Award Title: NIHR Global Health Research Group on Clean Energy Access for the prevention of Non-communicable disease in Africa through clean Air: CLEAN-AIR(Africa) at the University of Liverpool
Funder: Department of Health and Social Care

Abstract: More than 3 billion people worldwide still rely on traditional solid fuel and kerosene, burned in_x000D_
inefficient stoves, to meet their everyday household energy needs. The resulting household air_x000D_
pollution (HAP) is the single largest environmental cause of global disease burden, responsible for 4.3_x000D_
million premature deaths annually, of which 3.8 million are caused by non-communicable disease_x000D_
(NCD). HAP also results in over 100 million lost healthy life years (DALYs) in lower-and-middle_x000D_
income countries (LMICs) from respiratory, cardiovascular diseases and cancer, as well as serious_x000D_
injuries from scalds, burns and (kerosene) poisoning. Burning of solid fuels also contributes to climate_x000D_
change, deforestation and the poverty cycle disproportionately affecting women and children._x000D_
Our previous research has been instrumental in highlighting the global importance of moving from_x000D_
solid fuel cooking technologies to clean fuels such as liquefied petroleum gas (LPG) to impact on the_x000D_
Global Burden of Disease (GBD) from HAP (including developing WHO Guideline Recommendations_x000D_
for indoor air). Research is needed to identify and overcome the challenges of achieving large-scale,_x000D_
equitable and sustained transition to clean fuels and to demonstrate the achievable impacts on health,_x000D_
household finances and the environment, to inform national policies._x000D_
The CLEAN-AIR(Africa) Research Group will address this research gap by working directly with_x000D_
Cameroon, Ghana and Kenya government ministries who have recently made ambitious_x000D_
commitments to scale-up household access to LPG by a significant proportion of the population. The_x000D_
Group will benefit from enhanced UK expertise and will engage with the health sector, research and_x000D_
academic partners in each focus country._x000D_
The Group has four primary goals:_x000D_
Goal 1: to inform strategies to support more equitable uptake of clean fuel across the population by_x000D_
evaluating enabling/ inhibiting factors and testing interventions to address identified barriers and_x000D_
facilitate equitable adoption/ use of LPG (including consumer finance solutions)._x000D_
Goal 2: to estimate the impacts of scaled LPG adoption, in line with governmental targets, on health_x000D_
and climate by using advanced statistical techniques, thereby providing evidence for_x000D_
national/international policymakers to advocate for widespread transition to clean fuel._x000D_
Goal 3: to develop capacity through health systems strengthening in the partner countries, equipping_x000D_
health practitioners to intervene early to ‘prescribe’ clean household energy solutions to their patients._x000D_
With support from WHO and our focus country health sector and academic partners, we will develop_x000D_
curriculum materials for upskilling the health sector about the health impacts of HAP and prevention_x000D_
through clean household energy adoption. Training will be delivered through routine continuing_x000D_
professional development and national training programs for health professionals (e.g. community_x000D_
health workers, nurses and clincians) and bespoke in-country workshops._x000D_
Goal 4: to facilitate engagement between the general public and policymakers as research is_x000D_
undertaken alongside national policy implementation. Informed by experience in Cameroon, the_x000D_
Group will host public engagement events in all three countries, bringing communities, ministry_x000D_
representatives, private sector and civic society stakeholders together to exchange knowledge on_x000D_
how best to achieve rapid transition to clean household energy to benefit population health and_x000D_
environments.

Lay Abstract: a) Building on strategic objectives of University of Liverpool (UoL): The CLEAN-AIR(Africa) Research_x000D_
Group builds on the UoL’s 10-year ‘Strategy 2026’, placing global activities at its core, with the_x000D_
strategic aim of being ‘a global university at the forefront of knowledge leadership’. This builds on a_x000D_
history of global concerns, dating back to the founding of the Medical School in 1835, tropical_x000D_
medicine and global public health being a particular focus, given the importance of Liverpool as a_x000D_
world trading port. Today, UoL has an international reputation in public health and health equity._x000D_
Expanding our global health research addressing non-communicable diseases (NCDs), maternal_x000D_
health and child mortality is a priority._x000D_
b) Why the institution is well placed: The Institute of Psychology, Health and Society (IPHS), headed_x000D_
by Prof Tom Walley, is ideally placed to support the Group and its aspirations. Its applied research_x000D_
was ranked third in the UK for impact judged as outstanding in Unit of Assessment 2 (UoA 2) in_x000D_
Research Excellence Framework (REF) 2014. It hosts a number of NIHR investments, including_x000D_
membership of the NIHR School of Public Health Research, with funding for applied health research,_x000D_
totalling £44m._x000D_
Since 2005, the Department of Public Health and Policy within IPHS has been designated a WHO_x000D_
Collaborating Centre for Policy Research on the Determinants of Health Equity (WHO CC), codirected_x000D_
by Prof Dame Margaret Whitehead and Prof Nigel Bruce. The WHO CC has built up a critical_x000D_
mass of researchers from a range of disciplines, addressing questions around the causes and_x000D_
solutions to health inequalities, and with a record of successful research training. The Group will draw_x000D_
on the skills of the WHO CC to enhance the world-leading theme on household air pollution, energy_x000D_
and health, led by Pope. These skills include social anthropology (led by Kierans); policy impact_x000D_
simulation modelling of preventive measures for NCDs (O’Flaherty); and the evaluation of health_x000D_
inequalities impact of natural policy experiments (Barr). IPHS will contribute 1 fully-supported PhD_x000D_
studentship._x000D_
c) Institutional partnerships and investments: We will work closely with our network of UK and_x000D_
International partners, built up over two decades, to produce policy-relevant research directly_x000D_
informing Government decision-making and build training and research capacity in the UK and in our_x000D_
LMIC focus countries. Existing partnerships include leading international research groups in_x000D_
household air pollution (HAP) and health, WHO (Environmental and Social Determinants of Health),_x000D_
experts in modelling climate impacts and global networks for the clean energy and health agenda_x000D_
(see Partnerships for details). Working directly with the health sectors of Cameroon, Ghana and_x000D_
Kenya (through partnerships with leading Universities and their Schools/ Departments of Public_x000D_
Health, WHO country offices and with support form WHO head office) we will develop sustainable_x000D_
health systems capacity through health professional education in household air pollution, NCDs and_x000D_
equitable approaches to prevention._x000D_
d) Involvement of partners in the research: Our LMIC partners comprise leading research institutions -_x000D_
Douala General Hospital (DGH - Cameroon), Kintampo Health Research Centre (KHRC - Ghana) and_x000D_
Stockholm Environment Institute-Africa (SEI-Africa - Kenya). Their established research_x000D_
infrastructures and networks are essential in supporting the Group’s research program and they will_x000D_
be involved in all aspects of the research program (e.g. through our steering committee meetings,_x000D_
team briefings and the public-stakeholder engagement events). Our collaborating partners from each_x000D_
institituion all have (i) extensive relevant research experience in household air pollution, noncommunicable_x000D_
diseases and prevention strategies and (ii) established health research networks and_x000D_
have the experience and expertise necessary to inform the strategic direction of the Group to achieve_x000D_
its goals. Our research programme compliments activities that our LMIC partners have been_x000D_
undertaking through their own institutions. In Cameroon our partner from DGH has led the Cameroon_x000D_
Burden of Obstructive Lung Disease (BOLD) Study (Wellcome Trust funding) and has coordinated_x000D_
both of the LPG Adoption in Cameroon Evaluation (LACE) 1 and 2 Studies (US CDC and NIH_x000D_
funding). In Ghana our partner from KHRC co-led the Ghana Randomised Air Pollution and Health_x000D_
Study (GRAPHS – NIH funding) and has since coordinated the Ghana Rural LPG Programme_x000D_
(USAID funding). In Kenya our partner leads a substantive research portfolio in sustainable_x000D_
development including a specific action agenda of “bringing clean, safe, affordable cooking energy to_x000D_
households across Africa”._x000D_
In addition to our research partners, we have engaged with leading academic insitutions in each of_x000D_
our focus countries who have (i) connections with our lead research institutions and (ii) strong public_x000D_
health departments and expertise. These include the University of Douala (Cameroon), the University_x000D_
of Ghana and Moi University (Kenya). Our academic partners are all highly experienced in the field of_x000D_
Public Health and in training medical students and health practitioners. Assisted by WHO country_x000D_
officers, they will lead in the development of training modules of HAP, health and prevention_x000D_
strategies within the health sector._x000D_
e) Involvement of the public in the research: Local users of our research include community members,_x000D_
leaders and in-country stakeholders and policymakers (e.g. ministry of health, energy and_x000D_
development) who will be involved through community-participtatory approaches (e.g. Photovoice),_x000D_
consultations, workshops, and our 2-way public engagement and stakeholder events that will be held_x000D_
in each country towards the end of the third year of funding.

Research Activity Codes: 8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health Categories: RESPIRATORY;GENERIC HEALTH RELEVANCE