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Imperial College London (2005)

Solid fuel use and child health in Africa : a causal analysis of social determinants

Rehfuess, Eva Annette.

Titre : Solid fuel use and child health in Africa : a causal analysis of social determinants

Auteur : Rehfuess, Eva Annette.

Etablissement de soutenance : Imperial College London

Grade : Doctor of Philosophy (PhD) 2005

This thesis uses causal diagrams to describe and quantify the associations between social conditions - such as wealth, education and occupation ; proximal health risks - in particular indoor air pollution from solid fuel use ; and acute lower respiratory infections (ALRI) among African children. The aim is to delineate different pathways that translate lower socio-economic status into poorer health outcomes. A conceptual causal diagram is used to organise a series of a priori hypotheses, which are operationalised and tested using Demographic and Health Survey data for Benin, Ethiopia, Kenya and Namibia and, for the solid fuel use pathway, a pooled set of World Health Survey data for sixteen African countries. In doing so, this thesis employs a variety of statistical techniques, including cluster analysis, logistic and ordered logistic regression, survival analysis and Bayesian multilevel and spatial modelling. The results suggest that solid fuel use across sub-Saharan Africa is particularly strongly structured by wealth, maternal education and, to a lesser extent, paternal education as partially independent determinants. Heterogeneity at community and district levels strongly influences fuel choice ; in some countries this variation is spatially structured. With an adjusted hazard ratio of 2.35 (1.22 ; .4.52) cooking with solid fuels is confirmed as a major risk for ALRI mortality. However, socio-economic gradients in ALRI mortality are weak, and are not primarily mediated by smoke-producing cooking practices. Instead, across much of the social spectrum indoor air pollution appears to exert its effect on child health largely independently of p6 erty ; rlack of education. This thesis illustrates how the rigorous application of causal diagrams combined with standard statistical methods can characterise a complex web of interactions between distal and proximal causes of disease. The ALRI mortality risk associated with traditional fuel use points to a large potential for preventive interventions to reduce child. morbidity and mortality.


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