Impact of Outdoor Air Pollution on Health and Quality of Life of Individuals in Low-to-Middle Income Countries (LMICs)

Objectives: Few reviews have synthesized the association between outdoor air pollution and health/quality of life in Low-to-Middle-Income Countries (LMICs).
Content: We conducted a systematic review of peer-reviewed articles to summarize current research regarding the impact of outdoor air pollution on health and quality of life of individuals in LMICs. Electronic and manual searches were performed until November 2023. Preferred Reporting Items for Systematic Review and Meta-Analyzes (PRISMA) guidelines were followed.
Summary and outlook: 81 final studies were included after following PRISMA guidelines. The literature showed that the negative impacts of air pollution on health/quality of life in LMICs are greater compared to High-Income Countries. Due to resource limitations, LMICs lack resources and medical infrastructure to respond to the global trend of poorer air quality. Therefore, well-designed, cost-effective, and monitored inventions are required to combat this crisis. Furthermore, additional research to monitor air quality of life is required to identify policy changes that can decrease region-specific/population-driven impacts of air pollution.

Keywords:Air pollution; Public health; Low-to-middle income countries; Quality of life; Environmental health; Global health; Climate change; Health policy

Air pollution, both indoor and outdoor, threatens the health of millions of people worldwide [1,2]. The World Health Organization (WHO) defines air pollution as “a contamination of the indoor or outdoor environment by any chemical, physical, or biological agent that modifies the natural characteristics of the atmosphere” [3]. Air pollution results in significant health-related consequences. In the 2019 Global Burden of Disease study, it was reported that air pollution from fine particulate matter had resulted in 6.4 million premature deaths [4]. Furthermore, air pollution also imposes a significant cost burden on countries, largely Low-to-Middle-Income Countries (LMICs), who already suffer from declining health-related quality of life. In 2019, the economic burden of health-related expenses due to higher levels of air pollution was more than 6% of global Gross Domestic Product (GDP) [5]. Research has shown that residents in LMICs are more significantly impacted by air pollution [1,2] and Particulate Matter (PM)2.5 exposure was higher in these countries relative to high-income countries [6]. Disparities in outcomes have only increased as particulate matter concentrations have decreased in developed countries and increased in developing countries [7].

Particulate matter is defined by the United States Environmental Protection Agency (EPA) in two ways: PM2.5 and PM10. PM10 is defined as inhalable particles that are less than 10 micro meters in diameter, whereas PM2.5 refers to inhalable particles ≤2.5 micro meters in diameter [8]. When inhaled, particulate matter can cause serious health problems as PM2.5 can travel into your lungs and bloodstream [8]. In LMICs, the current economic growth leads to development in the form of industrialization, which has become a major contributor to outdoor air pollution [9]. Particulate matter PM2.5 from ambient air pollution is correlated with shortterm and long-term negative impacts on health [10]. Ambient air pollution also increases, across all age groups, morbidity, all-cause/ disease-specific mortality [11-13], and hospitalizations [14-15]. Furthermore, air pollution (both outdoor and indoor) can cause medical conditions including cancer [16], respiratory disease [17], paediatric asthma [18], cardiovascular disease [19,20], diabetes [21], coronary heart disease [22], stroke [23], and non-respiratory health hazard [24]. The significant health impacts of air pollution are exacerbated in residents of LMICs where resources and interventions to tackle these health problems are limited [25].

Outdoor air pollution occurs in the environment within a particular region and is different from indoor (household) air pollution. Risk factors for outdoor air pollution are primarily emissions from traffic, smoke emanating from industries and greater industrialization, natural pollutants, tobacco smoke, and in many cases, pollutants escaping from indoor/household cooking. Multiple studies have been conducted on the relationship between outdoor air pollution and health/quality of life in LMICs. This study aims to focus on outdoor air pollution and conduct an updated review of the literature focusing on individual components including the different medical conditions associated with outdoor air pollution, traffic-related and biomass use related-air pollution, impact of child and maternal health pre-pregnancy, and impact on Health-Related Quality of Life (HRQoL). This study also hopes to evaluate publications that have focused on technological innovations/interventions that will lead to improvement in air quality-related health.

Information sources

A systematic literature review of peer-reviewed articles written from 2000 to current (November 2023) in English was obtained from PubMed and Google. Abstracts, non-English published articles, and studies not including humans were excluded from this literature review. Search terms and keywords included “pollution”, “air pollution”, “outdoor air pollution”, “environmental pollution”, “health”, “quality of life”, and “Low- to Middle-Income countries”. From the initial search using the above keywords and the time, 220 articles were found. Upon further review of these articles, we were able to remove duplicates and studies that did not meet our inclusion criteria. Figure 1 describes the methodology for the final included studies.

Figure 1:PRISMA diagram of studies included in the review.

Study abstraction and evaluation

We utilized the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) (Figure 1) for data abstraction. From an initial search of the PubMed database and Google online database using the selected search terms, we identified 220 articles (195 from PubMed and 25 on the Google database). Upon further screening of these 220 articles, we excluded 65 (30%) studies [due to duplicates (n=17), non-English publications (n=29), and abstract-only publications (n=19). Out of the remaining 155 articles, a further evaluation excluded more (n=74) for having not met the current literature review objectives. The final number of studies that were selected for this review was 81. A condensed summary of the included studies distributed by the topic of interest (medical conditions, children/maternal pre-pregnancy health, traffic-related and biomass-use related outdoor air pollution, outdoor pollution linked with low income, and HRQoL) is captured in Table 1. Data from the final list of included studies were then summarized in detail from a study objective, design, and main findings perspective (Table 1 in supplementary file).

Table 1:Studies included in literature review classified by theme, outcome measures evaluated and region of conduct.

Table 1:Summary of the included review studies.

Out of the 81 studies that were included in this literature review, 21 studies looked at impact of air pollution on children and maternal pre-pregnancy health [16,26-43]; 5 studies looked at associations between air pollution and low income/poverty [44-48]; 11 studies looked at impact of traffic-related and biomass-use related ambient air pollution [49-59]; 40 studies evaluated associations between air pollution and several disease outcomes [20,60-71]; and 4 studies looked at associations between air pollution and HRQoL [72-75].

Outdoor air pollution has a detrimental impact on medical conditions

Air pollution was a significant cause of Global Disease Burden as ambient particulate matter resulted in a high-risk exposure [4]. Out of the 40 studies that evaluated associations between air pollution and disease, 13 studies looked at associations with cardiovascular disease [20,60-71], 14 with respiratory disorders [1,76-88], 6 on general health status [89-94], and 7 on other diseases including eye disorders, depression, CKD, RA, and diabetes [21,95-100].

Cardiovascular disease: Cardiovascular disease was found to be associated with outdoor air pollutants in LMICs in a 2023 review [60]. Several medical conditions, including myocardial infarction, stroke, and arrythmias, within the broad Cardiovascular Disease (CVD) were found to be associated with exposure to Particulate Matter (PM_2.5) in a 2023 review study [20]. Similar findings were found in another South Asian review where stress and inflammation due to exposure to PM_2.5 were found to be major causes [61]. A Saudi Arabian study evaluated perceptions, knowledge, and awareness on the impact of outdoor air pollution on diseases impacting both the cardiac and pulmonary function [62]. This survey study found increased awareness among the study participants of emissions from a higher rate of industrialization and tobacco smoke impacting their cardiac and pulmonary health [62]. Three epidemiological studies evaluating long-term exposure to outdoor air pollutants (PM_2.5) found increased rates of CVD and hypertension [63-65]. Findings pointing in a similar direction was found in two other studies in the Middle East where the authors found associations between PM_2.5 and CVD [66,67]. The difference though was CVD in the Iranian study was defined as acute myocardial infarction, stroke, or cardiac mortality [66]. A systematic review and meta-analysis study, from articles from 21 countries, looking at associations between air pollution and heart failure found several significant associations between various pollutants including PM_2.5, PM10, nitrogen oxide, and sulfur dioxide [68]. This study also reported higher rates of associations in LMICs versus richer countries [68]. Another study found increased number of emergency ambulance calls for patients diagnosed with heart failure with increased exposure to particulate matter [69]. Increased rates of hypertension were found with increasing number of air pollutants in a Lebanese study [70]. Finally, a study based out of Southern India estimated increased carotid intima-media thickness among the study participants with a higher exposure to outdoor PM_2.5 [71].

Respiratory disease: A study evaluating national Chronic Obstructive Pulmonary Disease (COPD) guidelines across High- Income (HICs) and LMICs found a large gap between HICs and LMICs as approximately 30% of people living in LMICs were not covered by any national guidelines and existing guidelines in LMICs (versus HICs) did not target as many healthcare professional groups [76]. On a similar note, another study found the need to tailor country-specific asthma guidelines based on social, financial, cultural, economic, and healthcare barriers specific to a particular country to adequately control asthma [77]. A correlation between air pollution and increased suffering and mortality with several medical conditions including cardiovascular, respiratory diseases, and lung cancer was established in another summary article [1]. This was due to a lack of air pollution control especially in LMICs, adequate identification of air pollution sources, and devising strategies to improve air quality [1]. An overview of the prevalence of medical conditions associated with allergy in India, with a focus on disease burden, found approximately 37.5 million people in India with asthma, with an increasing prevalence of allergic rhinitis and asthma [78]. Finally, the last study reviewed in this section described the prevalence and risk factors for a combination of asthma and chronic obstructive pulmonary disease (ACO) among adult residents in 6 LMICs [79]. Using cross-sectional data, the authors found the prevalence of ACO ranges between 3.8% (Peru) and 7.8% (Bangladesh). The odds of ACO were higher among residents who were exposed to household biomass fuel smoke, tobacco use, and had less education [79].

A literature review published in 2018 looked at smoke emanating from non-cigarette use, especially biomass fuel use, animal dung, and dust, and found there was a strong association between exposure to the smoke using these resources and diseases linked with the lungs [80]. The medical conditions included COPD, respiratory infections, bronchitis, and lung cancer [80]. Respiratory symptoms that were chronic in nature were found to be linked with outdoor air pollution, especially coming from tobacco smoke, in multiple regions of the world including the Middle East and Africa [81]. Similar results were also reported in an Indian study looking at associations between COPD and a few outdoor air pollutants including traffic emissions [82]. Various air pollutants including traffic emissions, nitrogen dioxide, and cigarette-use smoke were established as major drivers of asthma and poor lung function [83].

Two studies based out of China evaluated long-term exposure to outdoor air pollution on respiratory disease and tuberculosis [84,85]. The study on associations between respiratory disease and long-term exposure to outdoor air pollutants found PM10 and nitrogen oxide as primary risk factors contributing toward deaths due to respiratory disease. In the study, age, gender, income, smoking status, and level of education were found to be variables impacting the association [84]. Higher rates of tuberculosis were found with multiple outdoor air pollutants including PM2.5, PM10, nitrogen oxide, and sulfur dioxide [85]. A Malaysian study found similar evidence of the detrimental effect of exposure to PM2.5 and respiratory conditions [86]. Similarly, two city-based studies in Nigeria and Pakistan found a similar strong association between exposure to outdoor air pollution and respiratory conditions including asthma [87,88].

Other disorders: Using regression models, study authors looked at associations between ambient PM_2.5 and Chronic Kidney Disease (CKD) [95]. After considering evidence from previously published studies, the authors evaluated the 2017 global and local epidemiological estimates, including incidence, prevalence, and deaths due to CKD attributable to PM_2.5 in multiple countries. The authors found that, across the world, the burden of CKD associated with PM_2.5 was much higher in LMICs, and countries that target achieving PM_2.5 levels below WHO guidelines may benefit from lowering the CKD burden [95]. The same lead author, in another published study, looked at the relationship between PM_2.5 and incident diabetes among a large cohort (n=1,729,108) for 8.5 years and found an increased risk of diabetes (hazard ratio of 1.15; 95% CI: 1.08-1.22) [21]. A few studies have looked at how exposure to outdoor air pollution have affected residents in LMICs other than respiratory and cardiac medical conditions [96-100]. Though not that widely researched these studies have found a link between eye disease [96,99], rheumatoid arthritis [97], and depression [100], and ischemic stroke [98].

General health: Even though indoor/household air pollution was not the focus of this review, indoor pollutants can impact outdoor air pollution adversely and that can eventually lead to poorer health among the residents. A study in Southern Nepal looked at association between emissions from traditional indoor cooking methods and outdoor air pollution and found that close to 70% of smoke emanating from resources used traditionally in low-income countries for cooking escape and pollute the outdoor air [89]. These findings are supplemented in another global review study looking at the connection between indoor air quality and outdoor air pollution [90]. Another review article from Nepal concluded the lack of research on outdoor air pollution on human health and may be the case with other LMICs [91]. A very specific study looked at how outdoor air pollution impacts muscles and hand-grip strength in a few LMICs and found an inverse relationship between exposure and hand-grip strength [92]. Similar associations were found between greater exposure and the exposed residents tending to be more obese [93]. Finally, a study out of Ethiopia reviewed articles from the scientific literature reported ambient PM₁₀ levels not meeting WHO guideline recommendations and found very limited research on monitoring air quality in the country [94].

All the above studies have one common theme: polluted air is associated with multiple medical conditions, primarily respiratory illnesses, and to a large extent extending to cardiac-related conditions. These conditions can have potentially significant negative outcomes among residents. Improvements in the education level, awareness of the various risk factors for poor air quality and the deleterious effects of polluted air, resources needed for these awareness/educational outreach activities, and innovations in diagnosing/limiting exposure to polluted air are needed in LMICs. Outdoor air pollution has several components/risk factors including PM_2.5, PM₁₀, nitrogen oxide, sulfur dioxide, tobacco smoke, and traffic emissions. Finally, as the above interventions get identified and implemented, a willingness to create and adopt policies and guidelines to tackle the problem and means to spend medical resources wisely on managing the disease burden need to be investigated.

Air pollution directly impacts low-income and middleincome countries due to industrialization

A comprehensive study of data from more than 200 countries documented an association between air pollution and poverty [44]. This study found that more than 7 billion people globally are exposed to unsafe particulate matter; moreover, PM_2.5 levels were higher for more than 80% of people who reside in LMICs [44]. Of this 80% of people, around 716 million people living in poor countries/regions (less than $1.90 earned per day) are faced with extremely poor air quality (2021 WHO guidelines of 5μg/m³ that is more stringent than the 2005 WHO guidelines), particularly from technologies and industries that transmit and pollute the air [44]. Furthermore, in another study, residents of LMICs were still undergoing an urbanization and industrial development process relative to developed countries and were more likely to be exposed to polluted air [45]. Also, women and children in severely poor areas were more exposed to indoor air pollution due to solid fuel use [45]. A study evaluating Air Pollution Control Efficacy (APCI) as an indicator for controlling air pollution showed that this indicator demonstrated an opposite association with economic development [46]. This study concluded with a potential use of APCI to control pollution of the air thereby improving population health outcomes [46]. Greenhouse Gas-Air Pollution Interaction and Synergies (GAINS), a technological model that looked at exposure to fine Particulate Matter (PM_2.5) and mortality risks in India, found that even with minimal improvements in the quality of air significant health benefits can be gained [47]. In an African study, a link was reported between a region’s economic scarcity and the potential lack of resources to prevent exposure to air pollution by exploring the impact of smoke on air pollution in rural Malawi [48].

With globalization and technological advancements, countries/ regions that once were considered economically backward have started adopting policies and measures toward more industrialization and urbanization thereby providing opportunities for financial growth among the residents. This, in turn, needs to be balanced with policies and technologies to reduce smoke emissions from these industries/plants, better emission control from vehicles, and planned allocation of scarce resources toward detecting, measuring, and reducing air pollution risk factors. Resources are needed for economic development and growth, however, alternate resources to mitigate the impact of rapid industrialization on air pollution and residents’ health also need to be identified.

Air pollution and impact on children and newborns

A systematic review of the literature found that exposure to ambient air pollution was positively associated with an increased risk of childhood respiratory morbidity and mortality [16]. Furthermore, another study found that 67% of children in Peru had moderate to severe persistent asthma [26]. This study also found, through modelling techniques, that risk factors including PM2.5, black carbon, and nitrogen dioxide concentrations were each associated with higher asthma levels. In addition, these risk factors were also linked with poor Quality of Life (QoL) and increased risk of health care utilization [26]. In yet another study, the authors summarized the impact on health due to high levels of air pollution in Lower-to-Middle-Income Countries (LMICs), especially among children under 5 years old [27]. They reported that on a global level, approximately 93% of children live in regions with outdoor air pollution levels higher than World Health Organization (WHO) recommended estimates, and greater than 25% of child deaths <5 years is attributable to these higher pollution levels [27]. In another study, in Africa, children at different age groups (pre-natal to those going to school), a link between outdoor air pollution exposure and respiratory conditions were observed, both short-term and long-term [28]. Similarly, in another African study (Nigeria), traffic-related outdoor air pollution was linked with respiratory conditions in school-going children [29]. A longer-term study (8 years) in Vietnam showed similar findings [30].

Wheeze was reported to be linked with school-going children in a study in Iran [31]. Apart from the unusual levels of tobacco use in this country and the adverse effects of tobacco smoke, which was found to be a risk factor, other risk factors that were found in the study included family history of respiratory disease and working mothers, among others [31]. Additionally, tobacco-smoke was found to be associated with higher levels of urine cotinine levels among children who were exposed to multiple sources of air pollution relative to those who were exposed to just one source [32]. Younger children, especially under the age of 5 years, are more susceptible to adverse outcomes of outdoor air pollutants. This finding is corroborated from a study in India that evaluated respiratory disease among children under 5 years who are exposed to outdoor air pollution [33]. Poorer children were more likely than better familial income children to be diagnosed with respiratory disorders due to poor outdoor air quality [33]. Haemoglobin levels were also found to be lower in children under 5 years in a review from 36 countries [34].

A few studies have investigated how outdoor air pollution impacts a newborn’s immediate health and measurements through a mother’s exposure during pregnancy [35-38]. The hypothesis behind these studies is exposure to air pollutants during a woman’s pregnancy will have impact on children before they are born. Birth defects was found to be associated with every 10μg/m³ increase in PM_2.5 and PM₁₀ [35]. Low birth weight was found to be associated with exposure among pregnant women to outdoor air pollution in another study in 22 countries from 2004-2008 [36]. A global review of data from published studies from 204 countries found that 33% of the pre-term births and low birth weights could be attributable to a woman’s exposure to PM_2.5 during pregnancy [37]. Similarly, lower anthropometric measurements were recorded for boys going to school due to exposure to air pollutants [38]. In an Iranian study, the authors noted that exposure to air pollution by pregnant women was associated with higher fasting blood glucose levels in them [39]. Finally, in another study conducted in China, the authors found associations between newborn birth defects due to exposure to outdoor air pollution by pregnant women [40]. Mortality among children due to ambient air pollution was shown in a couple of studies [41,42]. These findings exacerbate the fact about negative effects of outdoor air pollution and the urgent need to tackle this issue in LMICs through multi-faceted ways. A study out of 164 countries showed similar findings where child deaths due to outdoor air pollution varies by country wealth and better standards of living [43].

Children (<18 years of age), and especially more younger children (<5 years) are a vulnerable sub-group of residents living in any country, especially in LMICs, and exposure to poor air quality can tend to lead to long-term health impacts that can significantly drain the already scarce medical resources. Moreover, exposure to outdoor air pollution among pregnant women are more likely to give birth to children who have lower birth weight and may be pre-term. A multi-faceted approach (more economic resources, education on risk factors in schools, medical facilities, and providers supporting these residents, and minimizing exposure to air pollutants) is strongly needed to improve health outcomes among children at risk of exposure.

Impact of traffic-related and biomass burning-related outdoor air pollution on health

Traffic-emissions due to a growing number of cars among residents in LMICs due to a burgeoning economy as led to a significant increase in outdoor air pollution and subsequently negatively impacting human health. A study in Ecuador looked at people working in traffic control police and evaluated their carotid intima-media thickness and found increased numbers among these workers versus those who had indoor work duties [49]. As traffic increases in LMICs studies have researched whether distance of homes of people living in countries to major roads have any association with health outcomes [50,51]. Findings from these studies suggest a potential for higher rates of wheeze [51] and hypertension [50]. Children and newborn birth measurements are equally impacted due to traffic-related air pollution [52-55]. The studies demonstrate lower birth weight among newborns born to women who were exposed to outdoor pollutants [54,55], reduced birth length [53], and a higher rate of allergic conditions among children [52].

Biomass/fire burning was also found to be associated with increased levels of outdoor air pollution in LMICs [56,57]. Outdoor burning of biomasses is more prevalent in LMICs versus more developed countries and has shown to be associated with infant mortality in Africa [56]. A couple of Brazilian studies have reported increased rates of cancer of the respiratory system and subsequent mortality and other malignancies [58,59]. As the LMICs become more developed and gain economic strength there is bound to be growing urbanization and a higher demand for personal vehicles. This needs to be well supplemented by adequate forward-thinking policies to build necessary infrastructure and manufacture vehicles with quality emission control. Additionally, there needs to be increased awareness of the negative impact of long-term impact of inhaling pollutants from traffic emissions through awareness campaigns and education.

Air pollution and health-related quality of life

In a study that evaluated the impact of air pollution on Health- Related Quality of Life (HRQoL) on Mongolian residents living in Ulaanbaatar, the authors collected perceptions of the study residents on HRQoL through surveys using self-completed questionnaires (SF-36 v2 and the Dartmouth Coop Functional Health Assessment/ World Organization of National Colleges, Academies, and Academic Association of General Practitioners (COOP/WANCA) [72]. In addition, health checkup data and pulmonary function test data performed by specialists were also collected. The findings showed that air pollution was worse in the cold season and was exacerbated by solid fuel combustion [72]. This poor air pollution was also correlated with lower HRQoL scores among residents with ventilatory impairment [72].

In another study, a similar impact of air pollution on respiratory symptoms and HRQoL (using the same instruments as used in the Mongolian study) in an outpatient population with chronic respiratory disease in Korea was evaluated [73]. This study, which was conducted from 2013-15, used a similar panel approach where patients filled out self-reported questionnaires. From an HRQoL perspective, lower daily activity scores were observed when particulate matter concentrations were < PM₁₀, and lower social functioning scores were observed with PM2.5 levels. In addition to particulate matter, the study also found that high Nitrogen Oxide (NO2) concentrations were also correlated with poor mental health scores [73].

A similar methodology was utilized to assess the short-term impact of poor air quality on HRQoL in another study [74]. The EuroQoL-Visual Analog Scale (EQ-VAS) was used to evaluate the impact of HRQoL among more than 5,000 study residents [74]. The main findings showed that the EQ-VAS scores decreased with an increase in the interquartile range of carbon monoxide in males between 40 and 49 years and with an increase in the interquartile range of sulfur dioxide in females between 50-64 years [74]. A Chinese study evaluated associations between perceived air pollution and HRQoL in a Chinese adult population [75]. 3,866 residents participated in a cross-sectional survey using the SF- 12 instrument to collect HRQoL scores. Perceived air pollution was found to have significant associations with poor Physical Component (PCS) and Mental Component (MCS) scores [75].

HRQoL is an important measure of evaluating an individual’s association between health and quality of life. As air pollution, both outdoor and indoor, has been previously associated with morbidity and mortality due to several medical conditions, its impact on HRQoL is also quite significant. Using several validated instruments, studies have determined that exposure to poor air quality, especially among LMICs where the risk factors linked with increasing air pollutants have a profound impact on several important domains within these instruments including activities of daily living, ability to perform routine daily tasks and social/ behavioural/mental health. The burden of medical conditions associated with air pollution exposure is significant, both clinically and economically, and this imposes a severe strain on the health of residents living in LMICs. More importantly, as HRQoL gets additionally impacted due to increasing air pollution among these LMICs, there needs to be an urgency to limit the exposure.

There has been no consolidated review that compiles all studies associating outdoor air pollution to health and quality of life in LMICs into one review and evaluates the current evidence on the impact of outdoor air pollution on poverty and younger population (children). Our study provides a consolidated approach to delineate the impact of outdoor air pollution on disease, HRQoL, specific outdoor air pollutants including traffic and tobacco smoke, and poverty. Our review focused on LMICs, associations between poverty levels and lack of infrastructure, and technological advancements that contribute to lower levels of available resources to combat high levels of air pollution. System infrastructure can potentially lead to lower rates of diseases and subsequent lower medical resource utilization and improved quality of life. Even though we found a few studies on the younger age residents (children) in our review, we did not make any comparisons of the impact of outdoor air pollution on the various outcome measures between children and the older residents as the literature could not support conclusions in this area. Additionally, there may be other variables that can be associated with outdoor air pollution levels that may be of interest from a scientific perspective including race and other demographic and socioeconomic factors that were not analyzed in this literature review.

Interventions have the potential to improve residents’ health including improvement in respiratory symptoms, cardiovascular illness, hospitalizations, and all-cause mortality [101]. Many of these interventions can target multiple sources of air pollution, both outdoor and indoor, including industries, residential, and vehicles. We identified a few studies in our review that looked at interventions targeting these different sources to monitor and potentially mitigate the impact of air pollution. In a prior literature review, three types of air pollution interventions: air purifiers, facemasks, and behaviour changes were evaluated [102]. Their review demonstrated substantial benefits of these interventions, especially, the air purifiers to lower indoor PM2.5 concentrations and improve health outcomes. These interventions provide a cost-effective way to reduce exposure to air pollution [102]. However, these interventions need to be supplemented by others to reduce harmful emissions in the air. In yet another review published in 2019, the study authors assessed 42 studies looking at 38 interventions [103]. One interesting study looked at personal wearables to monitor an individual’s exposure to air pollutants to study the usage of the device and actual exposure [104]. In this interventional study conducted in Ghana that included three study comparators [control, improved biomass, and Liquefied Petroleum Gas (LPG)], wearing the device was found to be positively associated with exposure to air pollutants in the control and biomass arms, and in a weaker manner with the LPG arm [104]. Similar wearable technologies should be looked into for monitoring and minimizing outdoor air pollution. A separate updated and consolidated review focusing on interventions for reducing ambient and indoor air pollution and outcomes is warranted. In a study that looked at transportation pollution control interventions in China (1998- 2015) including vehicle emission control and associated mortality attributable to long-term inhalation of fine particulate matter, PM_2.5, the researchers found that the impact was substantial and concluded that had these measures/interventions been not implemented, vehicular emissions would have been 2-3 times more and the mortality rate would have been higher by 510,000 [105].

Similarly, in another study conducted to look into indoor air pollution, the authors concluded that individual-level smoking interventions can reduce air pollution, however, there is a need for population-based and other regulatory measures to help reduce exposure to air pollution contaminants [106]. Such interventions need to be addressed for the more prevalent outdoor air pollution in LMICs. Low-cost technologies can also potentially be implemented in LMICs for monitoring of ambient air pollution as there is currently a lack of use of such monitoring in some countries [107-109]. With technological advancements including wearable devices [110], calculated investments should be made in such innovations. Additionally, a higher educational level and thereby awareness, thus potentially improving on the current neglect of the detrimental impact of outdoor air pollution can improve health outcomes [111-113]. There also needs to be appropriate legislation implemented to identify the main causes of air pollution [114], motivating manufacturers of low-cost technologies to monitor and minimize air pollution [115], and upgrading the current built environment [116]. Other ways, as shown in a Chinese study, include advertisements to promote a healthy lifestyle, construction of smart cities, and means to protect the ecological environment, that can be potentially implemented in other LMICs [117]. The benefits of any measure/s to control the outdoor air pollution are manifold, especially with regards to reducing mortality [118]. Most importantly, there needs to be a concerted effort to change the behaviour towards accepting outdoor air pollution as a health hazard [119].

In LMICs, developing low-cost and efficient technologies and widespread utilization in detecting and monitoring outdoor air pollution should be considered a high priority. With overall resources needed from a social, financial, and medical perspective being scarce among these countries, a concerted effort is warranted from multiple sources to aid in recognizing and improving outdoor air quality and allocating needed resources to help the residents improve on their health and quality of life outcomes.

Outdoor air pollution negatively impacts the health and quality of life of individuals in LMICs at higher rates than those in highincome countries. Poor outdoor air quality detrimentally impacts long-term health including chronic conditions that lead it to be one of the top ten leading causes of morbidity and mortality worldwide. Furthermore, particulates do not just impact the lungs as they have led to systemic conditions in the body including respiratory symptoms, diabetes, heart disease, chronic kidney disease, and more. Additionally, poor outdoor air quality, especially in LMICs, is correlated with a higher consumption of medical resources leading to an inequitable use of available resources for other areas of development. Due to higher mortality rates associated with diseases linked with higher outdoor air pollution, especially among children, prioritization of medical resources becomes very important. With overall air pollution predicted to increase over time, it is critical for well-designed, implemented, and monitored inventions to combat this evolving crisis. For example, by 2030, PM2.5 pollution in India is predicted to reach eight times the recommended World Health Organization air quality recommendations. Thus, if the sources of air pollution are not addressed, the health and quality of liferelated effects of air pollution must be addressed further through implementations like stove interventions or filtration masks which provide substantive and immediate improvements in the capacity of individuals to decrease the amount of particulate matter that they are absorbing. A more multi-faceted approach is needed in LMICs including transition to cleaner energy sources, improving waste management, enhancing vehicle emission standards, and implementing and executing policies aimed at reducing industrial pollution. Further research is warranted to keep monitoring air quality levels in LMICs and interventions, appropriate to the country or region, need to be identified and implemented to reduce exposure to air pollutants. Updated and frequent policy changes are also needed that are region-specific for a population-based drive to limit the short-term and long-term adverse impact of air pollution.

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