Household solid fuel exposure and linear growth faltering in rural Indian children
Abstract
Introduction: Stunting affects approximately one-quarter of children globally. This study aims to examine how exposure to Household Air Pollution (HAP) from solid fuel use contributes to growth faltering among children.
Materials and methods: The study utilized data from the National Family Health Survey (NFHS-5, 2019–21) and included 185,721 rural children aged 0–59 months. Bivariate and multivariable logistic regression analyses were performed to evaluate the association between household cooking fuel and childhood stunting, with findings reported as 95% Confidence Intervals (CIs). A mediation analysis was further undertaken to examine the potential mediating role of child morbidity.
Results: Using clean fuels was inversely associated with stunting; the odds of stunting were 62% and 54% lower among children in households using only clean fuels compared to those exposed to solid fuels. Based on the adjusted multivariable logistic regression, clean cooking fuel was significantly associated with a decreased prevalence of stunting (β = − 0.029, p = 0.050). Mediation analysis indicated significant effects of cooking fuel on stunting for the controlled direct effect (CDE = 0.972, p = 0.050) and natural direct effect (NDE = 0.973, p = 0.044) but not for the natural indirect effect via morbidity (NIE = 1.000, p = 0.893). The marginal total effect (MTE=0.973, p = 0.044) supported a small but significant protective association of child stunting with clean cooking fuel.
Conclusion: The findings suggest that reducing exposure to household air pollution through clean cooking fuels, alongside broader socio-economic interventions, may contribute to lowering childhood stunting in India.
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3. World Health Organization, UNICEF. State of the world’s children 2021: on my mind – promoting, protecting and caring for children’s mental health. Geneva: WHO; 2021.
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5. Mishra N, Salvi S, Lyngdoh T, Agrawal A. Low lung function in the developing world is analogous to stunting: a review of the evidence. Wellcome Open Res. 2020;5:147. doi:10.12688/wellcomeopenres.15929.2.
6. Aguayo VM, Branca F, Demaio S, Fanzo J, Haddad L, Menon P, et al. The state of the world’s children 2019: children, food and nutrition: growing well in a changing world. New York: UNICEF; 2019.
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8. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51. doi:10.1016/S0140-6736(13)60937-X.
9. Lin A, Arnold BF, Afreen S, Goto R, Huda TMN, Haque R, et al. Household environmental conditions are associated with enteropathy and impaired growth in rural Bangladesh. Am J Trop Med Hyg. 2013;89(1):130-7. doi:10.4269/ajtmh.12-0629.
10. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-2), 1998-99: India. Mumbai: IIPS; 1999.
11. Mishra V, Retherford RD. Does biofuel smoke contribute to anaemia and stunting in early childhood? Int J Epidemiol. 2007;36(1):117-29. doi:10.1093/ije/dyl234.
12. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), 2019-21: India. Mumbai: IIPS; 2021.
13. Fullerton DG, Bruce N, Gordon SB. Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Trans R Soc Trop Med Hyg. 2008;102(9):843-51. doi:10.1016/j.trstmh.2008.05.028.
14. Smith KR, McCracken JP, Weber MW, Hubbard A, Jenny A, Thompson LM, et al. Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial. Lancet. 2011;378(9804):1717-26. doi:10.1016/S0140-6736(11)60921-5.
15. Li Q, Jiang J, Wang S, Rumchev K, Mead-Hunter R, Morawska L, et al. Impacts of household coal and biomass combustion on indoor and ambient air quality in China: current status and implication. Sci Total Environ. 2017;576:347-61. doi:10.1016/j.scitotenv.2016.10.080.
16. Liu J, Mauzerall DL, Chen Q, Zhang Q, Song Y, Peng W, et al. Air pollutant emissions from Chinese households: a major and underappreciated ambient pollution source. Proc Natl Acad Sci U S A. 2016;113(28):7756-61. doi:10.1073/pnas.1604537113.
17. World Health Organization. Household air pollution and health [Internet]. Geneva: WHO; 2022 [cited 2026 May 24]. Available from: https://www.who.int/news-room/fact-sheets/detail/household-air-pollution-and-health
18. Rehfuess EA, Bruce NG, Smith KR. Solid fuel use: health effect. In: Nriagu JO, editor. Encyclopedia of environmental health. Burlington: Elsevier; 2011. p.150-61.
19. Martin WJ, Hollingsworth JW, Ramanathan V. Household air pollution from cookstoves: impacts on health and climate. In: Pinkerton KE, Rom WN, editors. Global climate change and public health. New York: Springer; 2014. p.237-55. doi:10.1007/978-1-4614-8417-2_13.
20. Desouza PN, Hammer M, Anthamatten P, Kinney PL, Kim R, Subramanian SV, et al. Impact of air pollution on stunting among children in Africa. Environ Health. 2022;21(1):128. doi:10.1186/s12940-022-00943-y.
21. Liang W, Wang B, Shen G, Cao S, McSwain B, Qin N, et al. Association of solid fuel use with risk of stunting in children living in China. Indoor Air. 2020;30(2):264-74. doi:10.1111/ina.12627.
22. Balietti ANCA, Datta S. The impact of indoor solid fuel use on the stunting of Indian children. Cambridge (MA): Center for International Development, Harvard Kennedy School of Government; 2017.
23. Nadhiroh SR, Micheala F, Tung SEH, Kustiawan TC. Association between maternal anemia and stunting in infants and children aged 0–60 months: a systematic literature review. Nutrition. 2023;115:112094. doi:10.1016/j.nut.2023.112094.
24. Rinaldi S, Balsillie C, Truchon C, Al-Mubarak A, Mura M, Madill J. Nutrition implications of intrinsic restrictive lung disease. Nutr Clin Pract. 2022;37(2):239-55. doi:10.1002/ncp.10849.
25. Tharumakunarajah R, Lee A, Hawcutt DB, Harman NL, Sinha IP. The impact of malnutrition on the developing lung and long-term lung health: a narrative review of global literature. Pulm Ther. 2024;10(2):155-70. doi:10.1007/s41030-024-00257-z.
26. Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, Morris SS, et al. Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol. 2008;37(4):816-30. doi:10.1093/ije/dyn099.
27. Richard SA, Black RE, Gilman RH, Guerrant RL, Kang G, Lanata CF, et al. Diarrhea in early childhood: short-term association with weight and long-term association with length. Am J Epidemiol. 2013;178(7):1129-38. doi:10.1093/aje/kwt094.
28. Wells JC. The capacity-load model of non-communicable disease risk: understanding the effects of child malnutrition, ethnicity and the social determinants of health. Eur J Clin Nutr. 2018;72(5):688-97. doi:10.1038/s41430-018-0142-x.
29. Smith LC, Haddad L. Reducing child undernutrition: past drivers and priorities for the post-MDG era. World Dev. 2015;68:180-204. doi:10.1016/j.worlddev.2014.11.014.
30. Corsi DJ, Mejía-Guevara I, Subramanian SV. Risk factors for chronic undernutrition among children in India: estimating relative importance, population attributable risk and fractions. Soc Sci Med. 2016;157:165-85. doi:10.1016/j.socscimed.2015.11.014.
31. Harttgen K, Lang S, Seiler J. Selective mortality and the anthropometric status of children in low- and middle-income countries. Econ Hum Biol. 2019;34:257-73. doi:10.1016/j.ehb.2019.04.001.
32. Spears D. Exposure to open defecation can account for the Indian enigma of child height. J Dev Econ. 2020;146:102277. doi:10.1016/j.jdeveco.2018.08.003.
33. Spears D, Ghosh A, Cumming O. Open defecation and childhood stunting in India: an ecological analysis of new data from 112 districts. PLoS One. 2013;8(9):e73784. doi:10.1371/journal.pone.0073784.
34. Fall CH, Sachdev HS, Osmond C, Restrepo-Mendez MC, Victora C, Martorell R, et al. Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration). Lancet Glob Health. 2015;3(7):e366-77. doi:10.1016/S2214-109X(15)00038-8.
35. Ghosh RE, Berild JD, Sterrantino AF, Toledano MB, Hansell AL. Birth weight trends in England and Wales (1986–2012): babies are getting heavier. Arch Dis Child Fetal Neonatal Ed. 2018;103(3):F264-70. doi:10.1136/archdischild-2016-311790.
36. Galofré-Vilà G, Harris B. Growth before birth: the relationship between placental weights and infant and maternal health in early twentieth-century Barcelona. Econ Hist Rev. 2021;74(2):400-23. doi:10.1111/ehr.13026.
37. Gao P, Schneider EB. The growth pattern of British children, 1850–1975. Econ Hist Rev. 2021;74(2):341-71. doi:10.1111/ehr.13002.
38. Bailey RE, Hatton TJ, Inwood K. Atmospheric pollution, health, and height in late nineteenth century Britain. J Econ Hist. 2018;78(4):1210-47. doi:10.1017/S0022050718000578.
39. Gauthier S. Late height growth from historical individual-level panel data [Internet]. SSRN; 2022 [cited 2026 May 24]. Available from: https://dx.doi.org/10.2139/ssrn.4047564
40. deSouza PN, Chaudhary E, Dey S, Ko S, Németh J, Guttikunda S, et al. An environmental justice analysis of air pollution in India. Sci Rep. 2023;13(1):16690. doi:10.1038/s41598-023-43628-3.
41. Aurino E, Lleras-Muney A, Tarozzi A, Tinoco B. The rise and fall of SES gradients in heights around the world. J Health Econ. 2023;91:102797. doi:10.1016/j.jhealeco.2023.102797.
42. World Health Organization. Levels and trends in child malnutrition: UNICEF/WHO/The World Bank Group joint child malnutrition estimates: key findings of the 2020 edition. Geneva: WHO; 2020.
43. Dherani M, Pope D, Mascarenhas M, Smith KR, Weber M, Bruce N. Indoor air pollution from unprocessed solid fuel use and pneumonia risk in children aged under five years: a systematic review and meta-analysis. Bull World Health Organ. 2008;86:390-8C. doi:10.2471/BLT.07.044529.
44. Aiyar A, Cummins JR. An age profile perspective on two puzzles in global child health: the Indian enigma and economic growth. J Dev Econ. 2021;148:102569. doi:10.1016/j.jdeveco.2020.102569.
45. Jayachandran S, Pande R. Why are Indian children so short? The role of birth order and son preference. Am Econ Rev. 2017;107(9):2600-29. doi:10.1257/aer.20151282.
46. Nguyen PH, Friedman J, Kak M, Menon P, Alderman H. Maternal depressive symptoms are negatively associated with child growth and development: evidence from rural India. Matern Child Nutr. 2018;14(4):e12621. doi:10.1111/mcn.12621.
47. Asare H, Rosi A, Scazzina F, Faber M, Smuts CM, Ricci C. Maternal postpartum depression in relation to child undernutrition in low- and middle-income countries: a systematic review and meta-analysis. Eur J Pediatr. 2022;181(3):979-89. doi:10.1007/s00431-021-04289-4.
48. Jelenkovic A, Sund R, Hur YM, Yokoyama Y, Hjelmborg JVB, Möller S, et al. Genetic and environmental influences on height from infancy to early adulthood: an individual-based pooled analysis of 45 twin cohorts. Sci Rep. 2016;6(1):28496. doi:10.1038/srep28496.
2. Wells JC, Briend A, Boyd EM, Berkely JA, Hall A, Isanaka S, et al. Beyond wasted and stunted—a major shift to fight child undernutrition. Lancet Child Adolesc Health. 2019;3(11):831-4. doi:10.1016/S2352-4642(19)30244-5.
3. World Health Organization, UNICEF. State of the world’s children 2021: on my mind – promoting, protecting and caring for children’s mental health. Geneva: WHO; 2021.
4. Sapartini G, Wong GW, Indrati AR, Kartasasmita CB, Setiabudiawan B. Stunting as a risk factor for asthma: the role of vitamin D, leptin, IL-4, and CD23+. Medicina (Kaunas). 2022;58(9):1236. doi:10.3390/medicina58091236.
5. Mishra N, Salvi S, Lyngdoh T, Agrawal A. Low lung function in the developing world is analogous to stunting: a review of the evidence. Wellcome Open Res. 2020;5:147. doi:10.12688/wellcomeopenres.15929.2.
6. Aguayo VM, Branca F, Demaio S, Fanzo J, Haddad L, Menon P, et al. The state of the world’s children 2019: children, food and nutrition: growing well in a changing world. New York: UNICEF; 2019.
7. Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the double burden of malnutrition and the changing nutrition reality. Lancet. 2020;395(10217):65-74. doi:10.1016/S0140-6736(19)32497-3.
8. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51. doi:10.1016/S0140-6736(13)60937-X.
9. Lin A, Arnold BF, Afreen S, Goto R, Huda TMN, Haque R, et al. Household environmental conditions are associated with enteropathy and impaired growth in rural Bangladesh. Am J Trop Med Hyg. 2013;89(1):130-7. doi:10.4269/ajtmh.12-0629.
10. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-2), 1998-99: India. Mumbai: IIPS; 1999.
11. Mishra V, Retherford RD. Does biofuel smoke contribute to anaemia and stunting in early childhood? Int J Epidemiol. 2007;36(1):117-29. doi:10.1093/ije/dyl234.
12. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), 2019-21: India. Mumbai: IIPS; 2021.
13. Fullerton DG, Bruce N, Gordon SB. Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Trans R Soc Trop Med Hyg. 2008;102(9):843-51. doi:10.1016/j.trstmh.2008.05.028.
14. Smith KR, McCracken JP, Weber MW, Hubbard A, Jenny A, Thompson LM, et al. Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial. Lancet. 2011;378(9804):1717-26. doi:10.1016/S0140-6736(11)60921-5.
15. Li Q, Jiang J, Wang S, Rumchev K, Mead-Hunter R, Morawska L, et al. Impacts of household coal and biomass combustion on indoor and ambient air quality in China: current status and implication. Sci Total Environ. 2017;576:347-61. doi:10.1016/j.scitotenv.2016.10.080.
16. Liu J, Mauzerall DL, Chen Q, Zhang Q, Song Y, Peng W, et al. Air pollutant emissions from Chinese households: a major and underappreciated ambient pollution source. Proc Natl Acad Sci U S A. 2016;113(28):7756-61. doi:10.1073/pnas.1604537113.
17. World Health Organization. Household air pollution and health [Internet]. Geneva: WHO; 2022 [cited 2026 May 24]. Available from: https://www.who.int/news-room/fact-sheets/detail/household-air-pollution-and-health
18. Rehfuess EA, Bruce NG, Smith KR. Solid fuel use: health effect. In: Nriagu JO, editor. Encyclopedia of environmental health. Burlington: Elsevier; 2011. p.150-61.
19. Martin WJ, Hollingsworth JW, Ramanathan V. Household air pollution from cookstoves: impacts on health and climate. In: Pinkerton KE, Rom WN, editors. Global climate change and public health. New York: Springer; 2014. p.237-55. doi:10.1007/978-1-4614-8417-2_13.
20. Desouza PN, Hammer M, Anthamatten P, Kinney PL, Kim R, Subramanian SV, et al. Impact of air pollution on stunting among children in Africa. Environ Health. 2022;21(1):128. doi:10.1186/s12940-022-00943-y.
21. Liang W, Wang B, Shen G, Cao S, McSwain B, Qin N, et al. Association of solid fuel use with risk of stunting in children living in China. Indoor Air. 2020;30(2):264-74. doi:10.1111/ina.12627.
22. Balietti ANCA, Datta S. The impact of indoor solid fuel use on the stunting of Indian children. Cambridge (MA): Center for International Development, Harvard Kennedy School of Government; 2017.
23. Nadhiroh SR, Micheala F, Tung SEH, Kustiawan TC. Association between maternal anemia and stunting in infants and children aged 0–60 months: a systematic literature review. Nutrition. 2023;115:112094. doi:10.1016/j.nut.2023.112094.
24. Rinaldi S, Balsillie C, Truchon C, Al-Mubarak A, Mura M, Madill J. Nutrition implications of intrinsic restrictive lung disease. Nutr Clin Pract. 2022;37(2):239-55. doi:10.1002/ncp.10849.
25. Tharumakunarajah R, Lee A, Hawcutt DB, Harman NL, Sinha IP. The impact of malnutrition on the developing lung and long-term lung health: a narrative review of global literature. Pulm Ther. 2024;10(2):155-70. doi:10.1007/s41030-024-00257-z.
26. Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, Morris SS, et al. Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol. 2008;37(4):816-30. doi:10.1093/ije/dyn099.
27. Richard SA, Black RE, Gilman RH, Guerrant RL, Kang G, Lanata CF, et al. Diarrhea in early childhood: short-term association with weight and long-term association with length. Am J Epidemiol. 2013;178(7):1129-38. doi:10.1093/aje/kwt094.
28. Wells JC. The capacity-load model of non-communicable disease risk: understanding the effects of child malnutrition, ethnicity and the social determinants of health. Eur J Clin Nutr. 2018;72(5):688-97. doi:10.1038/s41430-018-0142-x.
29. Smith LC, Haddad L. Reducing child undernutrition: past drivers and priorities for the post-MDG era. World Dev. 2015;68:180-204. doi:10.1016/j.worlddev.2014.11.014.
30. Corsi DJ, Mejía-Guevara I, Subramanian SV. Risk factors for chronic undernutrition among children in India: estimating relative importance, population attributable risk and fractions. Soc Sci Med. 2016;157:165-85. doi:10.1016/j.socscimed.2015.11.014.
31. Harttgen K, Lang S, Seiler J. Selective mortality and the anthropometric status of children in low- and middle-income countries. Econ Hum Biol. 2019;34:257-73. doi:10.1016/j.ehb.2019.04.001.
32. Spears D. Exposure to open defecation can account for the Indian enigma of child height. J Dev Econ. 2020;146:102277. doi:10.1016/j.jdeveco.2018.08.003.
33. Spears D, Ghosh A, Cumming O. Open defecation and childhood stunting in India: an ecological analysis of new data from 112 districts. PLoS One. 2013;8(9):e73784. doi:10.1371/journal.pone.0073784.
34. Fall CH, Sachdev HS, Osmond C, Restrepo-Mendez MC, Victora C, Martorell R, et al. Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration). Lancet Glob Health. 2015;3(7):e366-77. doi:10.1016/S2214-109X(15)00038-8.
35. Ghosh RE, Berild JD, Sterrantino AF, Toledano MB, Hansell AL. Birth weight trends in England and Wales (1986–2012): babies are getting heavier. Arch Dis Child Fetal Neonatal Ed. 2018;103(3):F264-70. doi:10.1136/archdischild-2016-311790.
36. Galofré-Vilà G, Harris B. Growth before birth: the relationship between placental weights and infant and maternal health in early twentieth-century Barcelona. Econ Hist Rev. 2021;74(2):400-23. doi:10.1111/ehr.13026.
37. Gao P, Schneider EB. The growth pattern of British children, 1850–1975. Econ Hist Rev. 2021;74(2):341-71. doi:10.1111/ehr.13002.
38. Bailey RE, Hatton TJ, Inwood K. Atmospheric pollution, health, and height in late nineteenth century Britain. J Econ Hist. 2018;78(4):1210-47. doi:10.1017/S0022050718000578.
39. Gauthier S. Late height growth from historical individual-level panel data [Internet]. SSRN; 2022 [cited 2026 May 24]. Available from: https://dx.doi.org/10.2139/ssrn.4047564
40. deSouza PN, Chaudhary E, Dey S, Ko S, Németh J, Guttikunda S, et al. An environmental justice analysis of air pollution in India. Sci Rep. 2023;13(1):16690. doi:10.1038/s41598-023-43628-3.
41. Aurino E, Lleras-Muney A, Tarozzi A, Tinoco B. The rise and fall of SES gradients in heights around the world. J Health Econ. 2023;91:102797. doi:10.1016/j.jhealeco.2023.102797.
42. World Health Organization. Levels and trends in child malnutrition: UNICEF/WHO/The World Bank Group joint child malnutrition estimates: key findings of the 2020 edition. Geneva: WHO; 2020.
43. Dherani M, Pope D, Mascarenhas M, Smith KR, Weber M, Bruce N. Indoor air pollution from unprocessed solid fuel use and pneumonia risk in children aged under five years: a systematic review and meta-analysis. Bull World Health Organ. 2008;86:390-8C. doi:10.2471/BLT.07.044529.
44. Aiyar A, Cummins JR. An age profile perspective on two puzzles in global child health: the Indian enigma and economic growth. J Dev Econ. 2021;148:102569. doi:10.1016/j.jdeveco.2020.102569.
45. Jayachandran S, Pande R. Why are Indian children so short? The role of birth order and son preference. Am Econ Rev. 2017;107(9):2600-29. doi:10.1257/aer.20151282.
46. Nguyen PH, Friedman J, Kak M, Menon P, Alderman H. Maternal depressive symptoms are negatively associated with child growth and development: evidence from rural India. Matern Child Nutr. 2018;14(4):e12621. doi:10.1111/mcn.12621.
47. Asare H, Rosi A, Scazzina F, Faber M, Smuts CM, Ricci C. Maternal postpartum depression in relation to child undernutrition in low- and middle-income countries: a systematic review and meta-analysis. Eur J Pediatr. 2022;181(3):979-89. doi:10.1007/s00431-021-04289-4.
48. Jelenkovic A, Sund R, Hur YM, Yokoyama Y, Hjelmborg JVB, Möller S, et al. Genetic and environmental influences on height from infancy to early adulthood: an individual-based pooled analysis of 45 twin cohorts. Sci Rep. 2016;6(1):28496. doi:10.1038/srep28496.
| Files | ||
| Issue | Vol 11 No 3 (2026): Summer 2026 | |
| Section | Original Research | |
| Keywords | ||
| Stunting; Mediation; Controlled direct effect; Regression; Education | ||
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How to Cite
1.
Das U. Household solid fuel exposure and linear growth faltering in rural Indian children. JAPH. 2026;11(3):361-376.
