Designs of two randomized, community-based trials to assess the impact of alternative cookstove installation on respiratory illness among young children and reproductive outcomes in rural Nepal

James M. Tielsch, George Washington University
Joanne Katz, Johns Hopkins University
Scott L. Zeger, Johns Hopkins University
Subarna K. Khatry, Johns Hopkins University
Laxman Shrestha, Tribhuvan University
Patrick Breysse, Johns Hopkins University
William Checkley, Johns Hopkins University
Luke C. Mullany, Johns Hopkins University
Steven C. LeClerq, Johns Hopkins University

Reproduced with permission of BioMed Central. BMC Public Health.


Acute lower respiratory infections (ALRI) are a leading cause of death among children. Low birthweight is prevalent in South Asia and associated with increased risks of mortality, and morbidity, high levels of indoor household air pollution caused by open burning of biomass fuels are common and associated with high rates of ALRI and low birthweight. Alternative stove designs that burn biomass fuel more efficiently have been proposed as one method for reducing these high exposures and lowering rates of these disorders. We designed two randomized trials to test this hypothesis.


We conducted a pair of community-based, randomized trials of alternative cookstove installation in a rural district in southern Nepal. Phase one was a cluster randomized, modified step-wedge design using an alternative biomass stove with a chimney. A pre-installation period of morbidity assessment and household environmental assessment was conducted for six months in all households. This was followed by a one year step-wedge phase with 12 monthly steps for clusters of households to receive the alternative stove. The timing of alternative stove introduction was randomized. This step-wedge phase was followed in all households by another six month follow-up phase. Eligibility criteria for phase one included household informed consent, the presence of a married woman of reproductive age (15–30 yrs) or a child < 36 months. Children were followed until 36 months of age or the end of the trial. Pregnancies were identified and followed until completion or end of the trial. Phase two was an individually randomized trial of the same alternative biomass stove versus liquid propane gas stove in a subset of households that participated in phase one. Follow-up for phase two was 12 months following stove installation. Eligibility criteria included the same components as phase one except children were only enrolled for morbidity follow-up if they were less than 24 months.

The primary outcomes included: incidence of ALRI in children and birthweight.


We presented the design and methods of two randomized trials of alternative cookstoves on rates of ALRI and birthweight.

Trial registration (NCT00786877, Nov. 5, 2008).