Designing a comprehensive behaviour change intervention to promote and monitor exclusive use of liquefied petroleum gas stoves for the Household Air Pollution Intervention Network (HAPIN) trial

Abstract

IntroductionIncreasing use of cleaner fuels, such as liquefied petroleum gas (LPG), and abandonment of solid fuels is key to reducing household air pollution and realising potential health improvements in low-income countries. However, achieving exclusive LPG use in households unaccustomed to this type of fuel, used in combination with a new stove technology, requires substantial behaviour change. We conducted theory-grounded formative research to identify contextual factors influencing cooking fuel choice to guide the development of behavioural strategies for the Household Air Pollution Intervention Network (HAPIN) trial. The HAPIN trial will assess the impact of exclusive LPG use on air pollution exposure and health of pregnant women, older adult women, and infants under 1 year of age in Guatemala, India, Peru, and Rwanda.MethodsUsing the Capability, Opportunity, Motivation–Behaviour (COM–B) framework and Behaviour Change Wheel (BCW) to guide formative research, we conducted in-depth interviews, focus group discussions, observations, key informant interviews and pilot studies to identify key influencers of cooking behaviours in the four countries. We used these findings to develop behavioural strategies likely to achieve exclusive LPG use in the HAPIN trial.ResultsWe identified nine potential influencers of exclusive LPG use, including perceived disadvantages of solid fuels, family preferences, cookware, traditional foods, non-food-related cooking, heating needs, LPG awareness, safety and cost and availability of fuel. Mapping formative findings onto the theoretical frameworks, behavioural strategies for achieving exclusive LPG use in each research site included free fuel deliveries, locally acceptable stoves and equipment, hands-on training and printed materials and videos emphasising relevant messages. In the HAPIN trial, we will monitor and reinforce exclusive LPG use through temperature data loggers, LPG fuel delivery tracking, in-home observations and behavioural reinforcement visits.ConclusionOur formative research and behavioural strategies can inform the development, implementation, monitoring and evaluation of theory-informed strategies to promote exclusive LPG use in future stove programmes and research studies.Trial registration numberNCT02944682, Pre-results.

Developing Visual Messages to Support Liquefied Petroleum Gas Use in Intervention Homes in the Household Air Pollution Intervention Network (HAPIN) Trial in Rural Guatemala

“…Previous evaluations of improved cookstove have shown continued use of traditional stoves with the new stoves-a practice known as "stacking"-which is believed to vitiate the potential health benefits (Ruiz-Mercado et al, 2013). Behavioral intervention strategies that encourage households to adopt and exclusively use LPG stoves are essential for achieving the research aims of the HAPIN trial (Williams et al, 2020).…”

Fidelity and Adherence to a Liquefied Petroleum Gas Stove and Fuel Intervention During Gestation: The Multi-country Household Air Pollution Intervention Network (HAPIN) Randomized Controlled Trial

“…LPG stoves and fuel cylinders were different in each research setting, according to local supply and cooking habits and informed by formative research on cooking practices in each community (Williams et al 2020a, Hengstermann et al 2021. Each LPG stove had at least two burners; stoves in Guatemala, Peru, and Rwanda had three burners.…”

“…Behavioral support of exclusive LPG use (and concurrent discouragement of traditional stove use) was another component of the intervention. Formative research influenced the exact form of these activities in each IRC (see Williams et al 2020a), but across all four IRCs these activities included: 1) a pledge requested of all intervention households at the start of intervention, by which they agreed to use the LPG stove for all their household cooking needs for the duration of the trial; 2) a training session at intervention delivery, covering safety and usage of the LPG equipment; and 3) tailored messages and materials provided at intervention start and thereafter as needed, to encourage and support exclusive use of LPG and to discourage any continued use of traditional stoves.…”

“…We assumed responsibility for ensuring consistent stove and cylinder deliveries and repairs, including provision of two cylinders to each home for easy switching when one cylinder was depleted. We monitored stove use continuously, and provided behavioral messaging when traditional stove use was detected, either by observation or self-report during home visits or by SUMs (Williams et al 2020a). We believe the high level of exclusive LPG use observed during pregnancy in this trial to be the combination of several factors, namely: the acceptability/likeability of the LPG stove-and-fuel system by the participants; its provision for free; and the investments of time and labor by our trial staff in training, support, and reinforcement of exclusive LPG use throughout the trial.…”

“…As models suggest that even occasional use of traditional stoves can lead to exposures above health-relevant guidelines (Johnson and Chiang 2015), the HAPIN trial was designed to enable and motivate participating households to use their LPG stoves for all their cooking needs, while simultaneously, through the use of behavioral change approaches, urging them to discontinue use of their traditional stoves. To this end, the development of tailored behavioral and stove use reinforcement messages and related media supporting the use of the LPG stove in each research setting was integrated into the intervention and has been described previously (Williams et al 2020a). This effort sought to reduce the continued use of traditional stoves to the absolute minimum in intervention homes and to discourage the practice of stove stacking.…”