Science of the Total Environment 709 (2020) 135110

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Science of the Total Environment

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Exposure to household air pollution during first 3 years of life and IQ

level among 6–8-year-old children in India – A cross-sectional study
Ajith Brabhukumr a, Prabhjot Malhi b, Khaiwal Ravindra a, P.V.M. Lakshmi b,⇑
a
Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India
b
Department of Paediatrics, PGIMER, Chandigarh, India

h i g h l i g h t s g r a p h i c a l a b s t r a c t

 There are limited evidence on HAP &

Cognitive performance of children.
 Exposure to HAP significantly affects
IQ among children.
 Low IQ during childhood predicts
poor academic performance during
later years of life.
 HAP significantly effects the maze,
digit span & arithmetic component of
IQ.
 Cognitive defects in children due to
HAP exposures could be prevented.

a r t i c l e i n f o a b s t r a c t

Article history: Many illnesses have been attributed to the exposure of solid biomass smoke but the effect on intelligence
Received 1 August 2019 has largely been unexplored. The study aims to examine the effect of exposure to solid biomass smoke
Received in revised form 2 October 2019 during the first 3 years of life on intelligence among 6–8-year-old children. Children aged 6–8 years were
Accepted 20 October 2019
enrolled from a primary school and their houses were visited to collect data on socio-economic status and
Available online 20 November 2019
household exposure assessment. Households using LPG as cooking fuel were considered as the unex-
Editor: Pavlos Kassomenos posed group. All the children were tested for their Intelligence Quotient (IQ) using Malin’s Intelligence
Scale for Indian Children (MISIC). The mean IQ was calculated as the average of Verbal and
Keywords:
Performance score. Potential confounders were adjusted using multivariate general linear model.
Solid biomass fuel About 45% of children had average or above-average IQ while the rest had below-average IQ. The mean
Children scores for the arithmetic component of IQ were found to be significantly lower among solid biomass fuel
Intelligence quotient users as compared to LPG users after adjusting for confounders. The mean IQ of LPG users were 5.58
Arithmetic component points higher (95% CI: 0.46–10.1) for the arithmetic component as compared to solid biomass users.
PMUY Children living in the houses using solid biomass fuel for cooking have lower IQ as compared to the chil-
dren living in the houses using LPG for cooking for arithmetic component even after adjusting for poten-
tial confounders.
Ó 2019 Elsevier B.V. All rights reserved.

⇑ Corresponding author at: Department of Community Medicine and School of
Public Health, Post Graduate Institute of Medical Education & Research, Chandigarh,
India.
E-mail addresses: Khaiwal@yahoo.com (K. Ravindra), pvm_lakshmi@yahoo.com
(P.V.M. Lakshmi).
1. Introduction
The recent WHO report highlights that 4.3 million premature
deaths could be associated with the use of solid biomass fuel for
cooking. According to the WHO report, about 3 billion people burn

https://doi.org/10.1016/j.scitotenv.2019.135110
0048-9697/Ó 2019 Elsevier B.V. All rights reserved.
2 A. Brabhukumr et al. / Science of the Total Environment 709 (2020) 135110
solid biomass for cooking and heating which include wood, animal
dung, and crop waste. Most of these people are poor, and live in
developing countries (WHO, 2011). The Lancet Commission on pol-
lution and health and Global Burden of Disease estimate also iden-
tify household air pollution as a major risk factor for human health
(Landrigan et al., 2018; Cohen et al., 2017). Though outdoor air pol-
lution has long been known to cause several diseases including res-
piratory, cardiovascular and neurological conditions there are
limited studies linking the illnesses caused by indoor or household
air pollution (HAP). The health effects of solid biomass smoke
include respiratory illness in children and adults, structural birth
defects, low birth weight and infant mortality, nutritional
deficiencies, interstitial lung disease, Chronic Obstructive Pul-
monary Disease (COPD), pulmonary tuberculosis, lung cancer,
nasopharyngeal and laryngeal cancers, cardiovascular diseases,
cataracts and exacerbation of health effects of HIV infection
(Fullerton et al., 2008; Kaur-Sidhu et al., 2019a).
Several toxic substances which are released during combustion
could be responsible for a range of physical and mental deficits in
children. There are studies linking nitrogen dioxide in indoor air
pollution with mental retardation and Attention Deficit Hyperac-
tivity Disorder (ADHD) (Morales et al., 2009). Exposure to
second-hand tobacco smoke is a well-known factor that has detri-
mental effects on children’s cognition (Chen et al., 2013). Though
there are some studies on the effect of outdoor air pollution
(Suades-Gonzalez et al., 2015), urban vehicular pollution
(Garcidueñas et al., 2016) and environmental tobacco smoke
(Jedrychowski et al., 2015), on cognitive and academic perfor-
mance of students, the association of HAP (Vrijheid et al., 2012)
and the cognitive performance has not yet been fully explored. Fur-
ther, most of the studies have assessed the effects of nitrogen diox-
ide (NO2) and particulate matter (PM) on the cognitive disorders in
children exposed during both the prenatal and postnatal period.
Few studies have also focussed on the elemental composition of
PM that affects the developing brain of the children (Bellinger,
2018). Studies focussing on comparison of different types of fuels
(LPG, Solid biomass fuel) and their cognitive effects on children
have not been studied previously.
Physical and mental development is more rapid in infants under
one year of age than at any other age and hence they are highly
vulnerable to the effects of HAP toxic substances that can interfere
with the biological systems. Developmental and neurological
toxins present in HAP are likely of greater concern to the
developing fetus because of the even more rapid physical and brain
development that occurs in-utero. Adding to this risk, the infants
are almost always carried by their mothers or allowed to roam
around or play around them wherever they work, which mostly
involve cooking in rural areas of India. This practice exposes the
child to harmful HAP, which can be detrimental to their develop-
ment. Studies have also shown that women exposed to solid bio-
mass smoke suffer more from health and respiratory illness
compared to women using other fuels, due their poorly ventilated
kitchen in their house (Kaur-Sidhu et al., 2019a,b; Sukhsohale
et al., 2013).
Thus, exposure to solid biomass fuel during fetal life and during
early life can produce children with neurological deficits, which
can, in turn, affect the society, economy, and growth of the country
to a large extent since less intelligent children by being less pro-
ductive, can further hinder development in developing countries
or Least Developed Countries (LDCs). Hence, the World Health
Organization (WHO, 2018) also stress that efforts should be made
to prevent the HAP exposure to improve their health. In India,
72.2% of population reside in rural areas with widespread use of
solid fuel, and 86.5% of the rural people use solid biomass fuel
for cooking (Census of India, 2011; Ravindra et al., 2019a;
Kaur-Sidhu et al., 2019a; Sharma et al., 2020). Further, cooking
with solid biomass fuel also alter the thermal comfort of rural
household and could synergistically add to adverse health impact
of HAP (Ravindra et al., 2019b) Thus, intervention on the usage
of solid biomass fuel gains significance in the step towards preven-
tion of health problems due to their use and betterment of health
of the most vulnerable sections of the society, i.e. the women and
the children.
Hence, there is a need to look into the association between
household air pollution due to solid biomass smoke and its effects.
Thus, the current study aims to investigate the association of HAP
during first three years of life with cognitive development at the
age of 6–8 years.
2. Materials and methods
2.1. Participants and recruitment
A cross-sectional study was conducted from July 2012 to June
2013. Children from two villages (Kheri and Samlehri), where the
Department of Community Medicine and School of Public Health,
PGIMER is providing community-based health services were
selected for the study. The estimated sample size was 108, assum-
ing an anticipated effect size (Cohen’s f2) for multiple regression
as 0.15, with the power of the study as 80%, 95% Confidence Inter-
val and the number of predictors as 7. The study participants
included 6–8-year-old children. Eligible study participants were
recruited from the primary school in the area after verifying their
date of birth, address and obtaining consent from the concerned
authorities (school principal) and the parents. Children who had
an acute illness at the time of enrolment were contacted again
after recovery from illness. There was no non-response in the
study.
2.2. Measurement of exposure variables
Socio-economic status was calculated using Udai-Pareek scale, a
standardized scale for Indian rural setting. The questionnaire was
filled by the interviewer based on the interview of the mother
and observation of the household by the investigator (Pareek and
Trivedi, 1964). The questionnaire developed by Sri Ramachandra
Medical College and Research Institute, Chennai for household
exposure assessment was adapted for the study (Balakrishnan
et al., 2004). The information about the family profile, components
to assess the socio-economic status of the family, housing charac-
teristics, kitchen characteristics, the main source of fuel used for
cooking, the time spent for cooking, usage of incense sticks and
mosquito coils in house, the source of lighting in the home, pres-
ence of smokers in home and the number of hours smokers smoke
inside the house, the birth history and birth order of the child etc.
were collected using the questionnaire (Supplementary Annexure
1). Details on air pollutant levels in houses using solid biomass
and LPG as fuels have been discussed in detail in other studies
(Ravindra, 2019; Ravindra et al., 2019e; Sidhu et al., 2017;
Ravindra et al., 2019d). The kitchen characteristics with particular
focus on ventilation of the kitchen were recorded. Ventilation was
graded based on the number and size of the windows. Ventilation
was graded as good if there are two or more windows of adequate
size present, presence of exhaust fan or chimneys and open-air
outdoor kitchen, moderate if only one window was present and
poor if no window was present or presence of windows of very
small size. Only those children from households where cooking
fuel or housing characteristics have not changed over the past 3–
5 years were included in the study.
 A. Brabhukumr et al. / Science of the Total Environment 709 (2020) 135110
2.3. Measurement of outcome variable
Those using LPG as cooking fuel were considered as the unex-
posed group. All the children were tested for their IQ using Malin’s
Intelligence Scale for Indian Children (MISIC) (Malin, 1971). MISIC
is the Indian adaptation of the Weschler Intelligence Scale for Chil-
dren (WISC). Picture arrangement present in WISC was excluded in
this version and some items were adapted to suit the Indian cul-
ture. The scale consists of two major components, the Verbal score,
and Performance score. The Verbal score has the components of
Information, Comprehension, Arithmetic, Similarities, Vocabulary,
and Digit Span. The Performance score has the components of Pic-
ture completion, Block design, Object assembly, Coding and Maze.
The mean IQ was calculated as the average of Verbal and Perfor-
mance score. The scores were calculated as percentiles according
to the age of the child as shown in Fig. 1. The person who admin-
istered the IQ test was trained and certified for conducting an IQ
test by a qualified child psychologist.
2.4. Analysis
The main fuel used for cooking i.e. either solid biomass or LPG
were taken as exposure variables, and IQ was taken as the outcome
variable. Independent t-tests were done to test whether the mean
IQ scores are different between solid biomass and LPG users. The
covariates included in the study were socio-economic status, age
and gender of the child, exposure to tobacco smoke inside home,
ventilation and type of kitchen, anthropometric measurements
Fig. 1. Overview of the methodology.
3
(Height and Weight), presence of pallor, use of mosquito coils
and incense sticks, source of lighting in the house, mode of deliv-
ery, place of delivery, and the educational status of the mother.
The confounders which were found to be significantly associated
with the outcome and the exposure in the bivariate analysis or
known confounders according to the literature were adjusted by
using multivariate general linear model using SPSS version 17.
3. Results
The socio-demographic characteristics, birth history and health
characteristics of the respondents are shown in Table 1. There were
more females (55%), compared to males (45%). The mean age of the
respondents was 7 years (SD: 0.742 years). Three fourth of the
respondents belong to either middle or lower socio-economic sta-
tus. Most of the mothers were literate (78%). Most of the respon-
dents were born by normal vaginal delivery (84%) and two-thirds
of them were born in hospitals (68%). Nearly three-fourths of the
children belong to the birth order 1 or 2. Almost all of the respon-
dents were exclusively breastfed (95%). All of the respondents were
fully immunized except one. Only 8% of the respondents had pallor.
The mean height of the respondents was 116.6 cm (SD: 3.2 cm).
The mean weight of the respondents was 18.7 kg (SD: 2.1 kg).
The household and kitchen characteristics of the respondents
are shown in Table 2. Nearly two-thirds of the respondents live
in pucca houses. About 75% of the households had less than 5
rooms. Only 18% of the households had good ventilation. About
43% of the respondents use oil or candle for lighting. In 58% of
the households, there was someone in the family who smoke
tobacco inside the house. Fifty-five percent of the households burn
either mosquito repellant coils or incense sticks in their house.
About 40% of the households have an indoor kitchen with or
without partition from the rest of the house. Among the house-
holds surveyed 16% of the kitchens do not have either window or
opening. Less than a quarter of kitchens have good ventilation.
Many of the solid biomass stoves (71%) are of fixed type. More than
half of the stoves were of simple type (55%). Most of the stoves
(95%) were made of mud. Households very rarely (1%) used solid
biomass stove for heating purposes. One-fourth (25%) of house-
holds used solid biomass stove for cooking food for their cattle.
There were no significant differences in the distribution of sex,
age group, birth order, literacy of the mother, place of delivery,
mode of delivery, exclusive breastfeeding practices and immuniza-
tion history of the respondents among LPG and non-LPG users. The
socioeconomic status of the respondents was associated with the
type of cooking fuel used. Most of the respondents who use solid
biomass fuel belong to the low socioeconomic status (54%)
whereas most of the LPG users belong to either middle or upper
socioeconomic status (83%).
There was no association with the number of rooms/ doors and
the use of mosquito coils/ incense sticks with the type of fuel used
for cooking. There was a statistically significant association
between the type of house, ventilation of the house and smoking
inside the house with main fuel used for cooking. About 91% of
LPG users had pucca houses, while only 46% of solid biomass users
had a pucca house (p-value: 0.001). About one-third of the house-
holds using solid biomass fuel had poor ventilation as compared to
only 8% households in the LPG users (p-value: 0.005). Only one-
third of LPG users had someone in the family who smoke indoors
as compared to 66% among solid biomass users (p-value: 0.009).
The kitchen characteristics of the LPG users and the solid biomass
fuel users were significantly different. An indoor kitchen was present
in 70% of LPG users whereas it was present in only 30% of the users of
solid biomass fuel. The ventilation of the kitchen was poor in 32% of
solid biomass fuel users whereas it was 17% among LPG users.
4 A. Brabhukumr et al. / Science of the Total Environment 709 (2020) 135110

Table 1
Association of socio-demographic characteristics, birth history and health characteristics of the respondents with the type of fuel used for cooking.

Characteristics Total (N = 108) LPG (N = 24) Bio-mass (N = 84) v2 df P-value

Gender Male 49 (45.4%) 14 (58.3%) 35 (41.7%) 2.09 1 0.17
Female 59 (54.6%) 10 (41.7%) 49 (58.3%)
Age 6 31 (28.7%) 9 (37.5%) 22 (26.2%) 1.23 2 0.54
7 49 (45.4%) 10 (41.7%) 39 (46.4%)
8 28 (25.9%) 5 (20.8%) 23 (27.4%)
Birth order 1 34 (31.5%) 8 (33.3%) 26 (31%) 0.07 2 0.96
2 45 (41.7%) 10 (41.7%) 35 (41.7%)
3 29 (26.9%) 6 (25%) 23 (21.3%)
Socio-economic status Upper 26 (24.1%) 6 (25%) 20 (23.8%) 13.41 2 0.001*
Middle 33 (30.6%) 14 (58.3%) 19 (19%)
Lower 49 (45.4%) 4 (16.7%) 45 (53.6%)
Literacy of mother Literate 84 (77.8%) 21 (87.5%) 63 (75%) 1.69 1 0.27
Illiterate 24 (22.2%) 3 (12.5%) 21 (25%)
Pallor Present 9 (8.3%) 1 (4.2%) 8 (9.5%) 0.70 1 0.68
Absent 99 (91.7%) 23 (95.8%) 76 (90.5%)
Place of delivery Hospital 73 (67.6%) 20 (83.3%) 53 (63.1%) 3.50 1 0.08
Home 35 (32.4%) 4 (16.7%) 31 (36.9%)
Mode of delivery Normal vaginal 91 (84.3%) 21 (87.5%) 70 (83.3%) 0.24 1 0.76
Caesarean 17 (15.7%) 3 (12.5%) 14 (16.7%)
Exclusive breast feeding Yes 103 (95.4%) 24 (100%) 79 (94%) 1.50 1 0.59
No 5 (4.6%) 0 (0%) 5 (6%)
Fully immunized Yes 107 (99.1%) 24 (100%) 83 (98.8%) 0.30 1 1.000
No 1 (0.9%) 0 (0%) 1 (1.2%)
*
Indicates statistical significance at p < 0.05.

Table 2
Association of household, kitchen and stove characteristics with the type of fuel used for cooking.

Characteristics Total (N = 108) LPG (N = 24) Bio-mass (N = 84) v2 df p-value

Type of house Kucha/semi-pucca 40 (37%) 2 (8.3%) 38 (45.2%) 10.90 1 0.001*
Pucca 68 (63%) 22 (91.7%) 46 (54.8%)
Number of rooms 1–2 34 (31.5%) 5 (20.8%) 29 (34.5%) 4.08 2 0.13
3–4 48 (44.4%) 15 (62.5%) 33 (39.3%)
>=5 26 (24.1%) 4 (16.7%) 22 (26.2%)
Number of doors 1–2 42 (38.9%) 6 (25%) 36 (42.9%) 2.75 2 0.25
3–4 41 (38%) 12 (50%) 29 (34.5%)
5 25 (23.1%) 6 (25%) 19 (22.6%)
Ventilation of the house Poor 28 (25.9%) 2 (8.3%) 26 (31%) 10.66 2 0.005*
Moderate 61 (56.5%) 13 (54.2%) 48 (57.1%)
Good 19 (17.6%) 9 (37.5%) 10 (11.9%)
Type of Kitchen Indoor with partition 30 (27.8%) 11 (45.8%) 19 (22.6%) 15.51 3 0.001*
Indoor without partition 12 (11.1%) 6 (25%) 6 (7.1%)
Separate indoor kitchen outside the house 50 (46.3%) 7 (29.2%) 43 (51.2%)
Open air kitchen outside the house 16 (14.8%) 0 (0%) 16 (19%)
No. of windows/openings 0–1 57 (61.0%) 16 (66.7%) 41 (60.3%) 0.31 1 0.63
2–3 42 (45.7%) 8 (33.3%) 27 (39.7%)
Ventilation of the kitchen Poor 31 (28.7%) 4 (16.7%) 27 (32.1%) 6.40 2 0.041*
Moderate 52 (48.1%) 10 (41.7%) 42 (50%)
Good 25 (23.1%) 10 (41.7%) 15 (17.9%)
Oil/candle for lighting Absent 62 (57.4%) 18 (75%) 44 (52.4%) 3.91 1 0.06
Present 46 (42.6%) 6 (25%) 40 (47.6%)
Tobacco smoking inside the house Absent 45 (41.7%) 16 (66.7%) 29 (34.5%) 7.94 1 0.009*
Present 63 (58.3%) 8 (33.3%) 55 (65.5%)
Mosquito coils and incense sticks Absent 49 (45.4%) 8 (33.3%) 41 (48.8%) 1.80 1 0.25
Present 59 (54.6%) 16 (66.7%) 43 (51.2%)
*
Indicates statistical significance at p < 0.05.

There was no association of the socio-demographic and house-
hold characteristics with the IQ of the respondents except for age.
The mean IQ of the respondents increased with increase in the age
of the respondents. The mean IQ of the respondents along with SD
according to socio-demographic, household and kitchen character-
istics were given in Tables 3 and 4. About 45% of children had aver-
age or above-average IQ while the rest fell under borderline and
below average.
The mean IQ of the various components of IQ of solid biomass
fuel users and LPG users was compared and the results are pre-
sented in Table 5. Though there was no significant difference in
the mean of the overall IQ of the respondents between LPG and
solid biomass fuel users, there were significant differences in the
mean scores of arithmetic, digit span and maze components of
IQ. The mean scores obtained in the solid biomass fuels in these
components were significantly lower than the mean scores
obtained by the LPG users. Multivariate analysis was used to adjust
for confounders. The confounders used for adjustment were age
and sex of the respondent, mother’s literacy, socioeconomic status,
smoking inside the house, oil and candle use for lighting, use of a
coil or incense sticks, ventilation of the house, type of house, type
of kitchen and ventilation of kitchen. After adjusting for con-
founders, the mean score obtained for the arithmetic component
was significantly lower among solid biomass users as compared
to LPG users. The results of the multivariate analysis were pre-
sented in Table 6. The mean IQ of LPG users was 5.58 points higher
 A. Brabhukumr et al. / Science of the Total Environment 709 (2020) 135110 5

Table 3
Association of socio-demographic characteristics with the IQ of the respondents.

Characteristics Mean IQ SD t df p-value

Gender Male 89.02 10.71 0.21 1 0.83
Female 83.40 7.52
#
Age 6 89.37 8.67 3.994 2 0.021*
7 87.03 9.82
8 92.93 6.92
Birth order 1 88.87 10.63 1.70# 2 0.19
2 90.93 7.24
3 87.01 9.41
Socio-economic status Upper 91.96 8.97 2.85# 2 0.06
Middle 90.25 10.61
Lower 87.09 7.54
Literacy of mother Literate 89.10 9.58 0.28 1 0.78
Illiterate 89.69 7.12
Pallor Present 90.91 8.58 0.58 1 0.57
Absent 89.08 9.13
Place of delivery Hospital 90.06 9.86 1.38 1 0.17
Home 87.43 6.93
Mode of delivery Normal vaginal 88.94 9.28 0.78 1 0.44
Caesarean 90.80 7.87
Exclusive breast feeding Yes 89.40 9.16 0.88 1 0.38
No 85.75 6.45
Fully immunized Yes 89.22 9.11 0.03 1 0.97
No 89.53 –
#
ANOVA F statistics.
*
Indicates statistical significance at p < 0.05.

Table 4
Association of household, kitchen and stove characteristics with IQ of the respondents.

Characteristics Mean IQ score SD F df (between, within) p-value

Type of house Kucha/ semi-pucca 88.43 5.68 0.49 1106 0.49
Pucca 89.70 10.58
Number of rooms 1–2 87.46 8.97 1.01 2105 0.37
3–4 90.32 9.82
>=5 89.52 7.63
Number of doors 1–2 87.62 8.66 1.14 2105 0.33
3–4 89.98 9.25
5 90.71 9.40
Ventilation of the house Poor 86.15 7.04 2.33 2105 0.10
Moderate 90.05 8.43
Good 91.11 12.53
Type of Kitchen Indoor with partition 89.85 11.24 1.65 3104 0.18
Indoor without partition 91.38 9.99
Separate indoor kitchen outside the house 89.77 7.32
Open air kitchen outside the house 84.767 8.21
No. of windows/openings 0–1 89.44 9.40 0.59 190 0.45
2–3 90.93 8.44
Ventilation of the kitchen Poor 88.82 6.29 0.05 2105 0.95
Moderate 89.45 9.46
Good 89.27 11.26
Oil/candle for lighting Absent 90.53 9.26 3.06 1106 0.08
Present 87.47 8.59
Tobacco smoking inside the house Absent 90.71 10.82 2.08 1106 0.15
Present 88.17 7.49
Mosquito coils and incense sticks Absent 89.98 9.60 0.6 1106 0.44
Present 88.61 8.63

(95% CI: 0.46 – 10.1) for the arithmetic component of IQ as com-
pared to solid biomass users.
Thus, it can be concluded that the IQ of the children measured
at the age of 6–8 was significantly lower among children who were
exposed to solid biomass fuel smoke as compared to those who
were not exposed, especially for the arithmetic IQ.
4. Discussion
The IQ of the children exposed to the smoke of solid biomass
fuel used for cooking is on average 5.5 points lower for the arith-
metic component of IQ as compared to those who were exposed
to smoke of LPG fuel used for cooking. An earlier study had shown
the neuropsychological impact on exposure to carbon monoxide
from kerosene stoves, in which digit span along with few other
components in Wechsler’s intelligence scale were found to be
affected (Amitai et al., 1998). A similar study on Carbon monoxide
exposure from wood smoke had shown negative co-relation with
digit span among three tests, Coding, Symbol Search and Digit Span
in Wechsler scale, that were administered. Other cognition func-
tion affected were visuospatial integration, short-term and long-
term memory recall and fine motor performance from other cogni-
tion tests (Dix-Cooper et al., 2012).
The present study has shown the impact of solid biomass fuels
including the commonly used cow dung and wood, on the arith-
metic function (p < 0.033) among the 11 tests in Malin’s scale
which is the Indian adaptation of Wechsler’s scale, after adjusting
6 A. Brabhukumr et al. / Science of the Total Environment 709 (2020) 135110

Table 5
Association of IQ components with type of fuel used for cooking.

Components Cooking fuel 95% Confidence Interval t df p-value

of the Difference
BiomassMean IQ LPG Mean IQ Lower Upper
Information 82.36 85.13 5.97 0.44 1.71 106 0.09
Comprehension 88.60 88.13 12.31 13.25 0.08 106 0.94
Arithmetic 75.87 82.04 10.70 1.64 2.78 106 0.009*
Similarities 100.77 99.42 5.59 8.30 0.39 106 0.70
Vocabulary 72.56 75.29 7.24 1.77 1.20 106 0.23
Digit span 85.64 94.21 15.86 1.27 2.40 106 0.023*
Picture completion 103.64 105.42 9.97 6.42 0.43 106 0.67
Block design 89.50 97.88 21.95 5.20 1.22 106 0.22
Object assembly 81.8 84.13 9.68 5.05 0.62 106 0.54
Coding 101.76 107.04 14.99 4.43 1.08 106 0.28
Maze 84.45 94.67 18.21 2.22 2.61 106 0.014*
Total verbal 84.30 87.37 8.46 2.32 1.17 106 0.25
Total performance 92.23 97.83 11.64 0.46 1.83 106 0.07
Full scale IQ 88.27 92.60 9.83 1.17 1.61 106 0.12
*
Indicates statistical significance at p < 0.05.

Table 6
Association of IQ components with the type of fuel used for cooking after adjusting for confounders.

Components Mean Difference IQ Scores Std. Error 95% Confidence Interval for t p-value
Mean Difference
Lower Upper
Information 0.99 2.19 5.33 3.35 0.45 0.65
Comprehension 3.21 5.62 14.37 7.96 0.57 0.57
Arithmetic 5.58 2.58 10.71 0.46 2.17 0.033*
Similarities 1.08 4.91 8.68 10.83 0.22 0.83
Vocabulary 4.81 3.19 11.14 1.53 1.52 0.13
Digit span 7.64 3.95 15.49 0.20 1.94 0.06
Picture completion 6.65 6.01 5.28 18.58 1.11 0.27
Block design 8.03 9.49 26.89 10.83 0.85 0.4
Object assembly 0.94 5.44 9.87 11.75 0.17 0.86
Coding 0.57 5.57 11.65 10.50 0.10 0.92
Maze 4.56 4.55 13.60 4.48 1.00 0.32
Total verbal 3.53 2.63 8.76 1.71 1.34 0.18
Total performance 1.12 4.18 9.42 7.19 0.27 0.79
Full scale IQ 2.32 2.89 8.05 3.41 0.80 0.42

Adjusted for sex, mother’s literacy, socioeconomic status, smoking inside the house, oil and candle use for lighting, use of coils or incense sticks, type of house, ventilation of
the house, type of kitchen and ventilation of the kitchen.

for confounders like socio-economic class, type of house, ventila-
tion of house, type of kitchen, ventilation of kitchen and exposure
to tobacco smoke inside the house. Biological plausibility exists
between outdoor air pollution and cognition and similar pathway
may exist for indoor air pollution too (Chen and Schwartz, 2009).
Studies have also shown extra-pulmonary translocation of inhaled
metal particles to brain through olfactory pathways may affect the
IQ of the children (Oberdörster et al., 2004). Previous studies have
shown association between NO2 exposure during both prenatal
and postnatal period and impaired neurodevelopment in children
(Sentís et al., 2017; Loftus et al., 2018). Exposure to fine PM during
fetal life also led to structural alterations in the brain (Guxens et al.,
2018). Studies have also shown that urban air pollution may lead
to cognitive disorders in children (Annavarapu and Kathi, 2016;
Pujol et al., 2016; Lubczyńska et al., 2017). This study thereby
establishes the impact of exposure to solid biomass fuel on the cog-
nitive functioning of brain to some extent.
Reduced arithmetic function and digit span can profoundly
affect the child’s academic performance which can affect their
future job prospects in the current competitive world. Maze test
in the performance part of the IQ scale can be related to their ana-
lytical function which when affected can impair their thinking pro-
cess and future decision making for themselves and their
dependents. Such decreased productivity of the individuals on a
large scale can contribute to under-performing population which
can have an adverse effect on the nation’s productivity as a whole.
It was also found that factors like literacy of mother, place of
delivery, exclusive breastfeeding of the child and immunization
had no association with the type of fuel used. Further, the current
study shows that 67.6% had institutional delivery, 95.37% had
exclusively breastfed their children and 99% of children were fully
immunized. These improvements can be attributed to improved
quality and access to health care in rural areas through integrated
care through Government of India’s National Rural Health Mission
(NRHM). Smoking was observed to be prevalent in the community
with beedi being the more commonly smoked form of tobacco
among the rural population.
Socioeconomic status shows a significant association (p < 0.001)
with the choice of fuel, with people opting for cheaper solid bio-
mass fuel. However, a recent study by Sharma et al. (2020) reports
that uses of solid biomass fuels may not cheap as compared to LPG.
The non-availability and the high cost of LPG cylinders coupled
with cheap and easy availability of solid biomass fuels in villages
in India are also seen as a major obstacle towards people’s choice
to switch to cleaner LPG fuel, despite their willingness to do so.
The reasons cited for not using kerosene as their source of fuel
were non-availability and difficulty in procuring kerosene.
Recently Government of India has launched several scheme o
enhance the use of clean fuel such as Pradhan Mantri Ujjwala
Yojana (PMUY); Give-it-Up (GIU), and direct benefit transfer of
LPG (DBTL) as detailed by (Smith, 2017; Ravindra and Smith
(2018). However, it was also observed during the study that free
 A. Brabhukumr et al. / Science of the Total Environment 709 (2020) 135110
meals provided to government school children at their schools
under Government of India’s flagship Mid-Day Meal program food
is commonly prepared using solid biomass fuels. Hence, there is a
need to extend the scope of clean fuel programs for Mid-Day Meal
program.
Although there was no significant association in the overall IQ
between the two groups, the mean IQ of the children exposed to
solid biomass fuels was less when compared to those using LPG
as the fuel. The mean total Verbal score comprising the individual
scores of Information, Comprehension, Arithmetic, Similarities,
Vocabulary, and Digit Span were found to be decreased insignifi-
cantly in the solid biomass group compared with the LPG group.
Similarly, the Performance score comprising the scores of Pic-
ture completion, Block design, Object Assembly, Coding, and Maze
were also decreased insignificantly in the solid biomass group
compared with the LPG group.
The insignificant results found in the current study is most
probably due to less sample size as the confidence intervals were
wider. Thus, a similar study with a large sample size will be helpful
in better understanding the association of IQ and the main cooking
fuel used by the households. Despite the small size of the study,
this study is one of its kind from South Asian countries where solid
biomass fuel for cooking is more common and for the first time has
shown that there is some evidence of association of cooking fuel
and cognitive function of children in the age of 6–8 years. Environ-
mental exposures like lead and pesticides were not assessed in this
study, assuming equal exposure among the study population.
5. Limitations
Though outdoor air pollution due to factories and heavy vehic-
ular traffic was not present at the place of study and the level of
pollution was not taken into consideration, it was assumed to have
an equal impact on all the children geographically. The level of
exposure due to solid biomass smoke measured in terms of PM2.5
and PM10 levels could have been a better estimate of the exposure
levels but was not carried due to financial constraints. Lead and
pesticide exposure to the children was a known factor to affect
children’s cognition but was not taken into consideration in this
study, assuming to have an equal impact on all the children. Air
velocities inside homes were not monitored and thus in-home
observation approach on the basis of number, size, and orientation
of windows provides a qualitative assessment of ventilation in
homes.
6. Recommendations
More studies with varied methodology with larger sample size
and accurate measurements of toxic chemicals in the smoke and
particulate matters (PM2.5 and PM10) may provide further insight
into the effects of solid biomass fuel on neurological development.
Effective government policies are needed to reduce the use of
solid biomass fuels in rural areas and switch over to cleaner fuel
to increase productivity, decrease morbidity and tackle climatic
changes (Ravindra et al., 2019c). Further, efforts should be made
to retain the LPG users, who have opted for it addressing various
barriers as highlighted by Ravindra et al. (2019a,b,e).
Contributorship statement
AP conducted the field work and wrote the first draft of the
manuscript. PVML, PM, and KR helped to develop the intellectual
content of the protocol and manuscript including review/editing.
7
Data sharing statement
A MD thesis is available on the topic and can be provided by e-
mail to Dr. PVML.
Ethical approval
The protocol was approved by Dissertation Approval Committee
of the Institute and Departmental Peer Review committee.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgments
We greatly acknowledge the support from the State School
Authority of Haryana and all the stakeholders who participated
in this study. RK would like to thank Indian Council of Medical
Research (ICMR), Ministry of Health and Family Welfare, for
funding the linked study on ‘Assessment of Impact of PMUY’ via
letter number No. 58/11/NTF-LPG/2019-NCD-II dated 28/05/19.
Funding statement
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.scitotenv.2019.135110.
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