**Background:** Indoor air pollution from solid fuel use is a major health risk, particularly for women in low-income countries who spend significant time cooking. In Ethiopia, biomass fuels are widely used, yet data on respiratory symptoms among women who cook are limited. This study aimed to assess the magnitude of respiratory disease symptoms and associated factors among women responsible for cooking in Mattu and Bedele towns, southwest Ethiopia.
**Methods:** A community-based cross-sectional study was conducted from February to June 2021. A total of 420 women were randomly selected using systematic random sampling from five kebeles (lowest administrative units) in the two towns. Data were collected via face-to-face interviews using a modified American Thoracic Society Respiratory Questionnaire (ATS-DLD-78-A). The questionnaire covered sociodemographic, behavioral, and housing characteristics. Respiratory symptoms were defined as having at least one of: cough, phlegm, blocked/runny nose, wheezing, or shortness of breath in the past 12 months. Data were analyzed using SPSS V.22. Bivariable and multivariable logistic regression identified factors associated with respiratory symptoms, with significance set at p<0.05.
**Key Results:** A total of 415 women participated (response rate 98.8%). The mean age was 33.47 years (SD 10.63). Most women (83.6%) used firewood for cooking, 77.6% used traditional stoves, 59.5% had thick black soot on the ceiling, and 54.7% cooked in a room without a window. The overall prevalence of respiratory symptoms was 34.9% (95% CI 30.6% to 39.4%). The most common symptoms were runny nose/sneezing (14.7%), cough (13.0%), and wheezing (9.6%). In multivariable analysis, the following factors were significantly associated with respiratory symptoms: unimproved floor (AOR=2.4, 95% CI 1.42 to 4.15), presence of thick black soot on ceiling (AOR=2.1, 95% CI 1.2 to 3.6), use of fuel wood (AOR=2.3, 95% CI 1.1 to 4.7), use of traditional stove (AOR=3.37, 95% CI 1.85 to 6.16), cooking more than 4 hours per day (AOR=2.52, 95% CI 1.4 to 4.5), and cooking room without a window (AOR=2.4, 95% CI 1.5 to 3.9).
**Clinical Implications:** The high prevalence of respiratory symptoms (34.9%) among women who cook underscores the urgent need for interventions to reduce indoor air pollution. Modifiable risk factors identified include floor type, soot accumulation, stove and fuel type, cooking duration, and ventilation. Public health strategies should promote improved stove designs, cleaner fuels (e.g., electricity), better kitchen ventilation (e.g., windows), and regular cleaning to reduce soot. Awareness campaigns on the health effects of indoor air pollution and policy engagement for housing improvements are essential. Limitations include the cross-sectional design (cannot establish causality), lack of direct air pollution measurements, and potential recall bias.