ABSTRACT: The domestic combustion of polluting fuels is associated with an estimated 3 million premature deaths each year and contributes to climate change. In many low- and middle-income countries (LMICs), valid and representative estimates of people exposed to household air pollution (HAP) are scarce. The Demographic and Health Survey (DHS) is an important and consistent source of data on household fuel use for cooking and has facilitated studies of health effects. However, the body of research based on DHS data has not been systematically identified, nor its strengths and limitations critically assessed as a whole. We aimed to systematically review epidemiological studies using DHS data that considered cooking fuel type as the main exposure, including the assessment of the extent and key drivers of bias. Following PRISMA guidelines, we searched PubMed, Web of Science, Scopus and the DHS publication portal. We assessed the quality and risk of bias (RoB) of studies using a novel tool. Of 2748 records remaining after removing duplicates, 63 were read in full. A total of 45 out of 63 studies were included in our review, spanning 11 different health outcomes and representing 50 unique analyses. In total, 41 of 45 (91%) studies analysed health outcomes in children <5 years of age, including respiratory infections (n = 17), death (all-cause) (n = 14), low birthweight (n = 5), stunting and anaemia (n = 5). Inconsistencies were observed between studies in how cooking fuels were classified into relatively high- and low-polluting. Overall, 36/50 (80%) studies reported statistically significant adverse associations between polluting fuels and health outcomes. In total, 18/50 (36%) of the analyses were scored as having moderate RoB, while 16/50 (32%) analyses were scored as having serious or critical RoB. Although HAP exposure assessment is not the main focus of the DHS, it is the main, often only, source of information in many LMICs. An appreciable proportion of studies using it to analyse the association between cooking fuel use and health have potential for high RoB, mostly related to confounder control, exposure assessment and misclassification, and outcome ascertainment. Based on our findings, we provide some suggestions for ways in which revising the information collected by the DHS could make it even more amenable to studies of household fuel use and health, and reduce the RoB, without being onerous to collect and analyse.
