Although our findings are limited to one province in Sri Lanka, this is the first study that we are aware of examining respiratory symptoms and personal CO levels in reproductive-aged women in Sri Lanka. This cross-sectional study mainly aimed to determine the effect of SFU on respiratory symptoms in reproductive-aged women living in Central Province, Sri Lanka. According to the current study, 23.1% of households used firewood exclusively, while 48.6% used firewood in conjunction with LPG or kerosene, bringing the total percentage of families that used firewood to 71.1%. This percentage is greater than the national data for the use of firewood as a cooking fuel (66%) reported in 2016 [6]. This higher percentage may be attributable to the abundance of firewood in Central Province compared to the countryside and the cost-effectiveness compared to LPG.

We discovered a higher prevalence of respiratory symptoms among firewood users, which is similar to the findings from Nepal [11], Bangladesh [12], and Mexico [13]. However, a study conducted in Nigeria found a low prevalence of coughing, wheezing, and dyspnea in both the biomass and non-biomass groups [14], which could be attributed to underreporting of respiratory symptoms that were frequently regarded as normal by the general population [11]. Except for phlegm, our findings support a higher incidence of cough-related symptoms, wheezing, and dyspnea among firewood users alone or in conjunction with LPG. These relationships persisted even after controlling for a variety of significant confounding variables.

Various contaminants, particularly respirable particulate matter, contribute to respiratory symptoms [15]. CO is regarded as a reliable proxy for individual exposure to respirable particles [16]. The current study found that women who reported respiratory symptoms had significantly higher CO and COHb levels. Moreover, firewood-only users had significantly higher mean CO and COHb levels than LPG-only users, implying that CO concentration may be a significant determinant of respiratory symptoms. In line with current study findings, a study carried out in rural Uganda revealed a connection between personal CO levels and exposure to biomass smoke and, consequently, a higher risk of respiratory symptoms in women who use biomass cooking fuels [17].

In Sri Lanka, the majority of cooking tasks are performed by women, while young children and elderly family members remain indoors, implying that a sizable portion of the population is exposed to HAP created by firewood burner operation [18]. Despite the fact that no research has been published in Sri Lanka that examined the respiratory health of reproductive-aged women and their personal CO levels, a study among children in a semi-urban Sri Lankan community found considerably higher CO and PM2.5 concentrations in the indoor air of households using wood fuel and a 1.6-fold increased risk of infection-induced asthma in children in high exposure groups [19]. Partially dried firewood is difficult to light and produces a lot of smoke. As a result, it is common to utilize a fire starter made from dried coconut leaves or waste papers, which results in much smoke being released during the fire-starting process. In addition, most women practiced using forcibly exhaled air to assist in starting fires, putting them at risk of breathing in excessive amounts of firewood smoke. According to the current study, 36% of firewood users reported using forced exhaled breath to start a fire, while 53% used a pipe to supply exhaled breath air to start a fire, both of which are extremely harmful behaviors that continue to be done due to a lack of understanding. Nonetheless, Sri Lankan women tend to stay close to the cooking stoves throughout the cooking process, which might cause harm even at modest levels of exposure over time. The current analysis found that firewood users spend an average of 158 ± 80.6 min per day cooking.

Studies suggest that well-designed and well-ventilated kitchen structures could help to limit exposure to cooking fuel smoke. According to the current study, 79.9% of firewood users had kitchens with chimneys. However, no significant difference in CO levels was found between women who had kitchen chimneys and women who did not have kitchen chimneys (data not shown). This could be because some kitchens have doors, kitchen windows, and existing open ventilation holes. Unfortunately, only 71.9% of households with windows in the kitchen practiced opening the windows while cooking with firewood.

While adjusting for other factors, the current study found that secondhand tobacco smoke was a risk factor for wheezing in reproductive-aged women (p < 0.001). The average CO concentration in this study was 4.09 ± 4.0 ppm, which was higher than the average CO levels reported for healthy non-smokers in a Turkish study [20], but lower than the levels seen among solid fuel users in Guatemala [21]. Furthermore, 8.5%of the women in this study sample had CO levels that fell into the borderline smoker category (7–9 ppm), while 4.2 percent fell into the low-addicted (10–15 ppm) and moderately addicted (16–25 ppm) categories, respectively. The problem is that these women had never smoked and had accidentally fallen into these risk categories due to this unaddressed community health concern. Thus, while tobacco smoking is a major cause of respiratory morbidity in the developed world, HAP exposure is expected to be a significant modifiable risk factor in low- and middle-income countries, particularly among women [22].

The current study focused specifically on reproductive-aged women, with a reported mean age of 37.4 ± 8.9 years. Firewood smoke exposure has a detrimental effect on not just their respiratory health but also on their reproductive health. The adverse perinatal outcomes associated with biomass fuel smoke exposure in pregnant women are well documented and include but are not limited to low-birth-weight deliveries [23,24,25], preterm births [23,24,25], stillbirths [24, 25] and neonatal mortality [25, 26]. Thus, this research area addresses a timely and significant health issue that can negatively impact both present and future generations, both directly and indirectly. Improved cooking stoves, alternate fuel sources, a better living environment, and changing user habits to decrease exposure have been suggested to decrease firewood smoke exposure among vulnerable populations [27]. Pre-processing (drying) the fuel, proper stove maintenance, and installing stoves at waist level are reasonable and affordable options in the Sri Lankan context to reduce the cooking fuel smoke exposure where most people belong to the middle-income level. Simple changes in user behavior to decrease their exposure to kitchen fuel smoke include utilizing a pot lid to preserve the heat while cooking, pre-soaking foods like grains and dhal to reduce cooking time, and not using the exhaled breath to start a fire in a wood stove [27]. However, the expansion of LPG is hampered significantly by its high price, limited supply and access in the Sri Lankan context; therefore, policymakers could supply cost-effective, efficient stoves to help reduce smoke exposure in Sri Lanka’s low-resource areas.

To our knowledge, this is the first study to examine household characteristics, cooking behaviors, respiratory symptoms, and CO and COHb levels in expired breath among reproductive-aged women in a Sri Lankan community. This study adds to a growing body of knowledge about the impact of HAP on respiratory symptoms and personal CO levels. This study relies on self-reported cooking habits and objective data on personal exposure levels. There were a few limitations, despite the study’s strengths. Some parts of the Central Province have a cold climate, which may have influenced our findings regarding respiratory symptoms. Also, the sample size used in this study may not be adequate to compensate for the bias introduced by the cluster sampling technique. Furthermore, we did not look at how long women used different types of cooking fuel over the years.

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