Adoption and impact of improved cookstoves in Lambayeque, Peru, 2017

Abstract

Introduction
Approximately three billion people in Asia, Africa, and the Americas cook with biomass, cleaner cooking technologies with the potential to reduce household air pollution exposure. It is necessary to assess the adoption and long-term use of these stoves, measure perceived benefits among users, and use this information to provide feedback to programs that are implementing new cooking technologies. The aim of this study is to determine the level of adoption and impact of improved biomass cookstoves in the rural area of Lambayeque, Peru, in 2017.

Methods
A descriptive cross-sectional study was conducted. A total of 52 homes were surveyed in the districts of Pacora and Íllimo where improved biomass stoves were introduced between 2005 and 2013. A questionnaire for the assessment of adoption and impact indexes proposed by the Global Alliance for Clean Cookstoves was applied. The STROBE checklist was used.

Results
The mean number of years with the improved biomass cookstove was 9.1 (standard deviation: 2.9); 51.9% always used the improved stove, and 34.6% never used it due to destruction during the El Niño phenomenon in 2017. The median impact index was 5.62; 19.2% had a very good/good adoption. The median adoption index was 6.5; 25% had a very high/high impact. The use of the traditional or open fire biomass stove persisted in 61.5% of the houses.

Conclusion
The adoption and impact of improved biomass cookstoves were acceptable, but traditional stove use persisted in more than half of the houses. Households used a mix of different stove technologies. Gas stoves were used more frequently for breakfast or dinner, while the traditional biomass stoves were used for larger lunchtime meals.

Full text

https://doi.org/10.1177/1757975920945248
Global Health Promotion 1757-9759; Vol 0(0): 1 –8; 945248 Copyright © The Author(s) 2020, Reprints and permissions:
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Introduction
Approximately three billion people in Asia,
Africa, and the Americas cook with biomass (wood,
animal waste, agricultural waste) and coal (1).
Nearly 55% of the global burden of disease due to
air pollution comes from cooking fires mostly in
low-socioeconomic status homes, when using
945248PED0010.1177/1757975920945248Global Health PromotionM. A. Díaz-Vásquez et al.
research-article2020
1. Faculty of Medicine, Universidad Catolica Santo Toribio de Mogrovejo, Chiclayo, Peru
2. Faculty of Medicine, Universidad San Martin de Porres-Filial Norte, Chiclayo, Peru
3. Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
4. Pan American Health Organization, Washington, DC, USA
5. Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y
Síntesis de Evidencias en Salud, Lima, Perú
Correspondence to: Virgilio E Failoc-Rojas, Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad
de Investigación para la Generación y Síntesis de Evidencias en Salud, Avenida la Fontana 501, La Molina, Lima 051,
Peru. Email: virgiliofr@gmail.com
(This manuscript was submitted on 29 October 2019. Following blind peer review, it was accepted for publication on 26
June 2020)
Adoption and impact of improved cookstoves
in Lambayeque, Peru, 2017
Maribel A. Díaz-Vásquez1, Rosa J. Díaz-Manchay1,
Franco E. León-Jiménez2, Lisa M. Thompson3, Karin Troncoso4
and Virgilio E. Failoc-Rojas5
Abstract:
Introduction: Approximately three billion people in Asia, Africa, and the Americas cook with biomass,
cleaner cooking technologies with the potential to reduce household air pollution exposure. It is
necessary to assess the adoption and long-term use of these stoves, measure perceived benefits among
users, and use this information to provide feedback to programs that are implementing new cooking
technologies. The aim of this study is to determine the level of adoption and impact of improved
biomass cookstoves in the rural area of Lambayeque, Peru, in 2017.
Methods: A descriptive cross-sectional study was conducted. A total of 52 homes were surveyed in
the districts of Pacora and Íllimo where improved biomass stoves were introduced between 2005 and
2013. A questionnaire for the assessment of adoption and impact indexes proposed by the Global
Alliance for Clean Cookstoves was applied. The STROBE checklist was used.
Results: The mean number of years with the improved biomass cookstove was 9.1 (standard
deviation: 2.9); 51.9% always used the improved stove, and 34.6% never used it due to destruction
during the El Niño phenomenon in 2017. The median impact index was 5.62; 19.2% had a very
good/good adoption. The median adoption index was 6.5; 25% had a very high/high impact. The
use of the traditional or open fire biomass stove persisted in 61.5% of the houses.
Conclusion: The adoption and impact of improved biomass cookstoves were acceptable, but
traditional stove use persisted in more than half of the houses. Households used a mix of different
stove technologies. Gas stoves were used more frequently for breakfast or dinner, while the traditional
biomass stoves were used for larger lunchtime meals.
Keywords: Air pollution, biomass, petroleum, rural health
Original Article

M. A. Díaz-Vásquez et al.
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IUHPE – Global Health Promotion Vol. 0, No. 0 201X
inefficient biomass cookstoves (2–5), as these fuels
are burned in inefficient conditions, causing indoor
air pollution (6).
Using improved biomass fuel stoves can reduce
air pollution in the homes (7). These cookstoves
burn mainly firewood, they use a combustion
chamber to increase efficiency, and typically have
chimneys that remove smoke from the house. Some
improved cookstoves have been shown to reduce
suspended particulate matter and carbon monoxide
by half (8,9).
At the 23rd World Conference on Health
Promotion in 2019, the theme was: ‘Waiora:
promotion planetary health and sustainable
development for all (10)’, of which the main message
was that we should identify opportunities to reduce
household air pollution while mitigating global
climate change (11).
The Clean Cooking Alliance supports global
programs that introduce cleaner cooking
technologies with the potential to reduce exposure
to air pollution in homes (5). Since the mid-20th
century, improved cookstove programs were
implemented to reduce deforestation (5,12).
However, it is necessary to evaluate the adoption of
improved cookstoves and their impact on the health
and wellbeing of their users. The aim is to verify if
the user likes and uses the adopted stove, and to
understand if users would acquire the same stove
again (12). Until now, the success of improved
cookstoves has been measured by the number of
stoves distributed, but there are few studies of their
sustainability (13). Evaluation of the program
promotion needs to identify if households use the
improved cookstoves. It is known that despite the
promise of improving stoves to reduce these impacts,
adoption rates at the population level are relatively
low (14).
It is necessary to assess the adoption and long-
term use of these stoves to measure perceived
benefits among users, and use this information to
provide feedback to programs that are implementing
new cooking technologies. Knowledge of favorable
and unfavorable factors is crucial for program
monitoring and sustainability efforts. This study
aimed at determining the level of adoption and
impact of improved cookstoves in a rural area of
Lambayeque, on the north coast of Peru, in 2017,
after the Coastal ‘El Niño’ weather phenomenon
of 2017.
Methods
Design and study subjects
A descriptive, cross-sectional study using
consecutive sampling was conducted. This study
followed the STROBE guidelines for reporting
observational studies (see STROBE statement in the
supplemental material). This project used a
community-based participatory research
framework, together with members of the university,
regional government, and primary care physicians.
A total of 52 families were interviewed in the
districts of Pacora and Illimo in Lambayeque, in
northern Peru. Improved cookstoves (ceramic
material, and fireplace and iron kitchens) provided
by a non-governmental organization were installed
in these districts between 2003 and 2013. Families
who used improved cookstoves for more than two
years were included. No sampling technique was
used because all of the 52 families were surveyed;
all families lived in low-socioeconomic status rural
areas. By the Peruvian definition, the head of the
household is defined as ‘the person that the family
recognizes as such and who in terms of income
contributes mostly to the family budget, is older
and lives in the home (15).
We used a questionnaire designed by the Global
Alliance for Clean Cookstoves, measuring the extent
to which the improved stoves have been integrated
into the lives of users (12), resulting in the
development of the adoption index (AI) and impact
index (II). This questionnaire was validated with
families from the Purepecha region in Mexico (13).
Survey
The questionnaire measures two indexes:
1) An AI, which depends on four variables: frequency
of use of the cookstove (FCS), condition of the
cookstove (CCS), level of satisfaction of user
(LSC), and interest in replacing with similar
cookstove (IRS). Each variable is multiplied by a
coefficient that reflects the weight that this variable
will have on the total value of the index. Indicative
values for each variable are proposed in
Supplemental Table 1. The formula for the AI is,
therefore, as follows: AI = 4(FCS) + 3(CCS) +

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IUHPE – Global Health Promotion Vol. 0, No. 0 201X
2(LSCS) + 1(IRS). The result is scored from 1 to
10, where 1–4 is very bad adoption, 5–6 is bad
adoption, 7–8.5 is regular adoption, 8.5–9 is good
adoption, and 10 is very good adoption (12).
2) An II, which depends on eight variables: frequency
of the use of the improved cookstove (FCS),
frequency of the use of the traditional stove
(FTS), frequency of use of other fuels to cook
(FOF), level of satisfaction with the traditional
stove (LSTS), changes in the location of the
traditional stove (CLTS), perceived health
improvements (PHI), perceived saving of fuel
(PFS), and quantity of cooking technologies used
(TS) (12). Each variable is multiplied by a
coefficient that reflects the weight that this
variable will have on the total value of the index.
Indicative values for each variable are proposed
in Supplemental Table 2. The formula for the II
is as follows: II = 2(FCS) + 2(FTS) + 1(LSTS)
+ 1(PHI) + 1(PFS) + 1(TS). The result is scored
from 1 to 10, where 1–4 is very bad impact, 5–6
is bad impact, 7–8.5 is regular impact, 8.5–9 is
good impact, and 10 is very good impact (12).
The questionnaire was applied by nurses trained
in scientific studies and was carried out in at least
two home visits to correctly collect the information.
In the present study, the outdoor kitchen (open
fire) is mentioned to be used as traditional stove, the
stove installed by the non-governmental organization
is mentioned to serve as an improved cookstove, and
mixed technology is the term applied to the use of
two or three types of stoves, including a liquefied
petroleum gas (LPG) stove.
Statistical analysis
Descriptive statistics were applied, calculating
absolute and relative frequencies for categorical
variables. Data normality was assessed using
skewness, kurtosis and the Shapiro–Wilk test. Age
and time in the house were normally distributed, so
they are presented as averages and standard
deviations (SDs). Income was not normally
distributed, so it was presented as median and
interquartile range.
There was no data loss or incomplete data in the
evaluation of the study. The STATA 14 (StataCorp
LP, College Station, TX, USA) program was used for
statistical analysis.
Ethical aspects
The Universidad Santo Toribio de Mogrovejo’s
Institutional Review Board issued approval to
conduct our study (408-2017-USAT-FMED). The
presidents of the ecological committee of the villages
(elected by the citizens who benefited with the
improved stoves of Pacora and Illimo, independent
of governmental and non-governmental
organizations) were contacted to give their
permission to conduct this study with villagers.
Visits to the households were conducted and the
survey was applied after receiving written informed
consent. Interviewers communicate the main
findings to participants and gave educational fliers
about impacts on health of traditional cookstove
smoke, and about how to give maintenance to
improved cookstoves.
The results of this study were explained to the
participants who were given educational material
about the effects of smoke from traditional
cookstoves on health, and the maintenance that
should be provided to improved cookstoves.
Results
Demographic characteristics
The sample was composed of 52 families, in
which the head of household from each home was
interviewed. Most of respondents were women
(78.9%) (41), with a mean age of 51.2 years (SD:
13.9 years). Thirteen (25%) were older adults (over
60 years of age). The median number of family
members was 4 (range = 3–7) and 38 (73%) were
nuclear families. More information is presented in
Table 1.
Use of improved biomass cookstoves
The mean years with the improved cookstoves
was 9.1 ± 2.9 years; 49 (94.3%) had the stove for
six or more years; 26 (50%) stated that they had
repaired the stove at least once.
Regarding the use of the improved stove, 27
(51.9%) reported that they always used it, and 18
(34.6%) stated that they never used it (15 families
used it as a platform to build an open fire, or a
traditional cookstove). Thirty-three families
(63.4%) had stoves that had been destroyed;

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IUHPE – Global Health Promotion Vol. 0, No. 0 201X
22 (42.4%) had them repaired, and three (5.8%)
kept the stove in perfect condition.
It is worth noting that 45 (86.6%) of the
participants reported being satisfied or very satisfied
with the improved cookstove, 47 (90.3%) would
use it again, and 21 (40.4%) who declared to be
satisfied reported having the stoves destroyed.
Of the 34 participants who used the improved
stove, 32 (94.1%) reported health improvement
(such as reduction of respiratory and gastric diseases
and better self-perception of health).
Other stoves in use
Twenty (38.4%) reported use of both traditional and
LPG cookstoves, while 12 (23.1%) reported use of
improved cookstoves and LPG stoves; three families
used traditional, improved, and LPG cookstoves.
Thirty-two people (61.5%) were still using the
traditional cookstove, either alone or with other
stove technologies (see Table 2). Of those, 19
(52.4%) used the traditional cookstove every day.
Twelve respondents (37.5%) used the traditional
Table 1. General characteristics of surveyed families in Lambayeque, Peru.
Numerical variables Mean SD
Age (years) 51.3 13.9
Time in the house (years) 27.2 12.6
Income (US dollars/monthly)* 156.3 101
Categorical variables N %
Sex
Female 41 78.8
Male 11 21.2
Educational stage
None 7 13.5
Elementary 30 57.6
High school 11 21.2
Higher education 4 7.7
Housing
Adobe 29 55.8
Noble material 23 44.2
SD: standard deviation.
*Expressed in median and interquartile range.
Table 2. Types of cooking technology used by families in Lambayeque.
Technologies N %
Traditional and LPG 20 38.4
Improved and LPG 12 23.1
Only traditional 9 17.3
Only improved stove 8 15.4
Traditional, gas, and improved 3 5.8
LPG: liquefied petroleum gas.

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IUHPE – Global Health Promotion Vol. 0, No. 0 201X
cookstove inside the house. Despite the high use of
the traditional cookstove, 30 participants (93.8%)
reported not being satisfied with the stove.
Adoption and impact indexes
The median AI was 6.5, with an interquartile
range of 3–8.3 (classified as regular adoption).
The median II was 5.6, with an interquartile range
from 4.3 to 9.3 (classified as low impact). The
information described in Table 3 was obtained after
categorizing adoption and impact.
Discussion
Average and poor adoption of improved
cookstoves were predominant in this study, and
impact was overall low. This is similar to a study
carried out in Puno, Peru. In that study, although
improved cookstoves and clean fuels like LPG were
available, adoption and sustained use were low (3).
This is probably because families cannot or do not
invest in the maintenance of the new stoves, even
though the stoves were built after reforestation
activities to be more accessible, and their
implementation included follow-up visits for two
years. Several important aspects such as household
priorities, traditions, and needs should be assessed
when examining the adoption of a new technology
in a population to ensure sustainable use over the
time (16). Assistance given to people in poor areas
of Peru, without a previous analysis of the needs and
possibilities of the inhabitants, could affect
prioritization of investment to repair the stoves.
We demonstrated that 94.1% of the participants
who used improved cookstoves reported health
improvement. This is similar to the results presented
by Briceño and Díaz (17), who found that two years
after the provision of improved cookstoves,
participants recognized that the stove reduced
respiratory diseases and other afflictions attributed
to cooking, such as back pain from bending over
fires (17).
Improved stoves may save time with cooking
activities and possibly reduce fuel use (17). In another
study in Peru, 97% of study participants perceived
a health improvement, and 89% identified
improvement in quality of life compared to those
who used traditional cookstoves or open fires (8).
Biomass smoke from traditional stoves produces a
chronic inflammatory status together with the
activation of metalloproteins and reduction of
mucociliary mobility, which significantly increases
the risk of suffering from respiratory diseases (18,19).
The replacement of these traditional stoves with
improved cookstoves reduces this smoke, resulting in
a perception of enhancement (20). Nevertheless, this
‘satisfaction’ is a subjective point of view of the
people interviewed and is one of the questions
included in the II.
In the present study, 63.4% had stoves that were
reported to be in poor condition, and 94.6% of the
participants reported having stoves for more than
six years, leading to stove deterioration. Literature
has shown that after three years of acquiring an
improved stove, deterioration affects the stove
function, compromising fuel savings and increasing
emissions (8). In this study, only 50% had repaired
the stove at least once. A factor that could influence
stove performance is that families could not afford
to repair the improved cookstoves. Median salary
with an average monthly income of US$156.3 was
probably too low to prioritize stove repairs. Another
Table 3. Impact and adoption index of improved cookstoves in Lambayeque.
Adoption index N %
Good/very good 10 19.2
Average 21 40.4
Poor/very poor 21 40.4
Index of impact N %
High/very high 13 25.0
Average 12 23.1
Low/very low 27 51.9

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IUHPE – Global Health Promotion Vol. 0, No. 0 201X
possible explanation for the deterioration of the
stoves could be the El Niño Phenomenon of 2017,
which affected the study area with flooding, and led
to the destruction of homes and stoves (21). This
study was carried out six months after this
phenomenon.
The AI was based on the report of the use of the
improved cookstove, level of satisfaction, condition
of the stove, and whether the stove will be built
again. The results of our survey indicated that the
conditions of most of the stoves was poor, with 63%
responding that stoves were destroyed or not used.
However, the level of satisfaction and the desire to
possess a functioning improved cookstove indicated
that people perceive the benefits of this technology,
even among those in 18 homes that never used the
improved cookstoves. This finding merits a future
study to understand the reasons why households do
not use improved stoves. Lack of maintenance is a
key consideration among those who continued
using the cookstove. Improved cookstoves in this
region have an average useful life of five to eight
years, which indicates that they should be replaced
with a new stove after an average of nine years of
use. This highlights the importance of developing
diffusion strategies for long-term alternatives that
consider the needs of the population, including
access to spare parts and repair services.
The II is based on frequency of use of the improved
cookstoves, frequency of the use of the traditional
stove, use of other fuels, change in the placement of
the traditional stove, satisfaction with the traditional
stove, perception of health improvements, perception
of fuel saving, and quantity of stoves used. The
results of the survey indicate that families used the
traditional stove frequently, but also used other
technologies such as the LPG stove. This greatly
reduces the impact of improved cookstoves because
the change is not highly perceived. If people perceive
the benefit of LPG, the use of the improved cookstoves
could be diminished. These results are understandable
if we consider that 94% of the stoves were in poor
conditions or destroyed after nine years of use.
Furthermore, the government of Peru started to
distribute kits of LPG stoves and provided a small
allowance to very low-socioeconomic status families.
Nevertheless, compelling results in this index were
the perceptions of the benefits of improved
cookstoves. Most of the people considered that these
stoves improved health and conserved firewood use
compared to the open fire.
Mixed use of fuels and technologies is common in
this area of Peru; 38.4% of the participants reported
they used traditional stoves and gas, and 23% used
improved cookstoves and gas. Adoption and impact
measurement of improved stoves is difficult because
users do not simply switch from one cooking
technology to another or from one fuel to another
completely. There is a transition process in which
the use of open fire stops and the use of the improved
cookstoves and other fuels are adopted (12). Rhodes
(8) found that 53% of families that received LPG
stoves considered that the cooking time was less, but
92% continued using a traditional stove (8). In our
study, this may be due to several reasons, mainly the
destruction of improved cookstoves during El Niño
Phenomenon when the families resumed use of
traditional stoves (21,22). The habit of cooking over
open fires, the easy access to fuel (firewood), and the
scarce economic resources have a marked impact on
the persistent use of traditional cooking, gas use, or
both. Reports demonstrate that these communities
appreciate the taste of food cooked with firewood,
compared to food prepared with LPG (23). This
remains a major barrier for the use of clean fuels
such as LPG. A traditional stove, which may be less
costly than LPG, remains a barrier to the adoption
of LPG (20). Therefore, programs should not only
provide access to improved cookstoves, but should
ensure regular maintenance of improved cookstoves
and LPG stoves.
This cross-sectional study may have biases such as
selection and reporting. Households were selected
from areas where there were health promoters, but
included all households. The households that
participated in our study may not be representative
of all rural Peruvian households that have participated
in a stove program, and households wishing to
participate in a stove program may differ from the
average rural Andean household. However, we
believe that our results are broadly generalizable to
the Peruvian rural Andean context, since we include
a large number of households from a representative
region. In addition, our results and exposures are
self-reported, which may overestimate the actual use
of the improved cookstoves. One limitation of this
study is the period of study – the abandonment of
improved cookstoves may have resulted from the El
Niño Phenomenon and might not have been driven
only by the natural decline in cookstove usage.

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IUHPE – Global Health Promotion Vol. 0, No. 0 201X
It is necessary to include homes within their
respective communities and stove programs within
their society to achieve the adoption and sustained
use of clean fuels. Quantitative and qualitative
studies about important factors that ensure adoption
and impact are needed, including the maintenance
and replacement needed for sustainable use (24).
Cultural aspects, such as cooking practices,
competing local priorities, and economic means of
poor communities, which are the target of stove
programs, should also be explored.
The use of the cleanest fuels (e.g. LPG, electricity)
and improved cookstoves (e.g. chimney stoves,
efficient combustion of biomass) are necessary in
rural communities (18,25). Emphasis should be
focused on reducing the use of traditional stoves and
messages should be developed so that behavior
change leads to the sustained use of LPG, electricity,
or wood-saving improved stoves. Ultimately, this
would contribute to health improvement and may
reduce global warming.
Conclusion
In our study, distributed improved cookstoves
were adopted by 65% of families. Although most of
these stoves were destroyed or reported to be in poor
condition, this is expected since stoves were built
approximately nine years ago without a follow-up
program to ensure maintenance. These findings
show that it is very important that governments
develop policies that assist low-socioeconomic status
families with maintenance of the improved
cookstoves and clean cooking technologies to
improve human health and wellbeing.
The provision of improved cookstoves allows
people to participate with government and non-
government organizations, and the commitment is
reciprocal. In addition, health education is provided,
people have control of their own health, and there is
also commitment to the environment; consequently,
there is a link between the use of improved
cookstoves and health promotion.
Relevance to clinical practice
Reducing the use of firewood will require strategies
that consider the preferences of the population of
users and their aptitude for maintaining the stoves in
good conditions and replacing stoves at the end of
their useful lives. Stove programs should be supported
by policy makers at the national level.
What does this paper contribute to the
wide global clinical community?
The impact of improved biomass cookstoves on
people’s perception of health is positive. Improved
cookstoves were well adopted initially. However,
due to flooding in the region, many of these
cookstoves were destroyed and not rebuilt.
Governmental policies and programs must ensure
access and ongoing maintenance for improved
cookstoves and clean fuels. Community nurses
should integrate public health messages when
working with community members to encourage the
sustained use of clean cook stoves, including clean
fuels like LPG and electricity in rural areas.
ORCID iDs
Maribel A. Díaz-Vásquez https://orcid.org/0000-0002-
7950-8805
Rosa J. Díaz-Manchay https://orcid.
org/0000-0002-2333-7963
Franco E. León-Jiménez https://orcid.
org/0000-0002-9418-3236
Virgilio E. Failoc-Rojas https://orcid.
org/0000-0003-2992-9342
Declaration of conflicting interests
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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