |
| Children | Respiratory | 19 |
| Birth | 3 | |
| Men | Respiratory | 11 |
| Ophthalmic | 2 |
Number of studies that showed an association between health outcomes, type of pollutants and their sources.
| Serious health outcomes | Bronchitis | Asthma | TB | COPD | Lung cancer | Hypertension | Cataract | Respiratory tract infections | |
|---|---|---|---|---|---|---|---|---|---|
| Pollutants | Carbon compounds | – | 3 | 1 | 1 | 2 | 1 | 1 | 1 |
| Nitrogen compounds | – | 2 | 1 | 2 | 1 | 1 | |||
| Sulfur compounds | – | 2 | 1 | 2 | 1 | 1 | |||
| Particulate matter | 1 | 2 | 2 | 2 | 3 | 1 | 2 | 2 | |
| Source of pollution | Solid fuel | – | 1 | 1 | 1 | 3 | 1 | 1 | 1 |
| Biomass fuel | 5 | 6 | 2 | 4 | 4 | 7 | 5 | 4 | |
| Fuelwood | – | 1 | – | ||||||
| Mixed fuel | – | 1 | 1 | 1 | |||||
| Kerosene | 2 | 2 | 1 | ||||||
| Biogas | – | – | – | 1 | |||||
| Tobacco smoke | 1 | 2 | 1 | 2 |
Respiratory outcomes
Of all the studies reviewed, 53.3% showed that indoor air pollution had adverse effects on the respiratory functions of the body [14, 32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75], [76], [77]. Moreover, 58.3% of the respiratory health outcomes were related to particulate matter, particularly carbon compounds. Effects of sulfur and nitrogen compounds on respiratory health were also studied. It was found that symptoms e.g., cough, phlegm, breathing difficulty, wheezing, sneezing, and nasal irritation, leading to respiratory disorders were more common in biomass fuel users than cleaner fuel users [54, 78], [79], [80], [81]. Poor respiratory health outcomes were commonly found in women (n=45) followed by children (n=19) and men (n=11). Women working with biomass fuel but having proper ventilation were less likely to suffer from poor health conditions as compared to those working in a poorly ventilated environment. As the age of the women using biomass fuel increased, they became more susceptible to developing respiratory problems [67, 80]. According to a study conducted in India, households burning biomass fuels had two folds higher risk of asthma in elderly people compared to those living in households burning cleaner fuels [82]. It was reported that children who spent more time with their mothers in close proximity to stove-burning biomass were at greater risk of developing respiratory problems [49].
Cardiovascular outcomes
Few studies reported a strong association between indoor air pollution and the incidence of cardiovascular diseases [15, 45, 48, 53, 83], [84], [85], [86], [87], [88], [89], [90]. In this regard, particulate matter [53, 87], carbon compounds [15, 86], and ozone [86] were identified. All these studies had studied women as a population of interest. The risk of cardiovascular diseases increased with an increase in the age of women [48, 89, 90]. A study also reported that with an increment of 10 years in the age of women, the risk of hypertension increased by 40% [83]. None of these studies directly stated the association of ventilation with cardiovascular outcomes. Although, it was reported that women working in the closed kitchen were more susceptible to suffering from negative cardiovascular outcomes such as hypertension.
Ophthalmic outcomes
Very few studies found a positive association between indoor pollution and ophthalmic outcomes [31, 39, 44, 45, 87, 91], [92], [93]. None of these eligible studies assessed the ophthalmic outcomes in relation to the pollutants but only in relation to the combustion of indoor solid fuel. It was reported that biomass users had a higher risk of nuclear cataracts [39, 92]. Strong evidence was found for the positive association between biomass fuel burning and cataracts in women but not in men. With an increase in the age of women the risk of cataracts also increased [91]. Poor ventilation facilities increased the risk of exposure to indoor air pollution and ultimately ophthalmic outcomes [44].
Birth outcomes
Concerning birth outcomes, 11 studies reported a significant association between birth outcomes and indoor air pollution [17, 44, 65, 68, 77, 94], [95], [96], [97], [98]. Higher levels of particulate matter [77, 94], carbon, nitrogenous, and sulfur compounds were reported to cause negative birth outcomes [11, 77]. In poorly ventilated areas, the risk of exposure to indoor air pollution increased, and eventually, the risk of adverse birth outcomes also increased [44]. Additionally, a significant risk of low birth weight was found to be associated with households using solid fuel for cooking and heating purposes. The decrease in birth weight estimated from individual studies ranges from 65 to 186 g [94, 95, 97]. Mothers who cooked in kitchens with poor ventilation and had no chimneys were more likely to have babies with low birth weight [95].
Confounding factors
We found huge differences in studies included in our review regarding their analysis methods, hence their consideration about confounding factors. Majority of studies have considered confounding factors to some or greater extent. The most common confounding factors were related to socio-demographic factors and housing conditions. However, depending on the study objectives, few studies have considered wide variety of factors.
Discussion
This review covered the studies of the past 20 years, which were conducted in South Asian countries to assess the link between types of indoor air pollutants and associated health outcomes. Most of the studies were cross-sectional and highlighted the extent to which the burning of solid fuels in households has affected the health of women and children, who are most exposed to the burning of solid fuel. Moreover, the most common activity that involved the combustion of biomass was cooking as indicated in 55 eligible studies. This combustion results in the emission of numerous toxic components including oxides of sulfur, oxides of nitrogen, carbon compounds, and particulate matter [99, 100].
Findings of this review approved that indoor air pollution has negative effects on the health of people including respiratory, cardiovascular ophthalmic, and birth outcomes. It was observed that there were disparities between methodological approaches (such as study design, sample size, and assessment method for exposure) that studies adopted. The majority of the studies were cross-sectional and hence could not capture the changing levels of exposure and symptoms. Such methodological limitations are consistent with the literature and are most likely to be addressed with better study designs [101, 102]. There were only nine cohort studies, more adoption of which can help generate better study results, including exposure levels and health outcomes.
In South Asian countries, gendered norms are prevalent which is reflected in women’s role in the kitchen, hence they are found to be exposed to biomass smoke during cooking. This exposure level varies according to the ventilation facility, the intensity of exposure, the time served for cooking, and the type of fuel used. Long-term exposure of women to such poor indoor environments may result in deterioration of their mental and physical wellbeing [103]. Evidence suggests that there are three times greater chances of women using biomass fuel suffering from respiratory disorders in comparison to women who use cleaner fuels [104]. Women using biomass fuel had poorer pulmonary function than women using clean fuel [105]. Studies on poly aromatic hydrocarbons (PAHs) which are produced as a result of incomplete combustion of fossil fuels has reported a potential to bound with particulate matter and are more hazardous than primary pollutants (PM) [106]. Further exploration on indoor air pollutants should encounter the effects of PAHs on human health in developing countries.
As the age of the women using biomass fuel increases, they are more susceptible to developing respiratory problems [67, 80], which might be because of the prolonged women’s exposure to biomass smoke [67]. According to a study conducted in India, the household burning biomass fuels had two folds higher risk of asthma prevalence in elderly people compared to those living in households burning cleaner fuels. Moreover, women were the most affected gender [82]. Women working with biomass fuel but having proper ventilation are less likely to suffer from poor health conditions as compared to those working in a poorly ventilated environment. Because concentrations of indoor pollutants would be more in poorly ventilated places than in places with exhaust and good ventilation [75, 77].
Caring for infants and younger children is another gendered norm in south Asian countries, cooking practices of mothers could have affected children’s health, negatively. Children who live in households where biomass fuel is burnt had a greater incidence of encountering respiratory disorders than those living in households using clean fuels [54]. Children in households with low income usually suffer from malnutrition which affects the development of their lungs as they have weak respiratory muscles [107] and hence can be easily invaded by toxic indoor pollutants. In children under five, the risk of pneumonia is doubled by exposure to indoor air pollution [108]. It is reported that children who spend more time in close proximity to stove-burning biomass are at greater risk of developing respiratory infections [49].
Broadly, socio-economic factors had a great impact on indoor air pollution and consequently on the health of people. Solid fuel being low quality, but cheaper fuel is mostly used by people having low economic status. Also, people using solid fuels are not well educated [83, 109], [110], [111], [112] and therefore, low awareness levels, combined with limited resources are resulting in the continued use of biomass fuel burning.
For the global burden of disease, indoor air pollution due to biomass burning is declared as the 10th most preventable risk factor, which for developing counties is among the top four most preventable risk factors [67]. Exposure to biomass fuel burning can be prevented or minimized by improving socio-economic status, promoting education, and raising awareness levels [113].
Although reducing IAP exposure from solid fuels can be accomplished via interventional strategies, such as a change in energy consumption source, energy technology, home design, and ventilation, and behavior and time-activity budget [20, 114, 115], the majority of current research has focused on the first method, with a focus on enhanced (efficient with lower emission) fuels and stoves, that will provide more cost-effective solutions shortly than a massive shift to nonsolid fuels. However, early research and development efforts on the advantages of better stoves were sometimes hampered by a lack of accurate data on stove performance. There are studies that have discussed some of the issues surrounding the success of intervention programs after community implementation (vs. technology performance) using a limited number of available case studies in various countries [114, 116].
Conclusions
Exposure to household-level air pollution due to biomass fuel burning is associated with negative health outcomes. Women and children are most likely to develop these negative health outcomes. Common health effects are related to respiratory system, cardiovascular system, vision and childbirth. To reduce the risk of negative health outcomes, attributable to indoor air pollution, we need to understand exposure levels better, i.e., how, and when these air pollutants can affect human health. This can be done by understanding when symptoms develop and when do they change. There is an imperative need for large-scale public health research to understand indoor activities, both in urban and rural areas, and the incidence and progression of health conditions. Therefore, the findings of this study suggests more longitudinal and instrument-based studies in the future to have more reliable data on indoor air pollution and its associated health outcomes.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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Informed consent: Not applicable.
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Ethical approval: Not applicable.
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