Methodology for a Comprehensive Health Impact Assessment in Water Supply and Sanitation Programmes for Brazil
Abstract
:1. Introduction
2. Materials and Methods
- “Plano Nacional de Saneamento Básico” (National Basic Sanitation Plan) (PLANSAB) [36], coordinated by the Ministry of Regional Development; in Portuguese, with relevant sections translated into English in Supplementary Material S1.
- “Pesquisa Nacional de Saneamento Básico” (National Survey on Basic Sanitation) (PNSB) [37], a survey applied by the Brazilian Institute of Geography and Statistics (IBGE); in Portuguese, with relevant sections translated into English in Supplementary Material S1.
- “Avaliação de Impacto na Saúde das Ações de Saneamento” (Health Impact Evaluation of Sanitation Actions) [38], a methodological proposal by the Pan-American Health Organization/World Health Organization (PAHO/WHO) in Brazil, together with the Ministry of Health in 2014; in Portuguese, with relevant sections translated into English in Supplementary Material S1.
3. Development of the Dimensions Applied to Health
3.1. Sanitary
3.2. Environmental
3.3. Technological
3.4. Sociocultural
3.5. Epidemiological
3.6. Mental Well-Being
3.7. Economic
4. The Development of Indicators for Each Health Dimension
4.1. Indicators Associated with Water Supply Dimensions
4.1.1. Sanitary
- Physical parameters of water quality (temperature, colour, and turbidity).
- Physical parameters for perception of water quality (taste, odour, colour); these may affect the approval of the water for human consumption.
- Chemical water-quality parameters (pH, total and free residual chlorine).
- Microbiological water-quality parameters (total coliforms and faecal coliforms, Escherichia coli). It should be noted that there are many types of biological agents. Some are important in the transformation processes of organic matter in biogeochemical cycles, but others are responsible for causing disease and generating health concerns. For this type of analysis, the most important micro-organisms are the coliform bacteria, which are associated with water-borne disease [69].
- Frequency of water analysis.
- Food safety—related to water quality in food preparation.
4.1.2. Environmental
- Frequency of extreme events.
- Frequency of supply.
- Quantity of water/source supply.
- Water uses: how extreme events (drought or flooding) affect water uses.
- Impact of extreme events on food—related to water quantity during food preparation and types of vegetables and fruits more resistant to extreme events such as drought.
4.1.3. Technological
- Type of source (public network, well, water tanker).
- Type of storage (water tank, cistern).
- Material the storage container is made of (polyethylene, fibreglass, metal, asbestos, cement).
- Frequency of water tank cleaning.
- Types of treatment (filtration, water boiling, chlorination or other disinfection process such as ozone, clay filter, activated carbon filter, or even water-treatment plant, i.e., complete treatment with: coagulation, decantation, filtration, and chlorination)
- Distribution points (drinking fountains, kitchen taps, washbasins, showers, etc.).
- Consumption points (kitchen, drinking fountain, etc).
- Operation and maintenance (how the operation is carried out: does the water arrive every day and every hour, or is there intermittent supply?), periodicity of maintenance (normally every 3 months to change the filter, clean the water tank, etc.).
4.1.4. Sociocultural
- Habits and customs (amount of water taken inside a household/ building, washing hands, washing fruit and vegetables, and how this is influenced by the source of supply (public mains, well, etc.))
- Quantity of water ingested.
- Hygiene habits.
- Rational use of water awareness.
- Raising awareness on the use and importance of water (if there are lectures or information on the importance of water conservation and the role of each person).
- Community interest.
- Educational and information, social mechanisms (programmes in schools, advertising, radio and television programmes, and projects).
- Awareness of waterborne diseases.
4.1.5. Epidemiological
- Symptom of diseases (diarrhoea, bloody diarrhoea, yellow skin and/or eyes, red eyes, fever with chills, joint pain, headache, abdominal pain, intestinal pain, lack of appetite, nausea, and/or vomiting and toothache).
- Incidence rates of waterborne diseases (cholera, leptospirosis, verminosis in general, amoebiasis, typhoid or paratyphoid fever, giardiasis or cryptosporidiosis, infectious hepatitis, gastroenteritis, leptospirosis, kidney diseases, hypertension, dental caries, and gingivitis) based on hospitalisation and mortality rates for waterborne diseases.
4.1.6. Mental Well-Being
- Depression (due to lack of water).
- Children’s concentration.
- Emotional and behavioural changes.
- Absenteeism from work and school.
- School learning abilities.
- Incidence rates of mental health-related diseases.
4.1.7. Economic
- Water consumption expenditure.
- Energy consumption expenditure.
- Disease expenditure.
4.2. Indicators Associated with Sanitation Dimensions (Lack of/Inadequate Sewage System)
4.2.1. Sanitary
- Physical parameters of water quality (temperature, taste, odour, colour, turbidity, total solids (suspended and dissolved)).
- Chemical water-quality parameters (pH, alkalinity, acidity, hardness, dissolved oxygen, chemical oxygen demand, biochemical oxygen demand, nitrogen series (ammonium ion nitrite ion, nitrate ion), phosphorus, iron and manganese, micropollutants (heavy metals eg arsenic, cadmium, chromium, copper, lead, mercury, nickel, silver, zinc, cyanides and fluoride), total chlorine, and free residual chlorine.
- Microbiological water-quality parameters (total coliforms and faecal coliforms, Escherichia coli).
- Frequency of water analysis.
- Food safety—related to water quality in food preparation.
4.2.2. Environmental
- Change in volume reduced due to an extreme event.
- Impact on sewage collection.
- Impact on the sewage treatment system.
4.2.3. Technological
- Individual or collective solution for sewage (septic tank or collection network).
- Treatment system adopted (primary, secondary, or tertiary treatment of sewage).
- Final disposal adopted (drying bed, incineration of sewage sludge).
- Operation and maintenance (necessary precautions for the operation of the system, both for the collection network and the treatment system, the need to dispose of the sludge, care with gas leaks (e.g., from a biodigester), etc.).
4.2.4. Sociocultural
- Habits regarding the use of sanitary facilities (how the toilet is cleaned, what is discarded in it such as absorbent pads, etc.) if there is a toilet or only a hole, etc.
- Raise awareness of the population regarding the disposal of sludge.
- Population’s knowledge about reuse of urine and faeces; use of biogas produced from sewage.
- Lectures and educational events, e.g., radio or television programmes, projects using sewage.
4.2.5. Epidemiological
- Incidence rates of diseases caused by inadequate sanitation.
- Hospitalisation rates for diseases caused by inadequate sanitation.
- Mortality rates from diseases caused by inadequate sanitation.
4.2.6. Mental Well-Being
- Depression (due to lack of/inadequate sewage management).
- Stress (due to lack of/ inadequate sewage management).
- Lack of concentration.
- Emotional and behavioural changes due to the type of solution (e.g., women going into the toilet, issues around violence, insecurity, embarrassment).
- Incidence rates of mental-health-related diseases.
- Absenteeism from work/school.
- Changes in school learning.
- Economic impacts.
- Energy consumption spent on sewage collection and treatment.
- The sewage tariff.
- Health expenditure due to diseases caused by sewage.
- Loss of work or absence from school due to illness caused by sewage.
5. Results of a Case Study Applying the HIA Methodology
6. Discussion
7. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Heller, H.L. Interfaces and inter-sector approaches: Water, sanitation and public health. In Water and Sanitation Services: Public Policy and Management; Castro, J.E., Heller, L., Eds.; Routledge: London, UK, 2009; pp. 119–136. [Google Scholar]
- United Nations. Glossary on the Human Right to Water and Sanitation. Available online: https://www.un.org/waterfordecade/pdf/hrw_glossary_eng.pdf(un.org) (accessed on 15 March 2022).
- WHO Constitution. Available online: https://www.who.int/about/governance/constitution#:~:text=Health%20is%20a%20state%20of,belief%2C%20economic%20or%20social%20condition (accessed on 30 September 2022).
- Card, A.J. Moving Beyond the WHO Definition of Health: A New Perspective for an Aging World and the Emerging Era of Value-Based Care. World Med. Health Policy 2017, 9, 127–137. [Google Scholar] [CrossRef]
- PAHO/WHO (Pan American Health Organization). Health Indicators. Conceptual and Operational Considerations; Pan American Health Organization: Washington, DC, USA, 2018; ISBN 978-92-75-12005-7. [Google Scholar]
- Landmann-Szwarcwald, C.; Macinko, J. A panorama of health inequalities in Brazil. Int. J. Equity Health 2016, 15, 1–3. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Portrait, F.; Lindeboom, M.; Deeg, D. Life expectancies in specific health states: Results from a joint model of health status and mortality of older persons. Demography 2001, 38, 525–531. [Google Scholar] [CrossRef] [PubMed]
- UK Government. Research and analysis: Chapter 6: Social determinants of health. 2017. Available online: https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health (accessed on 30 September 2022).
- Theofilou, P. Quality of Life: Definition and Measurement. Eur. J. Psychol. 2013, 9, 150–162. [Google Scholar] [CrossRef]
- Charlesworth, S.M.; Kligerman, D.C.; Blackett, M.; Warwick, F. The Potential to Address Disease Vectors in Favelas in Brazil Using Sustainable Drainage Systems: Zika, Drainage and Greywater Management. Int. J. Environ. Res. Public Health 2022, 19, 2860. [Google Scholar] [CrossRef]
- WHO Sanitation. 2022. Available online: https://www.who.int/news-room/fact-sheets/detail/sanitation#:~:text=Poor%20sanitation%20is%20linked%20to,the%20spread%20of%20antimicrobial%20resistance (accessed on 30 September 2022).
- UNICEF; WHO. State of the World’s Sanitation: An Urgent Call to Transform Sanitation for Better Health, Environments, Economies and Societies. New York: United Nations Children’s Fund (UNICEF) and the World Health Organization. 2020. Available online: https://www.who.int/publications/i/item/9789240014473 (accessed on 30 September 2022).
- Centre for Disease Control. Sanitation and Hygiene. 2021. Available online: https://www.cdc.gov/healthywater/global/sanitation/index.html (accessed on 11 May 2022).
- Brazil Ministry of Regional Development. Secretaria de Saneamento. In Thematic Diagnosis: Water and Sewage Services—Overview. Reference year 2020; Brazil Ministry of Regional Development: Brasillia, Brazil, 2021. [Google Scholar]
- Martel, P. Review of Options for Reporting Water, Sanitation and Hygiene Coverage by Wealth Quintile; MICS Methodological Papers, No. 4; Data and Analytics Section, Division of Data, Research and Policy, UNICEF: New York, NY, USA, 2016. [Google Scholar]
- Arruda, J.M.; Rutenberg, N.; Morris, L.; Ferraz, E.A.; Pesquisa Nacional Sobre Saude Materno-Infantil e Planejamento Familiar. PNSMIPF-BRASIL. 1987. Available online: https://dhsprogram.com/pubs/pdf/FR4/FR4.pdf (accessed on 30 September 2022). (In Portuguese).
- Ferraz, E.A.; Ferreira, I.Q.; Pesquisa Sobre Saúde Familiar no Nordeste Brasil 1991. Sociedade Civil Bem-Estar Familiar no Brasil–BEMFAM, Rio de Janeiro, Brasil. 1992. Available online: https://dhsprogram.com/pubs/pdf/FR5/FR5.pdf (accessed on 30 September 2022). (In Portuguese).
- Badiani, R.I.; Ferreira, Q.; Ochoa, L.H.; Patarra, N.; Wong, L.; Simões, C.; Camarano, A.A. Brasil Pesquisa Nacional Sobre Demografia e Saúde 1996. Sociedade Civil Bem-Estar Familiar no Brasil, BEMFAM. Programa de Pesquisas de Demografia e Saúde (DHS) Macro International Inc. 1997. Available online: https://dhsprogram.com/pubs/pdf/fr77/fr77.pdf (accessed on 30 September 2022). (In Portuguese).
- Osman, A.; Dar1, O.A.; Khan, M.S. Millennium development goals and the water target: Details, definitions and debate. Trop. Med. Int. Health. 2011, 16, 540–544. [Google Scholar]
- Clasen, T.F. Millennium Development Goals water target claim exaggerates achievement. Trop. Med. Int. Health 2012, 17, 1178–1180. [Google Scholar] [CrossRef]
- United Nations. The Sustainable Development Goals. 2022. Available online: https://sdgs.un.org/ (accessed on 30 September 2022).
- Pereira, M.A.; Marques, R.C. Sustainable water and sanitation for all: Are we there yet? Water Res. 2021, 207, 117765. [Google Scholar] [CrossRef]
- Pereira, M.A.; Marques, R.C. From a millennium to a sustainable water and sanitation development: Were we there already? J. Water Supply Res. Technol. 2022, 71, 293–300. [Google Scholar] [CrossRef]
- Pereira, M.A.; Marques, R.C. Technical and Scale Efficiency of the Brazilian Municipalities’ Water and Sanitation Services: A Two-Stage Data Envelopment Analysis. Sustainability 2022, 14, 199. [Google Scholar] [CrossRef]
- Cavalcanti, A.; Teixeira, A.; Pontes, K. Evaluation of the Efficiency of Basic Sanitation Integrated Management in Brazilian Municipalities. Int. J. Environ. Res. Public Health 2020, 17, 9244. [Google Scholar] [CrossRef] [PubMed]
- Ferreira, D.C.; Graziele, I.; Marques, R.C.; Gonçalves, J. Investment in drinking water and sanitation infrastructure and its impact on waterborne diseases dissemination: The Brazilian case. Sci. Total Environ. 2021, 779, 146279. [Google Scholar] [CrossRef] [PubMed]
- Brazil Presidency of the Republic. Casa Civil. Law No 14.026 15 July 2020; Diário Oficial da União: Brasília, Brazil, 2020.
- Abe, K.C.; Miraglia, S.G.E.K. Health Impact Assessment (HIA) in Brazil and Latin America: An essential tool for projects, plans and policies. Interface 2018, 22, 349–358. (In Portuguese) [Google Scholar] [CrossRef]
- Thondoo, M.; Rojas-Rueda, D.; Gupta, J.; de Vries, D.H.; Nieuwenhuijsen, M.J. Systematic Literature Review of Health Impact Assessments in Low and Middle-Income Countries. Int. J. Environ. Res. Public Health 2019, 16, 2018. [Google Scholar] [CrossRef] [Green Version]
- Abe, K.C.; Miraglia, S.G.E.K. Health Impact Assessment of Air Pollution in São Paulo, Brazil. Int. J. Environ. Res. Public Health 2016, 13, 694. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Silveira, M.; Fenner, A.L.D. Health impact assessment (HIA): Analyses and challenges to Brazilian health surveillance. Cienc. Saude Coletiva. 2017, 22, 3205–3214. [Google Scholar] [CrossRef] [Green Version]
- Heller, L. Sanitation and Health; Pan-American Health Organization: Brasilia, Brazil, 1997. [Google Scholar]
- PAHO/WHO. Health Impact Assessment: Concepts and Guidelines for the Americas. Special Program on Sustainable Development and Health Equity. Washington, D.C. 2013. Available online: https://paho.org/hq/dmdocuments/2014/health-impact-assessment-concepts-and-guidelines-2013.pdf (accessed on 30 September 2022).
- Harris-Roxas, B.; Viliani, F.; Bond, A.; Cave, B.; Divall, M.; Furu, P.; Harris, P.; Soeberg, M.; Wernham, A.; Winkler, M. Health impact assessment: The state of the art. Impact Assess. Proj. Apprais. 2012, 30, 43–52. [Google Scholar] [CrossRef]
- Dannenberg, A.L.; Bhatia, R.; Cole, B.L.; Heaton, S.K.; Feldman, J.D.; Rutt, C.D. Use of Health Impact Assessment in the U.S: 27 Case Studies, 1999–2007. Am. J. Prev. Med. 2008, 34, 241–256. [Google Scholar] [CrossRef] [PubMed]
- Brazil. (n.d.) Ministry of Regional Development. Plano Nacional de Saneamento Básico (PLANSAB). Available online: https://www.gov.br/mdr/pt-br/assuntos/saneamento/plansab (accessed on 11 May 2022).
- IBGE (Instituto Brasileiro de Geografia e Estatística). Pesquisa Nacional de Saneamento Básico 2017: Abastecimento de Água e Esgotamento Sanitário; IBGE, Coordenação de População e Indicadores Sociais: Rio de Janeiro, Brazil, 2020.
- BRASIL Ministério da Saúde/Organização Pan-Americana da Saúde. Avaliação de impacto na saúde das ações de saneamento: Marco conceitual e estratégia metodológica. In Marco conceitual e estratégia metodológica. Representação da OPAS/OMS no Brasil, Brasília: MS; 2014. Available online: http://www.funasa.gov.br/documents/20182/38937/AvaliaC3A7ao+de+impacto+na+saude+das+aC3A7oes+de+saneamento.pdf/9d28b0ee-2beb-4976-ab03-4f03b0512a69 (accessed on 30 September 2022).
- Sclar, G.D.; Penakalapati, G.; Caruso, B.; Rehfuess, E.; Garn, J.; Alexander, K.; Freeman, M.; Boisson, S.; Medlicott, K.; Clasen, T. Exploring the relationship between sanitation and mental and social well-being: A systematic review and qualitative synthesis. Soc. Sci. Med. 2018, 217, 121–134. [Google Scholar] [CrossRef] [PubMed]
- WHO. Preventing Disease through Healthy Environments: A Global Assessment of the Burden of Disease from Environmental Risks; World Health Organization: Geneva, Switzerland, 2016.
- Pruss-Ustun, A.; Corvalan, C. How much disease burden can be prevented by environmental interventions? Epidemiology 2007, 18, 167–178. [Google Scholar] [PubMed]
- United Nations. Office for Disaster Risk Reduction (UNDRR). PreventWeb. Basic Country Statistics and Indicators. Brazil Disaster & Risk Profile. 2014. Available online: https://www.preventionweb.net/countries/bra/data/ (accessed on 23 July 2021).
- Freitas, C.M.; Silva, D.R.X.; Sena, A.R.M.; Silva, E.L.; Sales, L.B.F.; Carvalho, M.L.; Mazoto, M.L.; Barcellos, C.; Costa, A.M.; Oliveira, M.L.C.; et al. Natural disasters and health: An analysis of the situation in Brazil. Ciênc. Coletiva 2014, 19, 3645–3656. [Google Scholar] [CrossRef]
- Murphy, H.M.; McBean, E.A.; Farahbakhsh, K. Appropriate technology—A comprehensive approach for water and san-itation in the developing world. Technol. Soc. 2009, 31, 158–167. [Google Scholar] [CrossRef]
- Moitta, F. Research on appropriate technology at the SESP Foundation. In Revista da Fundação SESP; Fundação Serviços de Saúde Pública: Rio de Janeiro, Brazil, 1982; Volume 27. [Google Scholar]
- Di Maio, D.V., Jr.; Oliveira, E.A.A.Q.; De Brito, L.A.P.F.; Silva, H.A.T. The perception and management of technological risks with surrounding externality: A case study. Rev. Espac. 2018, 39, 9–27. [Google Scholar]
- Chaves, V.T.; Tomaz, F.A.; Contrera, R.C. Performance evaluation of an appropriate technology for rural sanitation. DAE J. 2019, 220, 173–187. [Google Scholar]
- Ranis, G. Appropriate technology and the development process. In Appropriate Tech-Nology and Social Values—A Critical Appraisal; Long, F.A., Oleson, A., Eds.; Ballinger Publishing Company: Cambridge, MA, USA, 1980; pp. 99–120. [Google Scholar]
- Lobo, M.A.A.; Lima, D.M.B.; Souza, C.M.N.; Nascimento, W.A.; Araújo, L.C.C.; Santos, N.B. Economic evaluation of social technologies applied to health promotion: Water supply by Sodis system in riverside communities in the Amazon. Ciênc. Coletiva 2013, 18, 2119–2127. [Google Scholar] [CrossRef] [Green Version]
- Silva, F.A.C.; Naval, L.P. A contribution to develop strategies to support the social control of sanitation activities. Ambient. Soc. 2015, 18, 59–74. [Google Scholar] [CrossRef]
- Wanyera, L.A. Influence of community participation on sustainability of community based projects: A case of Kiambiu water and sanitation slum project, Nairobi county, Kenya. Unpub. MSc. University of Nairobi, Kenya. Available online: http://erepository.uonbi.ac.ke/bitstream/handle/11295/97282/FINAL%20REPORT.pdf?sequence=1&isAllowed=y (accessed on 30 September 2022).
- Barreto, M.L.S.; Genser, B.; Strina, A.; Teixeira, M.G.; Assis, A.M.O.; Rego, R.F.; Teles, C.A.; Prado, M.S.; Matos, S.M.A.; Santos, D.N.; et al. Effect of city-wide sanitation programme on reduction in rate of childhood diarrhoea in northeast Brazil: Assessment by two cohort studies. Lancet 2007, 370, 1622–1628. [Google Scholar] [CrossRef] [Green Version]
- Fewtrell, L.; Kaufmann, R.B.; Kay, D.; Enanoria, W.; Haller, L.; Colford, J.M., Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: A systematic review and meta-analysis. Lancet Infect. Dis. 2005, 5, 42–52. [Google Scholar] [CrossRef]
- Goswami, S.; Jha, A.; Sivan, S.P.; Dambhare, D.; Gupta, S.S. Outbreak investigation of cholera outbreak in a slum area of urban Wardha, India: An interventional epidemiological study. J. Fam. Med. Prim. Care 2019, 8, 1112–1116. [Google Scholar] [CrossRef] [PubMed]
- Swain, S.K.; Baral, P.; Hutin, Y.J.; Rao, T.V.; Murhekar, M.; Gupte, M.D. A hepatitis E outbreak caused by a temporary interruption in a municipal water treatment system, Baripada, Orissa, India, 2004. Trans. R Soc. Trop. Med. Hyg. 2010, 104, 66–69. [Google Scholar] [CrossRef] [PubMed]
- Barreto, M.L.; Genser, B.; Strina, A.; Teixeira, M.G.; Assis, A.M.O.; Rego, R.F.; Teles, C.A.; Prado, M.S.; Matos, S.M.; Alcântara-Neves, N.M.; et al. Impact of a Citywide Sanitation Program in Northeast Brazil on Intestinal Parasites Infection in Young Children. Environ. Health Perspect. 2010, 118, 1637–1642. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Farooqui, A.; Khan, A.; Kazmi, S.U. Investigation of a community outbreak of typhoid fever associated with drinking water. BMC Public Health 2009, 9, 476. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Brazil Ministry of Health Fundação Nacional de Saúde. Impactos na Saúde e no SISTEMA Único de SAÚDE Decorrentes de Agravos Relacionados a Saneamento Ambiental Inadequado; Funasa: Brasília, Brazil, 2010; p. 248.
- Cairncross, S.; Feachem, R. Environmental Health Engineering in the Tropics: An Introductory Text; Wiley: Chichster, UK, 1993. [Google Scholar]
- Mara, D.D.; Feachem, R.G.A. Water- and Excreta-Related Diseases: Unitary Environmental Classification. J. Environ. Eng. 1999, 125, 334–339. [Google Scholar] [CrossRef]
- Fonseca, F.R.; Vasconcelos, C.H. Análise espacial das doenças relacionadas ao saneamento ambiental inadequado no Brasil. Rio de Janeiro. Cad. Saúde Colet. 2011, 19, 448–453. [Google Scholar]
- Caruso, B.A.; Fehr, A.; Inden, K.; Sahin, M.; Ellis, A.; Andes, K.I.; Freeman, M.C. SH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An Assessment of Menstrual Hygiene Management in Schools; UNICEF: New York, NY, USA, 2013; Available online: https://healtheducationresources.unesco.org/library/documents/wash-schools-empowers-girls-education-freetown-sierra-leone-assessment-menstrual (accessed on 30 September 2022).
- UNICEF; WHO. Progress on Household Drinking Water, Sanitation and Hygiene 2000–2020: Five Years into the SDGs; World Health Organization: Geneva, Switzerland, 2021.
- World Health Organization. Global Costs and Benefits of Drinking-Water Supply and Sanitation Interventions to Reach the MDG Target and Universal Coverage; World Health Organization: Geneva, Switzerland, 2012.
- LIXIL, Oxford Economics, Water Aid Japan. The True Cost of Poor Sanitation. Tokyo: Lixil, 2016. Available online: http://www.lixil.com/en/sustainability/pdf/the_true_cost_of_poor_sanitation_e.pdf (accessed on 3 March 2020).
- Brazil Ministry of Health. Ordinance GM/MS n.0 888, of May 4, 2021. Amends Annex XX of the Consolidation Ordinance GM/MS n0.5 of 28 September 2017 on Procedures for Control and Surveillance of the Quality of Water for Human Consumption and its Potability Standard; Brazil Ministry of Health: Brasília, Brazil, 2021. [Google Scholar]
- Brazil Ministry of Health. National Guideline for the Sampling Plan of the Surveillance of Water Quality for Human Consumption; Brazil Ministry of Health: Brasília, Brazil, 2016.
- WHO. Guidelines for Drinking-Water Quality Recommendation, 3rd ed.; WHO: Geneva, Switzerland, 2004; 494p.
- Slekiene, J.; Mosler, H.-J. The link between mental health and safe drinking water behaviors in a vulnerable population in rural Malawi. BMC Psychol. 2019, 7, 44. [Google Scholar] [CrossRef] [Green Version]
- Mueller, N.; Rojas-Rueda, D.; Cole-Hunter, T.; de Nazelle, A.; Dons, E.; Gerike, R.; Götschi, T.; Panis, L.I.; Kahlmeier, S.; Nieuwenhuijsen, M. Health impact assessment of active transportation: A systematic review. Prev. Med. 2015, 76, 103–114. [Google Scholar] [CrossRef]
- Ammann, P.; Dietler, D.; Winkler, M.S. Health impact assessment and climate change: A scoping review. J. Clim. Chang. Health 2021, 3, 100045. [Google Scholar] [CrossRef]
Urban | Rural | South | South-East | North-East | North | Mid West | Total | |
---|---|---|---|---|---|---|---|---|
% HH with a water supply in the house/on the land | 84.3 | 24.9 | 78.9 | 83.6 | 66.9 | 73.7 | 71.3 | 72.7 |
% HH with a bathroom and sewage connected to a collection network | 50.5 | 6.3 | 31.9 | 61.6 | 14.7 | 5.6 | 29.2 | 41.7 |
Population (x 1000) 1996 | 128,897 | 35,718 | 23,356 | 63,000 | 45,540 | 11,410 | 10,465 | 157,871 |
Dimensions Related to Water Supply Provision | ||||||
---|---|---|---|---|---|---|
Sanitary health (a.) and (c.) | Environmental (b.) and (c.) | Technological (b.) and (c.) | Socio-cultural (c.) | Epidemiological (c.) and (d.) | Mental well-being (c.) | Economic (c.) and (d.) |
Indicators | ||||||
Physical water quality parameters | Frequency of supply | Type of source | Habits and customs | Incidence rates of waterborne diseases | School attendance | Water consumption |
Chemical water quality parameters | Quantity of water/source of supply | Storage type | Hygiene habits | Hospitalisation rates for waterborne diseases | School dropouts | Energy consumption |
Microbiological water quality parameters | Water use | Types of treatment | Raising awareness of the use and importance of water | Mortality rates from waterborne diseases | Absenteeism | Water expenditure |
Frequency of water analysis | Distribution points | Community interest | Emotional and behavioural changes | Energy expenditure | ||
Cleaning of the storage system and frequency | Operation and maintenance | Educational and information | Changes in school learning | Health expenditure | ||
Food safety | Socialisation | Incidence rates of mental health-related diseases | ||||
Quantity of water ingested and how |
Dimensions Related to Lack of/Inadequate Sanitation | ||||||
---|---|---|---|---|---|---|
Sanitary health (a.) and (c.) | Environmental (b.) and (c.) | Technological (b.) and (c.) | Socio-cultural (c.) | Epidemiological (c.) and (d.) | Mental well-being (c.) | Economic (c.) and (d.) |
Indicators | ||||||
Sewage system (mains or septic tank) | Due to extreme events: | Individual or collective sewage solution | Habits and customs regarding the use of toilet facilities | Rates of disease caused by inadequate sanitation | School attendance | Energy consumption spent on sewage collection and treatment |
Treatment | Change in volume | Treatment system adopted | Raising the population’s awareness of disposal | Hospitalisation rates for disease caused by inadequate sanitation | School dropouts | Sewage tariff |
Final disposal | Impact on sewage collection | Final disposal adopted | Population’s knowledge about reuse of urine and faeces; use of biogas produced from sewage | Mortality rates from disease caused by inadequate sanitation | Absenteeism | Health expenditure due to disease caused by sewage |
Leakage | Impact on the sewage treatment system | Operation and maintenance | Lectures and educational events | Emotional and behavioural changes | Loss of work or absence from school due to illness caused by sewage | |
Interconnection with the water supply system | Changes in school learning | |||||
Rates of mental health-related disease |
Indicator | Parameter | Water Quality Analysis | Participant Statements Collected from the School Community. Where: No (%) | Score (0 to 1) |
---|---|---|---|---|
Physical parameters of water quality | Colour | Samples were 0 µH, below the Maximum Allowed Value of 15 µH (Brazilian Water Potability Standard: Portaria MS n°2914/2011) | - | 1 |
Turbidity | Samples were 0.12UT to 0.41UT, below the Maximum Allowed Value, 5.0UT (Brazilian Water Potability Norm Portaria MS n°888/2021) | - | 1 | |
Temperature | Temperature was at a value accepted by the population and found in Brazilian aquatic environments (ie 20–30 °C) | - | 1 | |
Physical parameters for perception of water quality (n = 25) | Taste (adequate water is tasteless) | - | 11 (44%) the water was tasteless. | 0.44 |
Colour (suitable water is colourless) | - | 15 (60%) the water was transparent. | 0.60 | |
Odour (adequate water is odourless) | - | 19 (76%) the water had no smell | 0.76 | |
Average physical parameters | 0.8 | |||
Chemical parameters for water quality | pH | Results ranged from 7.4 to 7.7 within the range recommended in the Potability Standard (from 6.0 to 9.0). Portaria|MS No. 2914/2011 | 1 | |
Free residual chlorine | Results ranged from 0.06 to 0.08 mg/L indicating residual chlorine below the Potability Standard (0.2 to 2.0 mg/L) | 0 | ||
Average chemical parameters | 0.5 | |||
Microbiological Parameters | Total coliforms | Total coliforms were present: these should be absent in 100 ml of water according to The Brazilian Water Potability Standard. | 0 | |
Escherichia coli | E. coli was absent | 1 | ||
Average microbiological parameters | 0.5 | |||
Water analysis frequency: The Ordinance on Water Potability, Ministry of Health, Brazil requires annual sampling (n = 6) | - | 1 (17%) indicated once a year | 0.17 | |
Food safety (as related to water quality in food preparation) | The kitchen water sample was contaminated with total coliform, thus not suitable for food preparation | - | 0 | |
Average overall score = | 0.39 |
Indicator | Participant Statements Collected from the School Community. Where: No (%) | Observations during the Site Visit | Score (0 to 1) |
---|---|---|---|
Frequency of extreme events (drought) (n = 6) | 1 (17%) of respondents said that there has been no drought *1 | Annual rainfall index of 641.7 mm with droughts lasting 6 to 8 months. The site is classified as a hot semi-arid climate with a rainfall variation of 250–750 mm per year (Brazil, 2020). As the maximum rainfall in Brazil is 1800 mm per year, 641.7 mm is equivalent to 35.65% | 0.263 |
Frequency of water supply (4 teachers and 2 GSAs only, n = 6) | 3 (50%) of respondents said that water arrives every day. This question was only asked of 4 teachers and 2 GSAs. | Water supply was not regular. Water in the well was brackish; the school was supplied with a water truck every 15 to 20 days *2. | 0.25 |
Quantity of water | 9 (36%) there is abundant water | - | 0.36 |
Types of water use (n = 25) (n = 2) | 12 (48%) water was used for drinking, washing hands, brushing teeth and flushing toilets, it is also used in the kitchen. 2 (100%) toilet cleaning occurs daily using water and cleaning materials (GSA). | - | 0.74 |
Impact of drought on food (n = 25) | 7 (28%) the drought does not, or rarely, impacts food | - | 0.28 |
Impact of drought on cleaning (n = 2) | 2 (100%) drought does not harm the cleanliness of the school (GSA) | - | 1 |
Average overall score | 0.48 |
Indicator | Participant Statements collected from the School Community where: No (%) | Observations during the Site Visit | Score (0 to 1) |
---|---|---|---|
Water source type (n = 25) | 6 (24%): water was supplied from a well, considered a safe source according to WHO. 5 (20%): from a pipe from the street, 4 (16%): delivered by water tanker. | The well water was brackish and supplies the kitchen and lavatories. There was no frequent water supply. No water was supplied from the street pipe. The tanker supplied fresh water, distributed via the school’s drinking fountain. | 0.30 *1 |
Water storage type (n = 25) | 7 (28%): cisterns and water tanks. 13 (52%): water tanks, 1 (4%) cistern. | There was a cistern on the ground and a raised water tank. | 0.92 *2 |
Maintenance of the water supply system (teachers only; n = 4) | 4 (100%): the water tank had a lid. | The supported cistern had a lid, but the water tank was uncovered *3. | 0.5 |
Frequency of water tank cleaning (n = 6) | 4 (66%): water tank hygiene was carried out at intervals of between 1 and 6 months | - | 0.66 |
Maintenance of equipment used for water treatment (n = 6) | 3 (50%): the filter candle was changed at intervals of between 6 months to 1 year. | - | 0.50 |
Type of material used for storage (verified by colour) n = 25 | 11 (44%): blue (plastic), 5 (20%): white box, 2 (8%): cement, 1 (4%): grey. | The two boxes were made of concrete, with the cistern painted white *4 | 0.505 |
Water distribution points (n = 25) | 3 (12%): water was distributed via a drinking fountain, hand washing sink, the shower, toilet, kitchen sink and tank. | The places where water was delivered were verified, ie the drinking fountain, sinks, shower, toilet, kitchen sink and tank. However, there was no filter on the kitchen tap. | 0.56 |
Water consumption points (n = 25) | 14 (56%): drinking fountain, 6 (24%): kitchen tap with filter *5 | - | 0.80 |
Treatment, GSA only (n = 2) | 2(100%): washing was performed whenever the candle was dirty or every month | 1 | |
Average overall score | 0.64 |
Indicator | Information Collected from the School Community: No (%) of Respondents not Experienced Symptoms, Infections, Disease or Condition | Health Data (for the Municipality) | Score (0 to 1) | |
---|---|---|---|---|
Symptom N = 25 | Diarrhoea (stomach ache) | 6 (24%) | 0.24 | |
Bloody diarrhoea | 13 (60%) | 0.60 | ||
Yellowish skin and/or eyes | 18 (72%) | 0.72 | ||
Red eyes | 12 (48%) | 0.48 | ||
Fever with chills | 10 (40%) | 0.40 | ||
Joint pain | 8 (32%) | 0.32 | ||
Headaches | 2 (8%) | 0.08 | ||
Abdominal pain | 7 (28%) | 0.28 | ||
Intestinal pain | 11 (52%) | 0.52 | ||
Lack of appetite | 9 (36%) | 0.36 | ||
Nausea and/or vomiting | 11 (44%) | 0.44 | ||
Toothache | 5 (20%) | 0.20 | ||
Average symptoms | 0.39 | |||
Disease diagnosis N = 25 | Diarrhoea *1 | 6 (24%) | (a) 8(2019); 6(2020) and 1(2021) (b) 2(2020) | 0.12 |
Verminosis in general | 16 (64%) | 0.64 | ||
Amoebiasis | 17 (68%) | 0.68 | ||
Typhoid or paratyphoid fever | 16 (64%) | 0.64 | ||
Giardiasis or cryptosporidiosis | 17 (68%) | a) 1(2019) | 0.34 | |
Cholera | 16 (64%) | 0.64 | ||
Kidney disease | 19 (76%) | 0.76 | ||
Hepatitis, infectious | 16 (68%) | c) 1(2021) | 0.34 | |
Gastroenteritis | 17 (68%) | (c) 7(2019), 10(2020) and 2(2021) *2 | 0.34 | |
Leptospirosis | 19 (76%) | 0.38 | ||
Hypertension | 10 (40%) | 0.4 | ||
Dental caries | 9 (36%) | 0.36 | ||
Gingivitis | 11 (44%) | 0.44 | ||
Average disease diagnosis | 0.47 | |||
Average overall score | 0.43 |
Indicator | Participant Statements Collected from the School Community. Where: No (%) | Score (0 to 1) |
---|---|---|
School dropout (n = 4) | 4 (100%) no school dropout due to drought | 0 *1 |
Absenteeism from work and school (n = 6) (n = 19) | 2 (33%) no work missed due to drought. 12 (57%) no student absenteeism | 0.45 |
Depression (n = 25) | 11 (44%) no cases of depression | 0.44 |
Children’s learning (n = 25) | 5 (22%) no change in learning ability | 0.22 |
Children’s concentration (n = 4) | 1 (25%) students were not affected during drought | 0.25 |
Behavioural changes (n = 25) | 10 (40%) no behavioural changes during drought | 0.40 |
Average overall score | 0.29 |
Indicator | Participant Statements Collected from the School Community. Where: No (%) | Score (0 to 1) |
Daily amount of water intake (n = 25) | 6 (24%) 2 litres of water per day consumed as recommended by WHO | 0.24 |
Hygiene habits (brushing teeth, washing fruit and vegetables (n = 19) For 2 GSA only: wash eggs, wash hands, wear gloves and wear closed shoes when cleaning at school(n = 2) | 7 (38%) of students brush their teeth at school 12 (57%) wash fruit, vegetables and greens 2 (100%) GSA wash eggs 2 (100%) GSA wash their hands frequently 2 (100%) GSA wear gloves, 2 (100%) GSA wear closed shoes when cleaning and 2 (100%) GSA wear a cap to cover their hair when working in the kitchen | 0.85 *1 |
Use of personal protective equipment (use of gloves and wearing closed shoes) (n = 2) | 2 (100%) use gloves when cleaning and wear closed shoes during cleaning | 1 |
Rational use of water awareness (n = 25) (n = 19) | 22 (88%) ration their water use/turn off taps during and after use. 13 (69%) students use water when brushing their teeth or rinsing afterwards. | 0.785 *2 |
Raising awareness of the importance of water (n = 2) | 2 (100%) GSA showed the importance of water treatment as only clean or filtered water is good for drinking, cooking and brushing teeth. | 1 *3 |
Awareness-raising of water (importance of water, know that only clean is to be used, educational events, talking about water in the classroom, knowledge about waterborne disease) | 2 (100%) demonstrated care with water, promptly solving leaks and 2 (100%) know that only clean water is to be used in cooking, drinking and brushing teeth (n = 2) 7 (28%) said that there are educational events in the school (n = 25) 19 (83%) said that teachers talk about water in class (n = 25) 16 (76%) have heard about water borne diseases due to talks in school, on the radio or television (n = 25) | 0.88 *4 |
Average overall score | 0.83 |
Dimension | Weighting | Initial Score | Final Score |
---|---|---|---|
Socio-Cultural | 1 | 0.73 | 0.73 |
Mental well-being | 3 | 0.29 | 0.87 |
Environmental | 2 | 0.38 | 0.96 |
Sanitary | 3 | 0.39 | 1.17 |
Epidemiological | 3 | 0.43 | 1.29 |
Technological | 3 | 0.64 | 1.92 |
Weighted average | 6.94/15 = 0.46 |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Kligerman, D.C.; Cardoso, T.A.d.O.; Cohen, S.C.; Azevedo, D.C.B.d.; Toledo, G.d.A.; Azevedo, A.P.C.B.d.; Charlesworth, S.M. Methodology for a Comprehensive Health Impact Assessment in Water Supply and Sanitation Programmes for Brazil. Int. J. Environ. Res. Public Health 2022, 19, 12776. https://doi.org/10.3390/ijerph191912776
Kligerman DC, Cardoso TAdO, Cohen SC, Azevedo DCBd, Toledo GdA, Azevedo APCBd, Charlesworth SM. Methodology for a Comprehensive Health Impact Assessment in Water Supply and Sanitation Programmes for Brazil. International Journal of Environmental Research and Public Health. 2022; 19(19):12776. https://doi.org/10.3390/ijerph191912776
Chicago/Turabian StyleKligerman, Débora Cynamon, Telma Abdalla de Oliveira Cardoso, Simone Cynamon Cohen, Déborah Chein Bueno de Azevedo, Graziella de Araújo Toledo, Ana Paula Chein Bueno de Azevedo, and Susanne M. Charlesworth. 2022. "Methodology for a Comprehensive Health Impact Assessment in Water Supply and Sanitation Programmes for Brazil" International Journal of Environmental Research and Public Health 19, no. 19: 12776. https://doi.org/10.3390/ijerph191912776