Globally, indoor smoke from biomass fuels ranks eighth as a risk factor for burden of disease and in developing countries is associated with 4–5% of all deaths and disability-adjusted life-years lost [1]. An estimated 70% of the world’s poorest 1.3 billion people are women who rely on biomass energy, in the form of firewood, crop residues, and charcoal, burned in traditional and inefficient cookstoves [2]. More than an estimated 1.5 million deaths in children <5 years of age worldwide are caused by acute respiratory infections, and exposure to indoor smoke, often originating from inefficient cookstoves used for cooking and boiling water for drinking, more than doubles the risk of pneumonia [3,4,5].

Exposure to indoor air pollution is an important public health problem in rural Western Kenya as most households cook with open pit three-stone cookstoves that use biomass fuels and women and children in these households experience a daily median of five hours of exposure to indoor air pollution from cooking [6]. A survey conducted in Nyanza Province, western Kenya, in March-April 2007, found a heavy burden of respiratory illnesses, with caregivers reporting that 22% of children aged 6–35 months experienced an acute respiratory infection (defined as cough or difficulty breathing in the last 24 hours) in the past two weeks [7]. Effective strategies to improve indoor air quality include use of cleaner-burning, efficient cookstoves. Reducing exposure to indoor air pollution through cleaner-burning cookstoves represents one WHO-recommended intervention to reduce respiratory diseases and improve the health of women and children who spend more time around the hearth of the home [8,9].

In an effort to mitigate the negative effects of traditional three-stone and inefficient charcoal cookstoves, we initiated a pilot cookstove improvement project among poor Luo communities in Nyanza Province in Western Kenya. The project was conducted in 10 rural villages from July 2008–March 2009, in conjunction with the Safe Water and AIDS Program (SWAP), a Kenyan non-governmental organization that trains HIV self-help and support groups to provide health education and sell health products to their community members as an income generating activity in rural villages and peri-urban slums [7]. SWAP group members receive training on evidence-based health products (such as safe water systems, insecticide treated bednets, and soap), health education and promotion strategies, and microfinance skills. Following trainings, individual members take on the role of SWAP health promoters carrying out peer-to-peer health promotion and selling health products in their communities for a profit.

For the improved cookstove project, SWAP health promoters in the 10 villages received additional training on the prevention of respiratory illnesses and promotion of an improved cookstove, the upesi jiko, as well as how to permanently install it in the purchasers’ home. The upesi jiko (Swahili for “quick cookstove”) is a simple ceramic liner installed into a simple, earthen base that is constructed semi-permanently within a kitchen (Figure 1). The upesi jiko is locally produced by skilled pottery groups guided by the Kenya Bureau of Standards (KS 1814:2005) to ensure that the dimensions of the ceramic liner are energy efficient [10]. The cookstove costs 150 Kenyan Shillings (Ksh), or ~$2.00 U.S. Dollars (USD). Additional material and labor costs for the installation of the liner into a permanent earthen base typically added $1.50 to $3.00 USD to the purchase. Some testing has been conducted in both lab and field settings; however, findings from these evaluations have not yet been published.

Our study had three major components. We assessed current cookstove practices and approaches to adoption of the locally manufactured cookstoves. Additionally, we assessed the efficacy of the stove in reducing harmful emissions. Findings from these studies will be presented elsewhere. We also explored the actual experiences of stove promoters in persuading women to purchase and use the stove, as well as the actual experiences of women who purchased a stove and assessed what influenced their purchase and use of the improved stove. We present those narrative findings in this report. We explored from the SWAP health promoter’s perspective: the most effective cookstove promotion activities, community reactions to the cookstove intervention, perceptions of the SWAP cookstove trainings, and benefits experienced by using the new improved cookstove. In addition, we wanted to better understand from the purchaser’s perspective: their motivation to purchase and install the improved cookstove, how they secured the funds to purchase the improved cookstove, the benefits and challenges of the cookstove use, and other factors that influenced their experiences with or ability to use the upesi jiko.

There is a growing recognition for the need to understand which public health interventions work and how to make them succeed in the real world. Qualitative research utilizes a range of data collection approaches in a real life setting, which can inform health intervention projects in resource-poor countries, guide decision-making, assist in program design, explain behaviors, and better understand why programs succeed or fail [20,21,22]. This is especially important for public health interventions that reduce indoor air pollution, since the Global Alliance for Clean Cookstoves led by the United Nations was formed to promote cleaner burning cookstoves [23].

Findings from our qualitative inquiry provided valuable insights into both the SWAP health promoter and the cookstove purchaser and important information that was used in scaling up the intervention to a wider area. We determined that it was important to subsidize the upesi jiko and combine the purchase and installation cost. In addition, our findings allowed us to focus our messages on identifying community motivators along with emphasizing the role of cooking demonstrations to promote adoption of the upesi jiko. Similar to other studies, all participants identified problems with the traditional cookstove and reported considerable benefits of the improved cookstove to both their household environment and health [24,25,26]. Economic constraints profoundly affected participants’ day-to-day reality and income generated from promoting and selling cookstoves as well as income saved from using the cookstoves was seen as the greatest relative advantage over the traditional cookstove and a critical motivator for both promoters and purchasers. While health benefits were addressed, promoters more often focused on economic benefits of the improved cookstove due to the saliency of the topic to community members. Based upon the perceived local income levels of the community, the cost of the improved cookstove (150 Kenyan Schillings (Ksh) for purchase and 150 Ksh for installation—estimated $3 U.S.) was determined collectively by SWAP health promoters prior to the pilot. During implementation of the pilot, however, the SWAP health promoters determined that the cost was too high for many community members as the separate costs for purchase and installation of the improved cookstove often posed a barrier; use was often delayed for lack of money or supplies to finish installation. Cost is often a large factor in deciding whether to implement an intervention, especially in lower income communities. The literature regarding cost decisions for cookstoves is relatively limited and somewhat incomparable to literature regarding costs for other household health interventions as cookstoves tend to be more expensive and therefore, not as readily accessible for immediate purchase.

The intersection of drought, famine, and recent political instability, along with the household demands of potentially multiple wives and numerous children within a household compound often strained economic resources and limited women’s ability to purchase improved cookstoves. This is consistent with the findings of others who note that often the solutions to energy poverty are beyond the means of many in disproportionately poor populations [27].

As often seen in patriarchal societies in resource-poor countries, in this study, socially constructed roles for women related to household management, child care, and subsistence farming along with the additional requirement of searching, often for hours, for scarce biomass fuel increased the harsh burdens of day-to-day life among women [28]. Decision-making for household purchases, while often at the discretion of a woman, was nevertheless shaped by gendered power relationships with the husband and any co-wives, which is consistent with a similar study on improved cookstove use [26]. Men did not cook or collect fuel, and thus were less directly affected by the use of traditional cookstoves compared to women, which likely resulted in a lower motivation to purchase improved cookstoves for their wife (ves). For women, purchasing a cookstove with their own money often resulted in not purchasing other valuable household commodities such as food and clothing. These findings show that Luo women perceive the improved cookstove as a valuable product, but also highlight how their decision to purchase an improved cookstove can further exacerbate their economic vulnerability. This is an important factor to consider in determining pricing and promotion strategies for wider implementation of improved cookstove promotions.

Similar to findings from other qualitative studies on improved cookstove use, women in both groups reported that the use of inefficient traditional cookstoves resulted in numerous negative health consequences (irritated eyes, coughs, runny noses, difficulty breathing, and other respiratory illnesses) for themselves and their children, which then decreased when using an improved cookstove [29,30,31]. Furthermore, the need for less wood due to the improved efficacy of the cookstove reduced not only the labor and time required to search for and carry such wood but the accompanying joint pain, muscle strain, and other negative health effects which disproportionately affect women and children.

Consistent with the behavioral constructs of role modeling, observational learning, and self-efficacy, the most persuasive cookstove promotion strategy was that of seeing someone cooking on the jiko and discussing its economic and health benefits for women and the household [32]. Women who purchased the cookstove often talked with other women about their cookstove and described its numerous positive benefits, highlighting the critical role of interpersonal communication through social networks as primary to persuasive communication in the community setting. Health promoters found value in being part of SWAP along with the corresponding health education and health products they were able to offer the community.

As is shown in this study, qualitative inquiry is mainly an inductive rather than deductive analytical process concerned with the subjective experiences of participants around specific phenomena under study, such as the upesi jiko. Findings derived from qualitative formative data collection allowed for the scaling up of the pilot cookstove intervention in a locally relevant and appropriate way. While our findings showed that the upesi jiko was generally well received for various reasons, many of our participants noted that cost was an important barrier in the adoption of these cookstoves. Knowledge of this potential barrier to implementation allowed us to subsidize the cookstove as plans moved forward to scale up the project. The most salient pervasive factors for purchasing a cookstove were the economic savings and the perceived reduction of more immediate health effects of smoke to women and their children when cooking. Continuing to promote community identified motivators along with the potential long term health benefits will be critical in a community where long term health benefits may not be as salient as day-to-day concerns.

Previous studies have noted the importance of culturally relevant promotion and marketing strategies to effectively implement an improved cookstove intervention [24,33,34,35]. In our study, women described interpersonal communication through social networks of people they trusted, along with actual demonstrations of the cookstove in use as major influences on their decision to purchase and use the cookstove. The use of SWAP health promoters, who are members of the community and actively involved with local groups and individuals, will continue as a primary cookstove promotion approach with an emphasis on actual cookstove use demonstration. Enhancing the skills of SWAP health promoters and expanding the social network approach will allow for the promotion of the cookstoves throughout the community in a strategic, community-tailored approach. In addition, enhancing promotion activities to include male decision-makers may influence household discussion of purchasing an improved cookstove.

Our study has some limitations. Although, we believe that our findings would be transferable to poor populations near our study community with similar cultural characteristics and resource limitations, it may be less relevant to urban or nomadic populations in other parts of Kenya. We limited our inquiry to women who had purchased a cookstove. Additional inquires among women who had not purchased the cookstove and with men who are often in charge of household spending would have provided a more robust inquiry especially in resource-poor communities that have multiple demands on household income. Furthermore, all of the women in our study had recently purchased a cookstove and the women’s responses might have changed after a longer period of stove ownership. Lastly, some of our findings were based on self-report and not direct observation, which might have biased our findings if women responded with socially desirable answers.

Qualitative research allowed us to better understand the social setting, economic constraints, and complex social and gender processes surrounding household decision-making, as well as the perceived benefits and challenges of the improved cookstove in a rural Kenya community. These findings will be used to appropriately tailor future cookstove promotion activities in this disproportionately poor Luo community. Findings from our qualitative inquiry provided important guidance to program design and community promotion activities for scaling up a successful pilot cookstove improvement project. Qualitative research should play an important role in the scaling up of successful health promotion projects to ensure cultural relevance and health equity.