Correlates of Ghanaian households’ use of climate-friendly and health-promoting fuels: insight from the 2014 demographic and health surveys

Background About five of the Sustainable Development Goals (SDGs) directly calls for clean and climate-friendly household cooking fuels to help mitigate Carbon Dioxide (CO 2 ) and black carbon emissions to ensure that the global mean temperature is kept below 1.5 o C to promote good human health. In developing countries, climate-friendly and health-promoting fuels (CF&HPFs) are generally unaffordable and inaccessible. Studies on the prevalence and the predictors of household use of climate-friendly fuels and health-promoting fuels (CF&HPFs) in Ghana are few and nationally non-representative. To effectively design programs that encourage Ghanaian households to use CF&HPFs, the study estimated the proportion of households currently using CF&HPFs and delineated factors that account for their use.Methods The study used the data of the cross-sectional demographic and health surveys conducted in 2014. Chi-square test of independence was used to identify the predictors that were statistically significant related to households’ use of CF&HPFs for the multivariable model. In the multivariable model, we reported prevalence ratios using the generalized linear model (glm), setting the family to “Poisson” and the link to “log.” The estimation adjusted for the study designed and the household sampling weights.Results The main finding was that rich households were 8.85 times likely to use CF&HPFs compared to poor households. We further found that the following factors were associated with a higher probability of a Ghanaian household to use climate-friendly and health-promoting fuels for cooking: male-headed households, households’ headed by persons between 24years and 55 years, households with heads that were currently married or never married, households with heads that have attained at least a primary level education, households with less than eight members, households with at least two women, and households in Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Upper East region.Conclusion Given that the most important correlate of household’s use of CF&HPFs is household wealth, we recommend that significant attention should be given to economic of in policies and interventions aimed at encouraging to use this type of fuel.


Abstract
Background About five of the Sustainable Development Goals (SDGs) directly calls for clean and climate-friendly household cooking fuels to help mitigate Carbon Dioxide (CO 2 ) and black carbon emissions to ensure that the global mean temperature is kept below 1.5 o C to promote good human health. In developing countries, climate-friendly and health-promoting fuels (CF&HPFs) are generally unaffordable and inaccessible. Studies on the prevalence and the predictors of household use of climate-friendly fuels and health-promoting fuels (CF&HPFs) in Ghana are few and nationally nonrepresentative. To effectively design programs that encourage Ghanaian households to use CF&HPFs, the study estimated the proportion of households currently using CF&HPFs and delineated factors that account for their use.Methods The study used the data of the cross-sectional demographic and health surveys conducted in 2014. Chi-square test of independence was used to identify the predictors that were statistically significant related to households' use of CF&HPFs for the multivariable model. In the multivariable model, we reported prevalence ratios using the generalized linear model (glm), setting the family to "Poisson" and the link to "log." The estimation adjusted for the study designed and the household sampling weights.Results The main finding was that rich households were 8.85 times likely to use CF&HPFs compared to poor households. We further found that the following factors were associated with a higher probability of a Ghanaian household to use climate-friendly and healthpromoting fuels for cooking: male-headed households, households' headed by persons between 24years and 55 years, households with heads that were currently married or never married, households with heads that have attained at least a primary level education, households with less than eight members, households with at least two women, and households in Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Upper East region.Conclusion Given that the most important correlate of household's use of CF&HPFs is household wealth, we recommend that significant attention should be given to economic empowerment of citizens in policies and interventions aimed at encouraging Ghanaians to use this type of fuel.

Background
The campaign to curb the devastating effects of global warming on humanity and the ecosystem is yielding positive results, with many state and non-state entities pursuing and adopting environmental and energy policies that promote the health of humans and the planet at large [1,2]. Greenhouse emission has largely been identified as the prime cause of climate change; however, the negative impact of using certain types of fuels for household needs on climate change and health has also received policy and scholarly attention [3,4]. About 5 of the Sustainable Development Goals (SDGs) directly calls for clean and affordable household cooking energy to help mitigate CO2 and black carbon emissions and to ensure the global mean temperature is kept below 1.5 o C, promote good health and gender equality [5][6][7]. The types of fuels used in households across the globe can broadly be categorized into climate-friendly (electricity, liquefied petroleum gas, natural gas) and nonclimate-friendly fuels (wood, agricultural/crop residue, animal dung, coal, charcoal, kerosene), with the former also described as human health-promoting fuels [8]. Globally, an estimated 3 billion people rely on non-climate friendly fuels (NCFFs) for cooking and heating purposes and about 97% of the population in Sub-Sahara Africa's depends on these solid and biomass fuels [9,10]. This figure is expected to remain unchanged until 2030 [10].
The consequences of using NCFFs are two folds: environmental degradation and ill-health. Using NCFFs for household cooking and heating resulted in the annual emission of a little over one billion tons of carbon dioxide (CO2) into the atmosphere constituting 3% of global carbon dioxide (CO2) and 25% of black carbon emissions [3,11]. Also, an estimated 55% of woods harvested globally are consumed as fuelwoods and for burning charcoal [12], and this has resulted into deforestation and biodiversity loss [13]. Regarding health repercussions, NCFFs produces smoke of incomplete combustion, which reduces the ambient air quality of the immediate environment. The smoke also contains harmful pollutants such as carbon monoxide, sulphur dioxide, nitrogen dioxide and particulate matter (PM) such as PM 2.5 that are harmful to human health [8]. About 4 million premature deaths are directly associated with household air pollution (HAP) resulting from the use of NCFFs for cooking [14]. The inhalation of particulate matter from HAP, for instance, accounts for nearly 45% of all pneumonia-related deaths among children under 5 years globally and other deadly respiratory infections and diseases.
A number of studies investigated factors that account for households' continuous reliance on NCFFs in developing countries. Some of these factors include poverty, large household sizes, lack of formal education, and dwelling in a rural area [15,16]. In developing countries, climate-friendly fuels (CFFs) are generally unaffordable and inaccessible in many parts. Studies on the prevalence and the predictors of household use of CFFs and health-promoting fuels (HPFs) in Ghana are few and nationally non-representative. To effectively design programs that encourage Ghanaian households to use CF&HPFs, it is important to estimate the proportion of households currently using CF&HPFs and delineate factors that account for their use. We fill this gap in the literature by employing a complex survey design analysis and developing prevalence ratio model of socioeconomic and demographic predictors of household use of CF&HPFs by using the nationally representative 2014 Ghana Demographic and Health Survey (GDHS) dataset.

Design
The 2014 Ghana Demographic and Health Surveys (GDHS) data was collected in line with a crosssectional survey design [17].The survey employed two-stage probability sampling, stratified by urban and rural areas of the ten administrative regions of Ghana [17]. The sampling frame for the survey was based on the updated sampling frame from the 2010 Ghana Population and Housing Census [17].
The first stage of the probability sampling involved the selection of enumeration areas (EAs), which was stratified by place of residence [17]. A total of 427 EAs were selected, 216 in urban areas and 211 in rural areas [17]. The second stage of the probability sampling involved the systematic sampling of households [17]. The implementers of the survey undertook a household-listing operation in all the selected EAs from January through March 2014, and households to be included in the survey were systematically selected from the list [17]. Approximately 30 households were selected from each EA to constitute the total sample size of 12,831 households [17].

Data collection
Trained enumerators collected the data from early September to mid-December 2014 using paper-based questionnaires [17]. The selected sample size for the 2014 GDHS was 12,831 households, of which 12,010 were occupied [17]. Out of the occupied households, 11,835 were successfully reached, resulting in a 99% response rate [17]. In the GDHS, household heads provided information on their demographic characteristics and household characteristics such as household population and composition, housing structure, household assets, access to basic utilities, sources of drinking water, water treatment practices, access to sanitation facilities, and type of fuel used for cooking [17].

Study sample
The unit of analysis is households, and the dataset contains 11,835 households. The data were weighted using the household weight variable in the dataset. A sample of 513 households indicated that they cooked no food in the house, so they were excluded from further analyses. Therefore, the analytic weighted sample is 11,322.

Outcome variable:
In the dataset, the household head was asked to select the main source of fuel for cooking in the household from the following categories: electricity, LPG, natural gas, kerosene, coal, lignite, charcoal, wood, straw/shrubs/grass, and agricultural crop. Electricity, LPG, and natural gas was defined in our study as CF&HPFs and all other sources of fuels as non-climate friendly and health promoting.

Predictor variables:
Ten sociodemographic characteristics variables were selected as potential predictors in the study.
Marital status was recoded as follows: never in union (as never married), married and living with partner (as currently married), widowed, divorced, and no longer living together/separated (as formally married). For the multivariate model, household wealth was dichotomized as follows: poorest, poorer, and middle (as poor) and richer and richest (as rich).

Data analysis
We used STATA version 14 for the data analyses. Summary statistics, chi-square test of independence, and complex sample prevalence ratio modelling were performed. The analysis accounted for sampling design (cluster, strata) and household weights. The complex sample analysis eliminates the underestimation of the Standard Errors (SE) associated with the confidence intervals of the regression coefficients. We chose to report prevalence ratios using the generalized linear model (glm) in STATA, setting the family to "Poisson" and the link to "log," to avoid the potential overestimation of effects from reporting odds ratios when the prevalence of the outcome of interest is above 10%.

Sample Characteristics
In the dataset, 3040 (26.9%) households were using CFFs and HPFs for cooking. Majority of the households were headed by males (64.9%). Most of the household heads were currently married (62.9%). The summary statistics for the remaining study variables are reported in Table 1.

Chi-square test of independence between the outcome variable and potential predictors
Results from the chi-square test of independence revealed that sex, age, marital status, and education of HH, size of household, number of women or men in the household, household wealth, locality of residence, and region of residence were statistically significantly associated with the use of CF&HPFs for cooking.

Predictors of climate-friendly and health-promoting cooking fuels
We built a prevalence ratio model of predictors of climate-friendly and health-promoting cooking fuels with variables that were statistically significantly related to the outcome variable in the bivariate analysis. The following factors were associated with a higher probability of a Ghanaian household to use CF&HPFs for cooking: male-headed households, households' headed by persons between 24years and 55 years, households with heads that were currently married or never married, households with heads that have attained at least a primary level education, households with less than eight members, households with at least two women, rich households, and households in Western, Central, Greater Accra, Volta, Eastern, Ashanti, Brong Ahafo, Upper East region. Details of the prevalence ratio estimates of each predictor in the model with its corresponding 95% confidence intervals are reported in Table 3.

Discussion
The study sets out to estimate the proportion of Ghanaian households currently using CF&HPFs and delineate factors that account for their use. The findings reveal that less than a third of Ghanaian households were using CF&HPFs for cooking. The households' use of CF&HPFs were also found to be positively associated with certain household head demographic factors, household characteristics, and place and region of residence.
To begin with, male-headed households were more likely to use CF&HPFs for cooking compared to female-headed households. Men have more economic advantage in most Ghanaian communities. This advantage position of men enables them to purchase CF&HPFs that are generally considered expensive in Ghana. Even though some studies present similar results, others present contrary findings. For example, one study conducted in South Asia found that female-headed households were more likely to use CF&HPFs fuels [18,19]. The authors mentioned the ability of CF&HPFs to reduce the drudgery associated with cooking as a major influential factor for its adoption and use by femalehead households.
Again, households headed by persons between 24 years and 55 years were observed to more likely to use CF&HPFs. Conventionally, persons within this age group belong to the active working-age population, granting them easier access to economic opportunities. Therefore, these individuals are more likely to afford the usage of CF&HPFs. Additionally, persons above 55 years may find it difficult and inconvenient to adopt CF&HPFs for cooking because they perhaps belonged to a generation that predominantly relied on solid fuels for cooking [20]. Other scholars also explain that the tendency to experiment and to adopt efficient modern technologies and behaviour may be a contributing factor for the adoptions and use of CF&HPFs among the younger generation [21].
Furthermore, we found that households with currently married or never-married individuals were more likely to use CF&HPFs. In today's Ghana, it is trendy for couples to rely on LPG and electricity for cooking. Also, anecdotal evidence suggests that couples may be more likely to use CF&HPFs because of its convenience. Even though undocumented in the literature, it is prudent to argue that households with never-married heads were more likely to use CF&HPFs due to the its convenience and the high tendency of reducing exertion often associated with traditional cooking methods.
Moreover, we found education as another key contributing factor influencing for adoption and use of CF&HPFs among households. This is because the educated household head is more informed on the environmental and health benefits of cleaner cooking fuels hence its choice and usage. One scholar in a similar study opined that educated household heads in urban communities are more inclined to use CF&HPFs [22]. In addition, it is instructive to reason that educated household heads may have more access to economically viable opportunities than their uneducated counterparts. This economic advantage provides educated households with high-income levels hence their ability to purchase CF&HPFs which are relatively expensive but convenient to use.
Besides, the study revealed that household's with less than eight members have a higher likelihood of using CF&HPFs. We attribute this phenomenon to the reduction in the financial burden in smaller households than larger households. Large households in Ghana are most often dominated by dependent individuals. The high demand for cooking energy uses due to the family size and the challenge of limited resources create the situation of treating the adoption and use of CF&HPFs which are most often expensive as a periphery or less of a household need due to prevailing household welfare status. Other studies confirms this finding [16,23,24].
We also found that households with at least two women had a higher likelihood of using CF&HPFs. In Ghana, cooking activities are mostly a preserve of adult female household members. This exposes them, (especially women without clean cooking methods) to chronic obstructive pulmonary diseases (COPD) such as bronchitis, lung cancer, asthma etc than their counterparts who adopt and use CF&HPFs. We argue that in an attempt to avert the physical drain and negative health implications associated with the burning of solid biomass for cooking, households with 2 or more adult females are more likely to combine financial resources to adopt CF&HPFs which is more convenient, timesaving and healthy. Findings from a study conducted by some authors concur with this observation [16].
The adoption and use of cooking fuels like other graded commodities are highly influenced by the purchasing power of the household. Our study revealed that rich households were 8.85 times likely to use CF&HPFs compared to poor households. The finding agrees with the Energy Ladder Theory that explains the direct relationship between the rise in household income and the adoption of clean cooking energy sources [25]. Again, apart from the ability to purchase CF&HPFs which are most often expensive, there appears to be some luxurious prestige attached with the adoption and use of CF&HPFs which rich households want to be associated with [24].
We investigated whether regional variations influenced the likelihood of a Ghanaian household to use climate-friendly and health-promoting fuels for cooking. The study observed that households within some political administrations in Ghana had a higher probability of using improved cooking methods than others. For example, we observed that households in the Greater Accra, Ashanti, Brong Ahafo, Central, Western and Eastern regions were more likely to use CF&HPFs than traditional biomass such as animal dung, fuelwood and biochar. One possible explanation for this observation can be attributed to the urbanized nature of these regions [26]. The Greater Accra region, for example, is the political head and administrative region of Ghana. It is the most urbanized region with about 87.4% of its population living in urban centres with access to viable economic and political resources for an improved standard of living [27]. This implies that households within these regions are more likely to utilize the available economic and political advantage to adopt or adapt climate-friendly and healthpromoting fuels for cooking than their counterparts in the other regions of the country. These finding shares some similarities with findings of one other study [28].
Of particular interest in the above finding was the higher probability of households in the Upper East region to use climate and health-promoting fuels for cooking. This is quite revealing because The has certain strength and limitations that are worth mentioning. The study employed the cross-sectional analysis which did not permit the researchers to derive causal relationships between predictors and the outcome variable. It is also worth mentioning that few households were excluded from the analysis because they did not cook at home and therefore did not use any domestic cooking energy. Close to four decades, the GDHS program has been conducting its survey every five years, and this has improved the quality of the sampling methodologies, data collection procedures, and the development of the questionnaires. Given that the study used the GDHS dataset that is nationally representative and large, the estimates from the analyses can be generalized for the entire Ghanaian population.

Conclusions
The adoption and sustained use of CF&HPFs are important in enhancing good health for nearly half of the world's population, mostly women and children in developing countries and to help protect the global environment. Our study finds household characteristics and region of residence as influential factors in the adoption of CF&HPFs in Ghana. The level of education, wealth status, age and marital status of household heads positively influenced the use of CF&HPFs. It became evident in this study that male-headed households were more likely than female-headed households to adopt CF&HPFs even though it dissented to most literature. Additionally, having two or more adult females in a household positively influences the chances of using clean cooking energy. Large family size (above 8 individuals) and residence in the Upper West region of Ghana were found to negatively influence the adoption of clean cooking fuels.
To increase the adoption and use of CF&HPFs to advance Ghana's cause towards achieving the SDGs, we recommend: a national effort to improve the economic standards of the poor majority to switch to clean cooking fuel use; education on efficient and sustainable consumption must be intensified and incorporated in the basic school's curriculum to ensure the future generation are more environmental sustainability and health-conscious.

Ethics approval and consent to participate
The Ghana Health Service Ethical Review Committee and the Institutional Review Board of ICF International reviewed and approved the 2014 GDHS protocol. Enumerators obtained informed consent from mothers between 15-49 years with children under-five years before interviewing them [17]. The GDHS did not obtain assent from parents or guardians of childbearing women who were either 15 or 16 years because they already had children and were independent of their guardians or parents. The GDHS is publicly available upon a simple, registration-access request, so no further ethical clearance was sought

Consent for publication
Not Applicable

Availability of data and materials
The 2014 Ghana DHS dataset supporting the analysis of this study is available in the DHS repository.
The DHS datasets are available for free after a simple registration process.

Competing Interests
The authors declare no competing interests.

Funding
Authors did not receive any funding.