Introduction

The right to breathe clean air, which is essential for health and wellbeing, is one of the most fundamental human rights1. Goal 7 of the sustainable development agenda also aims to guarantee universal access to clean fuels and technologies2. However, due to its accessibility, affordability, and limited access to clean energy sources, biomass fuel is widely used in peri-urban areas3,4. Despite this fact, it is estimated that exposure to IAP from biomass fuel smoke results in over 4 million deaths annually throughout the world, with a further half million outdoor air pollution deaths5,6. Moreover, IAP was responsible for 3.2 million premature deaths in 2019, including over 237,000 deaths of under-five children7. Close to half of deaths from ARI among under-five children in low-and middle-income countries are attributed to IAP8,9.

Globally, more than 2.6 billion people lack access to clean cooking technologies and over 900 million people in Sub-Saharan Africa (SSA) alone depend on biomass fuels for cooking, heating, and lighting10,11. In SSA, where polluting biomass fuels are extensively used for cooking, heating, and lighting, IAP is a serious problem12,13,14,15. The United Nations Environment Programme (UNEP) established that thirteen countries in the SSA, including Ethiopia, are among the 20 countries with the least access to electricity16. In Ethiopia, where 95% of the country’s energy comes from biomass sources, IAP has been linked to more than 50,000 annual fatalities and 5% of the country’s total disease burden17,18.

The application of low-emission materials and products, careful selection of the appliances and fuels used for indoor combustion, venting of products to the outside air, and ventilation control are some of the methods that can be used to control sources of pollution and their dispersion, and in particular, to achieve acceptable indoor air quality19,20. Additionally, a number of international initiatives have recently been launched to accelerate access to clean household energy, including UN Sustainable Energy for All21 and the UN Foundation Global Alliance for Clean Cook Stoves22. These strategies can effectively enhance IAP prevention measures and help prevent ARI in children under five when properly applied.

Although a variety of interventions exist, ARI due to IAP remains one of the leading causes of morbidity and mortality among under-five children in developing countries, like Ethiopia23. A finding from a systematic review in Ethiopia showed that the pooled prevalence of ARI among under-five children due to biomass fuel use was 17.75%24. A recent systematic review and meta-analysis on the relationship between ARI and biomass fuel consumption in Ethiopian under-five children also discovered a greater prevalence of ARI, at 22%25. Amhara, where the peri-urban areas of Dessie City are located, is one of the most affected Ethiopian regions, with ARI accounting for 7% of infections among under-five children26.

Although the link between biomass fuel use and under-five ARI has been found in earlier Ethiopian research, factors that affect the use of biomass fuels in households with under-five children are not addressed. Additionally, while various studies demonstrate the public’s knowledge, attitude, and prevention regarding IAP27,28,29,30, there is limited research in Ethiopia regarding the issue among mothers with under-five children, especially in peri-urban areas. However, pneumonia due to IAP was more prevalent (17.1%) and higher than the national average (7%) among under-five children in the peri-urban areas of Dessie City23. Moreover, Dessie City’s peri-urban areas had a cold temperature, which added burdens from burning biomass fuels for heating, leading to an increase in IAP. Thus, this study aimed to evaluate IAP prevention practices and associated factors among mothers with under-five children in peri-urban areas of Dessie City. As a result, the study will give decision-makers information on the problem as they create IAP intervention guidelines, which are essential for lowering ARI-related mortality in under-five children.

Methods and materials

Study area

This study was conducted in peri-urban areas of Dessie City. Dessie City is located about 401 km northeast of Ethiopia’s capital city of Addis Ababa in Amhara Regional State. Dessie City Administration has 16 kebeles, 10 urban and 6 peri-urban kebeles. Kebele is Ethiopia’s smallest administrative unit, each consisting of about 5000 people. Based on the national census, Dessie City Administration had a total population of 212,436 in 2014. Of the total, 34,748 (16.4%) lived in peri-urban kebeles31. The six peri-urban kebeles of Dessie City Tita, Kurkur, Boru-Selase, Kelem-Dereba, Gerado-Bilen, and Gerado Endodber were the sites of this investigation.

Study design and period

A community-based cross-sectional study was conducted to evaluate IAP prevention practices and associated factors among mothers with under-five children in peri-urban areas of Dessie City, Northeastern Ethiopia, from May 1 to June 30, 2024.

Source and study population

In this study, all mothers or caregivers with under-five children in peri-urban areas of Dessie City were considered the source population, and those selected mothers or caregivers with under-five children in peri-urban areas of Dessie City during the data collection period were considered the study population.

Sample size determination

The sample size was determined using a single population proportion formula (\(n=\frac{(Z_{a/2})^2*p(1-p)}{d^2}\))32 considering the proportion of good IAP prevention practice of 50%, as there were no similar studies in peri-urban mothers with under-five children, 95%CI and a 5% marginal error. After adding a non-response rate of 10%, the final sample size was 422.

Sampling techniques

Initially, a preliminary study was conducted to identify households with under-five children in the six peri-urban kebeles. Then, the final sample size was proportionally distributed for the six peri-urban kebeles based on the number of households with under-five children in each peri-urban kebele. The study household is divided by the final sample size to get the sampling interval (k), and a random number within that interval is chosen as the starting point. Then, the participant households from each peri-urban kebeles were selected using systematic random sampling, using the kth value determined. Households in which study participants were not available at the first visit were revisited once more on the same day or the following day. If a participant was still not available, he or she was considered as a non-respondent.

Operational definitions

Good IAP prevention practices: Respondents who scored above or equal to the mean of IAP prevention practice questions.

Poor IAP prevention practices: Respondents who scored below the mean of IAP prevention practice questions.

Good knowledge about IAP: Respondents who answered above and equal to the mean of IAP knowledge questions.

Poor knowledge about IAP: Respondents who answered below the mean of IAP knowledge questions.

Positive attitude towards IAP: Respondents who answered above and equal to the mean of attitude towards IAP prevention questions.

Negative attitude towards IAP: Respondents who answered below the mean of attitude towards IAP prevention questions.

Data collection tools

The data were collected using a structured, pre-tested, interviewer-administered questionnaire and an on-the-spot observational checklist. To ensure the content and proper construction of the survey tool, the structured questionnaire was developed after reviewing formerly published articles and the WHO guidelines about IAP. The questionnaire comprised six sections. The first section of the questionnaire was designed to elicit questions on socio-demographic and economic variables such as age, education status, marital status, occupational status, monthly income and household size. The second section focused on the respondents’ knowledge of IAP, including its causes, prevention strategies, and health effects. The third section was about attitude towards IAP prevention practices, such as attention to IAP, satisfaction with indoor air quality, protective measures against IAP, the health effects of IAP, exposure to IAP, and prevention measures.

The fourth section of the questionnaire covered housing and kitchen factors associated with IAP, including the number of windows in the house, the number of windows that can open, the number of rooms in the living room, the existence of a separate kitchen, the structure of the kitchen, the presence of a chimney, the type of cooking stove that is typically used, and the presence of windows in the kitchen. The fifth part of the questionnaire was about households’ sources of energy for cooking, heating and lighting. The final section contains questions on IAP prevention practices, such as using a separate kitchen, fuel used for cooking, heating and lighting, ventilating the living room during heating and cooking, avoiding carrying children while cooking, avoiding smoking in the house, avoiding overcrowding, ensuring good ventilation, using modern stoves for cooking, and outside complete combustion of charcoal.

Data quality control

To keep the questions consistent, the questionnaire was first developed in English, translated into Amharic (the local language), and then retranslated back to English. Three MScs in Environmental Health who could speak Amharic, which is the local language, were recruited as data collectors. The supervision of the data collection process was conducted daily by two masters in environmental health. Prior to the actual data collection, training was given for 2 days by the principal investigator for data collectors and supervisors on the method of extracting the needed information, how to fill out the information in a structured questionnaire and checklist, the ethical aspects of approaching the participants, the aim of the study, and the contents of the questionnaire.

A pre-test was done among 10% of the sample in the peri-urban kebeles of Kombolcha Town. The reliability of the questionnaire was checked based on the pre-test results. Then, the questionnaire was modified based on the reliability test results and feedback from experts. The reliability of the questionnaire was tested using Cronbach’s α, which was found to be 0.87. Data collectors submitted the collected data on a daily basis by incorporating their names for daily correction. Data coding and entry were checked at the beginning and midway stages of the work, while cleaning was conducted at the end of data entry. Moreover, to check the reliability of the information entered, 10% of the study participants were randomly selected and re-interviewed by another interviewer. Furthermore, double data entry was done in 10% of the randomly selected questionnaire to control data entry errors.

Data processing and analysis

After the appropriate coding, data entry was done using Epi-Data version 4.6 and was exported to Statistical Package for Social Science (SPSS) version 25.0 for analysis. Descriptive statistics, like frequencies, percentages, and mean ± SD (standard deviations), were computed. For categorical variables, frequencies and percentages were determined, while the mean and standard deviation were determined for continuous variables. Continuous variables were categorized using information from the literature, and categorical variables were re-categorized accordingly. The proportion of good IAP prevention practice among mothers or caregivers with under-five children was determined by dividing the number of mothers or caregivers with good IAP prevention practice by the total number of study participants.

Dependent and independent variables were entered into the bivariable logistic regression to detect their associations. Bivariable (Crude Odds Ratio (COR) (95%CI)) analysis at a p-value of < 0.25 was used to select independent variables for the multivariable (Adjusted Odds Ratio (AOR) (95%CI)) analysis. From the multivariable analysis, variables with a significance level of p-value < 0.05 were taken as factors significantly associated with IAP prevention practices. Multicollinearity was checked by a variance inflation factor (VIF), to assess the existence of a correlation among the predictor variables and all variables had values less than five. The model’s fitness was also checked using the Hosmer-Lemeshow goodness of fit test and was found to be fit at (P = 0.78).

Results

Socio-demographic characteristics of mothers

In this study, a total of 401 mothers completed the survey with a response rate of 95%. Of all study mothers, 190(47.4%) were aged 18–30 years, with a mean age (± SD) of 31(± 6.59) years. Regarding the marital status of the mothers, 219(54.6%) were married, and 118(29.4%) were divorced. Regarding educational levels, 74(18.5%) of the mothers were unable to read and write, and 126 (31.4%) had a primary educational level (Table 1).

Table 1 Socio-demographic characteristics of mothers in peri-urban areas of Dessie city, Northeastern ethiopia, 2024.
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Knowledge and attitude of the mothers about IAP

A total of 14 questions were used to measure knowledge about IAP. The mean (± SD) knowledge score among mothers was 9.1 (± 4.47). Of the 401 mothers who took part in this study, 67.6% [95%CI: 63.1–72.1] of them had good knowledge about IAP. With regard to mothers’ attitude, 9 questions were used for the assessment of participants’ attitude towards IAP prevention. Out of the total 401 participants, 59.1[95%CI: 53.9–64.1] had a positive attitude towards IAP prevention with a mean score of 25.2 (± 3.94) (Table 2).

Table 2 Knowledge and attitude about IAP among mothers in peri-urban areas of Dessie city, Northeastern ethiopia, 2024.
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Housing and kitchen characteristics related to IAP

Among the 401 households, three hundred and fifty-three (88%) households’ windows are present. However, only 95 (23.7%) households had three and above windows which were able to open. Nearly half, 191 (47.6%) of households, had three or more rooms in the living house. In terms of the kitchen, 153 families (38.2%) had a separate kitchen with four walls. Only 139 (34.7%) and 100 (16.5%) of households had a window in the kitchen and a chimney, respectively. Additionally, open stoves were used for cooking in the majority of 250 (62.6%) of the households (Table 3).

Table 3 Housing and kitchen characteristics related to IAP in peri-urban areas of Dessie city, Northeastern ethiopia, 2024.
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Household sources of energy for cooking, heating and lighting

Regarding sources of energy, merely 100 (24.9%) of the 401 households under investigation utilized electricity for cooking. On the other hand, 395 (98.5%) and 380 (94.7%) of households prepared their food using charcoal and wood, respectively. In a similar vein, 370 (92.3%) and 150 (37.4%) of households, respectively, used charcoal and wood for heating. Regarding the energy source for lighting, almost half 200 (49.8%) of the mothers used electricity, while a small percentage, 66 (16.4%), used kerosene (Table 4).

Table 4 Household sources of energy for cooking, heating and lighting in peri-urban areas of Dessie city, Northeastern ethiopia, 2024.
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IAP prevention practices of mothers

The potential range of cumulative IAP prevention practice domain score was 1–12, and we assessed a mean score of 6 ± 2.38. Out of 401 participants, the overall number of mothers who had good IAP prevention practice was 57.6% [95%CI: 52.6–62.1]. According to this study, more than one-third, 42.4% [95%CI: 37.9–47.4] of the study participants had poor IAP prevention practice. Of the respondents, only 57 (14.2%) always use a separate kitchen, 63 (15.7%) always cook with clean fuel, 29 (7.2%) always heat with clean fuel, and 72 (18%) always light with clean fuel (Table 5).

Table 5 IAP prevention practices among mothers in peri-urban areas of Dessie city, Northeastern ethiopia, 2024.
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Factors affecting IAP prevention practices

The multivariable analysis results of this study showed that higher educational level (AOR = 4.9, 95%CI: 2.10–11.69), and good knowledge about IAP (AOR = 3.8, 95%CI: 2.29–6.34) were the factors significantly associated with good IAP prevention practices among mothers. Mothers with a higher educational level were 4.9 times more likely to practice good IAP prevention practices than their counterparts. In addition, mothers who had good knowledge about IAP were 3.8 times more likely to practice good IAP prevention practices than their counterparts (Table 6).

Table 6 Factors affecting mothers’ IAP prevention practices in peri-urban areas of Dessie city, Northeastern ethiopia, 2024.
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Discussion

IAP from biomass fuels is known to be a major health risk, leading to such serious illnesses as ARI in young children9,33,34. IAP has a significant effect on households that use biomass fuel as an energy source, particularly in developing nations33,35. Evidence suggests that controlling IAP exposure could reduce the risk of multiple child and adult health outcomes by 20–50%36. Preventing IAP also helps combat outdoor air pollution, as it has a major impact on this problem. Thus, this study evaluated IAP prevention practices and associated factors among mothers with under-five children in peri-urban areas of Dessie City. In this study, 57.6% of mothers had good IAP prevention practices, and the factors that were most strongly linked to mothers’ good IAP prevention practices were higher educational level and good IAP knowledge.

Despite the fact that ARI from IAP is the primary cause of death for children under five25,37,38, surprisingly, only 57.6% [95%CI: 52.6–62.1] of mothers in this study reported good IAP prevention practices. This statistic is quite concerning, and it calls for stricter enforcement measures to be taken in order to support mothers’ IAP prevention behavior. However, the value obtained as a result of this study is higher than the studies conducted in Ethiopia (45%)39 and Colombia (50%)40. The possible reason for this difference might be due to variation in methodological issues, sociodemographic factors, and the educational level of the study participants. In spite of this variation, the study’s IAP prevention practice is low enough to effectively control under-five ARI. The low IAP prevention measures in our study area might be caused by the study area’s cold temperatures, which also led to the use of biomass fuel for heating. The frequent power outages that have made the widespread use of biomass fuel may be another important factor contributing to the low IAP prevention practices. Thus, all concerned bodies should focus on strengthening training on IAP to prevent ARI in under-five children. Moreover, the Ethiopian Electric Utility is required to supply electricity regularly to prevent biomass fuel use due to power interruption. Also, a variety of mitigation strategies should be implemented, such as the introduction of clean and less expensive cooking fuels, in order to lower exposure to IAP.

We found good IAP prevention practices to be influenced by good knowledge of IAP. For instance, respondents with good knowledge were 3.8 times more likely to practice good IAP prevention practices than their counterparts. This could be related to mothers’ instinctive reactions that recognize the longer-term effects of IAP, which are more important for under-five children. This finding was also in line with scientific reasons, as the community’s level of knowledge increased their level of practicing preventive behaviour41,42. The current community service training on ARI prevention provided by Wollo University may be the cause of having good IAP knowledge, as it has led to the development of effective IAP prevention strategies. The findings also have implications for the urgent requirement for the relevant bodies to create strict IAP awareness. Therefore, to improve mothers’ IAP prevention measures, a rigorous training program followed by frequent monitoring of IAP prevention practices is needed. Furthermore, in order to emphasize the issue, it is crucial to distribute IAP-related information via SMS messages and using a variety of information dissemination channels, including television and radio.

Educational level was also significantly associated with good IAP prevention practices. In this study, mothers with higher educational levels were 4.9 times more likely to practice good IAP prevention measures than their counterparts. This is comparable to a recent study that examined a related problem in Ethiopia39. However, in another study, a higher educational level was not associated with good IAP prevention practices29,43. This discrepancy could be due to the difference in knowledge about IAP, as training could not be given in all areas equally. On the other hand, under-five children can be at lower risk of ARI if mothers have solid IAP knowledge. A recent study indicates that very few mothers have higher levels of education, which could be the reason behind this. Therefore, it is imperative to reinforce knowledge by focusing on mothers at a lower educational level to improve mothers’ IAP prevention activities. Enhancing effective IAP prevention strategies may involve providing training on the health effects of IAP and disseminating information through reliable media. Therefore, to prevent ARI in Ethiopia’s peri-urban areas, cooperation between communities, governmental agencies, and non-governmental organizations is desperately needed.

In terms of housing conditions, only 23.7% of the houses had three or more windows able to open. The study’s findings are also consistent with an Ethiopian study that found that 5.2%44 more windows could open. Regarding the kitchen, the majority of the households, 248 (61.8%), cooked inside the house without separating. Studies conducted in Ethiopia revealed that 56.6% of kitchens were unseparated45, which supported the finding. Moreover, concerning fuel sources, 380 (94.7%) of the households used wood for cooking, 370 (92.3%) used charcoal for heating, and 200 (49.8%) used electricity for lighting. Extensive use of wood for cooking was also reported in the three studies in Ethiopia: 62.76%46, 80%47, 99.3%39. Thus, a thorough awareness-raising campaign should be launched to ensure proper ventilation, use a separate kitchen, and implement other housing design elements that are essential to preventing IAP in order to lessen the harmful health effects of this pollution.

Overall, the current study found that mothers with under-five children had remarkably low IAP prevention measures. However, the risk factors for the infections and the mothers’ practices towards IAP prevention mechanisms determine how well ARI is managed and prevented. Therefore, the relevant sectors ought to collaborate in order to create awareness for mothers with under-five children in the peri-urban areas. Given the problems’ substantial effects on health and outdoor air pollution, the ministry of education and the ministry of health should address the issue in more detail. Thus, the cooperation of various organizations that aim to reduce morbidity and mortality among under-five children can help solve this issue.

This study has some limitations: first, it cannot prove a cause-and-effect relationship because it was a cross-sectional study. Second, the study was only conducted on the peri-urbans of the city of Dessie. The use of the self-reported data may also increase the proportion of good IAP practices among mothers, and this may be compensated by the observational checklist. Despite these limitations, this study provides a basis for future researchers to conduct better study designs in this setting to make the results more valid, which is important in preventing deaths from ARI in under-five children. The results of this study are also very important for preventing the negative effects of IAP on mothers and other family members. Furthermore, since IAP plays a significant role in the problem of outdoor air pollution, the study’s findings are crucial in mitigating this issue.

Conclusion

The aim of this study was to evaluate IAP prevention practices and associated factors among mothers with under-five children in peri-urban areas of Dessie City. In the current finding, only 57.6% of mothers in Dessie City’s peri-urban areas practiced good IAP prevention. Mothers’ IAP prevention practices were more significantly associated with the educational level and knowledge of IAP. These findings provide strong evidence that IAP can be prevented through enhancing IAP knowledge, through intensive health education aimed at lower educational levels. Thus, Dessie City Health Department should give intensive health education and that the strictest IAP reduction strategies should be properly implemented. In addition, a variety of coordinated initiatives, including educational campaigns and studies that make use of diverse media capabilities to announce and distribute reliable and accurate information, are needed. Furthermore, it is imperative to guarantee the execution and adherence to the current government regulations concerning IAP. Moreover, governmental and non-governmental organizations should cooperate to stop frequent power outages and provide peri-urban areas with better cook stoves at a low cost. Also, further studies are needed to compare the extent of IAP prevention measures in various regions of the nation with varying socioeconomic backgrounds. Furthermore, additional studies based on measuring the concentrations of indoor air pollutants are highly encouraged.