Multiple fuel use in low-income communities: socio-economic determinants and impacts on household air pollution and respiratory health in South Africa

Domestic fuel use contributes significantly to household air pollution levels and to the disease burden in low-income households in South Africa. The link between residential fuel stacking and switching, and respiratory health, mediated by household air pollution, remains underexplored, posing challenges to transition to cleaner fuels. This study identified socio-economic determinants of fuel use patterns in two low-income communities of KwaZamokuhle and eMzinoni in South Africa. It also examined the impacts of these patterns on household air pollution levels and respiratory health outcomes. Over half of households relied on dirty fuels across all needs. Average household PM 2.5 levels exceeded national daily standards (40 μg/m 3 ). Education level and employment status were significant factors in determining fuel choice, with employed participants less likely to rely on dirty fuels. Town-specific characteristics also influenced household fuel use patterns. In terms of health, 9.5% of participants had obstructive airways disease and 26.9% tested positive for inhalant allergens. Heating fuels were strongest predictor of obstructive airways disease (>75%) whereas cooking fuels were the main predictor of allergen sensitivity (∼75%). The stepwise introduction of cleaner fuels predicted better respiratory health outcomes. The findings of this study suggest that even the partial adoption of cleaner fuels has health benefits and supports the formulation of context-specific mitigation efforts aiming to address negative health effects associated with household air pollution. • Dirty fuels remain part of the energy mix despite electrification in many places. • Obstructive airways (9.5%) were driven >75% by heating fuels. • Allergen sensitivity (26.9%) was driven ∼75% by cooking fuels. • Households are unlikely to stop fuel stacking in the near future. • Interventions should introduce clean energy sources into fuel stacking practices.