Proposition and application of an environmental salubrity index in rural agglomerations

Braga, Débora de Lima; Bezerra, Nolan Ribeiro; Scalize, Paulo Sérgio

doi:10.11606/s1518-8787.2022056003548

ABSTRACT

OBJECTIVE

Propose an Índice de salubridade ambiental (ISA_Rural – environmental salubrity index) that expresses the conditions experienced in rural agglomerations, including indicators and subindicators for its subsequent application in rural communities in the state of Goiás.

METHODS

We developed the research in three phases: 1) previous analysis for the proposition of an ISA_Rural, with the participation of seven specialists; 2) proposition of the ISA_Rural by means of the Delphi method, starting with 168 specialists from 26 federative units of Brazil and Distrito Federal; and 3) application of the ISA_Rural in 43 rural communities in the state of Goiás.

RESULTS

The proposed ISA_Rural resulted in the composition of eight indicators, four of which related to basic sanitation, and the others to health, socioeconomic conditions, public services offered, and housing conditions. The weight assigned to each indicator ranged from 22.82% for the water supply indicator to 6.35% for the service indicator, it is possible to apply the ISA_Rural fully or to evaluate each indicator individually. The application of ISA_Rural in communities of Goiás classified 86% of them with low salubrity, highlighting the worst conditions for quilombola communities. The sanitary sewage had the lowest score among the ISA_Rural indicators, requiring greater attention from public authorities.

CONCLUSIONS

This study contributed to the proposition of an index in line with the concept of environmental salubrity, useful in the scope of public policies as a conditioner for the prioritization of actions needed to improve the salubrity conditions identified. The proposed ISA_Rural can be fully applied or used in the individual evaluation of each indicator of its composition. The results of its application made it possible to identify the communities with the worst environmental salubrity conditions and the indicators that require greater priority attention in the communities studied.

Indicators (Statistics; Environmental Salubrity; Rural Areas; Social Planning; Environment and Public Health

INTRODUCTION

Health is the result of living conditions of a population, expressing the social and economic organization of the country, having as determinants and conditioning factors: food, housing, basic sanitation, environment, work, income, education, physical activity, transportation, leisure and access to essential goods and services, among others¹1. Brasil. Lei Nº 12.864, de 24 de setembro de 2013. Altera o caput do art. 3º da Lei n. 8.080, de 19 de setembro de 1990, incluindo a atividade física como fator determinante e condicionante da saúde. Brasília, DF; 2013. .

Thus, these basic individual and collective needs promote the environmental salubrity of a population. Internationally, there is no direct concept of environmental salubrity, since the terminology is presented by the expression environmental health, and, in Brazil, differs from the concept of salubridade ambiental (environmental salubrity). In general, papers use the terms health, hygiene and cleaning to address the salubrious issue. In Brazil, environmental salubrity was initially defined by State Law no. 750, of March 31, 1992, in Article 2, Section II, “as the environmental quality capable of preventing the occurrence of diseases transmitted by the environment and of promoting the improvement of mesological conditions favorable to the health of the urban and rural population”²2. São Paulo (Estado). Lei Nº 7.750, de 31 de março de 1992. Dispõe sobre a Política Estadual de Saneamento e dá outras providências. Diário Oficial Estado de São Paulo.1 abr 1992; Executivo:1 . This concept has been undergoing changes, as presented in several publications³3. Dias MC, Borja PC, Moraes LRS. Índice de Salubridade Ambiental em áreas de ocupação espontâneas: um estudo em Salvador - Bahia. Eng Sanit Ambient. 2004;9(1):82-92. .

The study of the environmental salubrity of a place is important to measure the health situation that a certain population enjoys as a result of their living conditions. Therefore, it is possible to measure a healthy environment by determining the health status of a population, influenced by socioeconomic conditions, education, basic sanitation, and the environments in which they circulate daily.

In this context, to determine environmental salubrity, the Conselho Estadual de Saneamento (Conesan – State Sanitation Council)⁶6. Conselho Estadual de Saneamento. ISA - Indicador de Salubridade Ambiental: manual básico. São Paulo: Conesan; 1999. proposed the indicador de salubridade ambiental (ISA – Environmental Salubrity Indicator), from which its original composition has been adapted, with the inclusion and exclusion of indicators and/or subindicators and the alteration of their weights. Many times this occurs arbitrarily or through the replication of existing studies, considering, or not, the peculiarities of the analyzed region⁷7. Lima ASC, Arruda PN, Scalize OS. Indicador de salubridade ambiental em 21 municípios do estado de Goiás com serviços públicos de saneamento básico operados pelas prefeituras. Eng Sanit Ambient. 2019;24(3):439-52. https://doi.org/10.1590/S1413-41522019188336
https://doi.org/10.1590/S1413-4152201918... . It is important to select carefully the indicators to compose the ISA, interrelating its problem and objective of analysis. Few studies have used the literature review¹⁰10. Pedrosa RN, Miranda LIB, Ribeiro MMR. Avaliação pós-ocupação sob o aspecto do saneamento ambiental em área de interesse social urbanizada no município de Campina Grande, Paraíba. Eng Sanit Ambient. 2016;21(3):535-46. https://doi.org/10.1590/S1413-41522016146176
https://doi.org/10.1590/S1413-4152201614... and employed the Delphi method¹¹11. Costa RVF. Desenvolvimento do Índice de Salubridade Ambiental (ISA) para comunidades rurais e sua aplicação e análise nas comunidades de Ouro Branco – MG [dissertação]. Ouro Preto, MG: Universidade Federal de Ouro Preto; 2010 , ¹²12. Teixeira DA, Prado Filho JF, Santiago AF. Construção da equação do Indicador de Salubridade Ambiental (ISA/OP) da cidade de Ouro Preto (MG) para o gerenciamento do saneamento municipal urbano. Rev Nac Gerenc Cidades. 2020;8(60):1-23. https://doi.org/10.17271/2318847286020202403
https://doi.org/10.17271/231884728602020... to propose an index.

Despite the good acceptability of ISA, little research exists on environmental salubrity in rural areas. Of 76 studies on the ISA⁹9. Braga DL. Construção e aplicação de índice de salubridade ambiental em aglomerados rurais [dissertação]. Goiânia, GO: Universidade Federal de Goiás; 2021. , only seven were applied to rural areas, where only one study adapted the ISA, considering the conceptual relations of sanitation and health. However, the object of study in that case was the rural households, not the rural agglomeration¹³13. Bernardes C, Bernardes RS, Gunther WMR. Proposta de índice de salubridade ambiental domiciliar para comunidades rurais: aspectos conceituais e metodológicos. Eng Sanit Ambient. 2018;23(4):697-706. https://doi.org/10.1590/S1413-41522018141631
https://doi.org/10.1590/S1413-4152201814... .

Thus, the objective of this work was to propose an index to determine environmental salubrity in rural agglomerations (ISA_Rural) and apply it to rural communities in the state of Goiás.

METHODS

We carried out the research methodology in three phases, preceded by a literature review using the following databases: Scientific Electronic Library Online (SciELO); Periódicos Capes; Web of Science, and other online search tools. For this, we used the keywords in English and Portuguese: “indicator”; “index”; “salubrity”; “environmental health”; “environmental”; “health”; “ indicador ”; “ índice ”; “ salubridade ”; “ salubridade ambiental ”; “ saúde ambiental ”; “ indicador de salubridade ” and “ISA”. The material found provided subsidies for the elaboration of the forms used in the first and second phases.

Phase One: Preliminary Analysis to Propose an ISARural

We carried out this phase in order to define the methodology to apply for the proposition of an ISA_Rural. For this, we selected specialists based on their area of expertise, related to ISA and to environmental indicators or environmental health, in addition to their availability to contribute to the project. Therefore, we chose seven experts who could participate in the activities and be present at a face-to-face activity. In order to guide and bring subsidies for the discussions, we prepared and applied a semi-structured interview form containing: the program, the purpose of ISA, concepts of environmental salubrity, the Basic Manual of ISA⁶6. Conselho Estadual de Saneamento. ISA - Indicador de Salubridade Ambiental: manual básico. São Paulo: Conesan; 1999. , and six guiding questions (in a complementary file)^aaSupplementary material available from: https://files.cercomp.ufg.br/weby/up/780/o/Arquivo_complementar_proposicao_e_aplicacao_ISA_Rural.pdf . After planning the answers, we had a meeting, in Goiânia, on March 20, 2019, when we discussed the topic, culminating with the indication of a method to apply in the proposition of an ISA_Rural, besides the initial indicators useful for its composition and the definition of consultation with experts per domain area.

Phase Two: ISARural Proposition

We built the ISA proposition using the Delphi method, useful to structure the communication process of a group in such a way that it can, in an integrated way, deal with complex problems¹⁴14. Linstone HA, Turoff M, editors. The Delphi method: techniques and applications. Newark, NJ: University Heights, New Jersey Institute of Technology; 2002. . We built it in the following sequence:

Selection of Experts

Group 1: made up of 168 specialists from all the Federal Units (UF) of Brazil, the Distrito Federal, and representatives of the rural communities, with their areas of expertise related to the research, who guided the choice and evaluation of the indicators for the ISA_Rural.
Group 2: made up of 66 members formed from the members of Group 1 who agreed to participate in the research; and two more researchers from the environmental health area. We subdivided them by areas of activity (water supply; sewage; solid waste; rainwater; environmental health; management; and community) and used them for the choice and evaluation of the subindicators.

a) 1st step: Indicator Selection
- 1st round: choice of indicators pre-selected by the experts in the face-to-face discussion, as well as the suggestion of new indicators and subindicators for each proposed indicator. We used a form with the contextualization steps to choose the indicators and suggest subindicators.
- 2nd round: reevaluation of the answers in light of the answers of the other experts and inclusion, or exclusion, of the indicators suggested in the 1st round. Suggestion and evaluation of new indicators by means of a form containing the results of the 1st round.
b) 2nd step: Evaluation of indicators
- ISA_Rural formulation: presentation of the chosen indicators and weighting of the ISA_Rural indicators by applying a form containing the results of the 1st and 2nd rounds.
c) 3rd step: Selection and evaluation of subindicators
- 1st round: aimed at choosing and weighting of the subindicators and suggesting new ones. It counted on the application of forms with the results of the first round of choice of indicators sent to each subgroup of experts related to their area of work, by means of which occurred the presentation and analysis of the suggested subindicators. Then, we selected and evaluated the subindicators for each ISA_Rural.
- 2nd round: reevaluation of the responses of the other experts. By applying a form containing the results of the first round of analysis, we selected and evaluated the subindicators of each ISA_Rural^bbOnly the form referring to the IHealthsubindicators obtained one more stage for presentation and analysis of the changes suggested by the experts. .

The Research Ethics Committee of the Universidade Federal de Goiás (UFG) approved the project, with consultation with experts, under protocol no. 3.893.454/2020.

Phase Three: Applying ISARural

The third and last phase consisted in applying the ISA_Rural and in measuring and analyzing the environmental salubrity in 43 rural and traditional communities in the state of Goiás, being 16 agglomerations, 21 quilombolas , and six riverside communities ( Table 3 ). The data for the calculation of the ISA came from the project sanitation and environmental health in rural and traditional communities of Goiás (SanRural), developed by UFG and financed by the National Health Foundation (Funasa), of which the authors are part. We collected the data locally, including water analysis, blood and stool tests, application of forms and checklists to survey the conditions of sanitation, health, housing, hygiene, soil use and occupation, collective infrastructure, and socioeconomic conditions. The Research Ethics Committee of the UF Goiás approved the project, under protocol no. 2.886.174/2018.

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Table 3
Decreasing position and values of the ISARural indicators of rural communities in the state of Goiás classified according to their salubrity.

We calculated all the indicators and subindicators that made up the ISA_Rural using Microsoft Excel software. We presented the results for each community studied, as well as from the worst to the best environmental salubrity condition among them, according to the following scoring ranges: insalubrious (between 0 and 25), low salubrity (from 26 to 50), medium salubrity (from 51 to 75) or salubrious (from 76 to 100)³3. Dias MC, Borja PC, Moraes LRS. Índice de Salubridade Ambiental em áreas de ocupação espontâneas: um estudo em Salvador - Bahia. Eng Sanit Ambient. 2004;9(1):82-92. .

RESULTS AND DISCUSSION

Preliminary Analysis for the Proposition of an ISARural

The meeting in person started with a discussion about the answers of 57.14% of the experts consulted in the first phase. Based on the existing concepts of environmental salubrity and having as main reference the concept currently used by Funasa⁵5. Ministério da Saúde (BR), Fundação Nacional de Saúde. Manual de saneamento. 5. ed. Brasília, DF: Funasa. 2019. , we discussed and proposed, together with the specialists who contributed to the study, that “environmental salubrity consists of the health situation that a certain population enjoys as a result of the socioeconomic and environmental conditions in which they live”. We used this as a reference for the determination of indicators and subindicators and their weightings.

Due to the diversity of the rural environment, we defined the ISA_Rural proposition to be for rural agglomerations, and not for all rural areas. The Brazilian Institute of Geography and Statistics (IBGE) defines rural agglomerations as residential units with adjacent buildings, that is, 50 meters or less in distance from each other and with characteristics of permanence¹⁵15. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2020: manual do recenseador – Parte 1. CD-1.09. Rio de Janeiro: IBGE; 2019. . In this sense, ISA_Rural can be applied to census sectors:1b, 2 and 4 (agglomerations close to urban areas); 3 (more densely populated isolated agglomerations), 5, 6 and 7 (less densely populated isolated agglomerations), defined in the programa nacional de saneamento rural (PNSR – national rural sanitation program)¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. , one of the three programs of the Plano Nacional de Saneamento Básico (Plansab – National Basic Sanitation Plan)¹⁷17. Brasil. Ministério de Desenvolvimento Regional. Secretaria Nacional de Saneamento. Plano Nacional de Saneamento Básico. Brasília; 2019. .

By consensus of the experts, we chose Delphi as the most appropriate method, developed in three stages: 1) choice and/or complementation of the indicators suggested in the meeting; 2) evaluation of the indicators, and 3) choice and evaluation of the subindicators. Initially, we suggested seven indicators for the consultation with experts: indicador de abastecimento de água (I_AB – water supply indicator); indicador de esgotamento sanitário (I_ES – sewage indicator); indicador de resíduos sólidos (I_RS – solid waste indicator); indicador de drenagem (I_DR – drainage indicator); health indicator (I_Health); indicador socioeconômico (I_SE – socioeconomic indicator); and service indicator (I_Services). Finally, we defined that the specialists should be selected and divided by areas of expertise, composing seven groups, four related to basic sanitation, one to environmental health, and two others to environmental management and rural communities. The last two groups have the function of allowing the analysis of the composition of the indicators and revealing, by the representatives of the communities, the particularities and limitations of the rural areas. Thus, the previous analysis phase fulfilled the task of defining the methodology for the ISA_Rural proposition.

ISARural Proposition

After the consensus obtained in the previous phase, we began proposing the ISA_Rural using the Delphi method, divided in three stages as described in Table 1 . It presents the number of invited specialists, the frequency and time of feedback, as well as the UF and the Distrito Federal without feedback, representing, at the end of the ISA_Rural composition, 70.4% of participation, which, given the geographical dimensions of the country, was considered excellent.

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Table 1
Stages of the Delphi method application, with the number of invited experts, feedback frequency, period, and Brazilian federative units without feedback of experts.

The frequency of agreement of the seven indicators, defined in the previous analysis and suggested in the 1st and 2nd rounds of selection of ISA_Rural indicators ( Table 1 ), is presented in Figure 1 , together with the frequency of suggestion of three new indicators suggested in the 1st round and the percentage of agreement of their inclusion. In the 1st round, the indicators I_AB, I_ES, I_RS and I_Health obtained 100% frequency of agreement, with only a few exceptions of partial agreement, such as the inclusion of the word “management” in the I_RS, changing to indicador de manejo de resíduos sólidos (I_MRS – solid waste management indicator). Most experts agreed, totally or partially, with the I_DR (89.06%), I_SE (98.44%) and I_Services (79.69%).

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Figure 1
Frequency of agreement on the permanence and inclusion of indicators in the ISARural composition obtained in the first and second rounds of the first stage of the Delphi method.

Regarding the I_DR, the specialists who did not agree with its inclusion (10.94%) justified that its relevance is only for urban areas, because, for rural areas, drainage is a natural process, and that Federal Law no. 11.455/2007¹⁸18. Brasil. Lei Nº 11.445, de 5 de janeiro de 2007. Estabelece as diretrizes nacionais para o saneamento básico; cria o Comitê Interministerial de Saneamento Básico; altera as Leis nos 6.766, de 19 de dezembro de 1979, 8.666, de 21 de junho de 1993, e 8.987, de 13 de fevereiro de 1995; e revoga a Lei nº 6.528, de 11 de maio de 1978. Diário Oficial da União. 5 jan 2007. only contemplates urban areas. However, we considered rainwater management in the PNSR¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. indicators. For this indicator, the suggestion is to include the word “management”, with reference to the rural sanitation components of the PNSR, changing it to indicador de manejo de águas pluviais (I_MAP – rainwater management indicator) in place of the I_DR. Regarding the I_SE, only one expert did not agree with its inclusion, but did not provide any justification. For I_Services, the reasons for not agreeing were that it is a very broad indicator, it is difficult to obtain data, and it is included in the previous indicators. In this round, we observed the suggestion of 21 more indicators different from the initial seven, and we considered relevant the one suggested by two or more experts, resulting in three indicators: 1) indicador de condições de moradia (I_CM – housing conditions indicator); 2) indicador de energia elétrica (I_EL – electric power indicator); and 3) indicador de controle de vetores (I_CV – vector control indicator) ( Figure 1 ).

Also during the 1st round, we separated the subindicators suggested by the specialists into groups that encompassed the same theme. We used those with higher frequency in the proposition of subindicators in the 3rd stage of the Delphi method application.

In the 2nd round, we presented all the questions and observations to the experts, with the option of performing a new analysis on the ISA_Rural composition. Among the ten suggested indicators, eight presented a frequency greater than 70% of agreement (total and partial), which we maintained and considered for the weighting of the formula. We considered that the other indicators contemplated I_EL and I_CV, and we removed them from the index. Eight indicators defined the ISA_Rural, four related to basic sanitation components, one to health, one to socioeconomic conditions, one to services offered in rural agglomerations, and one to housing conditions. Thus, the following indicators remained: I_AB; I_ES; I_MRS; I_MAP; I_Health; I_SE; I_Services; and I_CM. The sanitation and health indicators accounted for 75.81% of the weight of the ISA_Rural.

In the next round, relative to the 2nd stage of the Delphi method application, the experts considered the weights for each one of the indicators, resulting in the following average values and standard deviations for each indicator: I_AB = 22.82 ± 7.45; I_ES = 19.44 ± 5.29; I_MRS = 13.16 ± 4.01; I_MAP = 7.82 ± 3.39; I_Health = 12.55 ± 4.85; I_SE = 8.70 ± 3.92; I_Services = 6.35 ± 2.94 and I_CM = 9.16 ± 4.62. ISA_Rural resulted from the average value of the weights assigned by the experts for each indicator, resulting in Equation 1,

ISARural=0.2282IAB+0.1944IES+0.1316IMRS+0.0782IMAP+0.1255IHealth+0.0870ISE+0.0635IServices+0.0916ICM(1)

Legend: water supply indicator = I_AB; sewage indicator = I_ES; solid waste management indicator = I_MRS; rainwater management indicator = I_MAP; health indicator = I_HEALTH; socioeconomic indicator = I_SE; service indicator = I_Services; and housing conditions indicator = I_CM.

For the 1st round of the 3rd stage of the Delphi method application, and based on the groups of subindicators that obtained the highest percentage of suggestion in the 1st round of the 1st stage, we consulted the specific technical-scientific bibliography, considering the concept of environmental salubrity, used to formulated a list of subindicators sent for consultation to the specialists. Figure 2 shows the frequency of agreement of the inclusion of subindicators in the formulas and the scores.

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Figure 2
Agreement frequency on the inclusion of the subindicator for each indicator, as well as the suggested formulas and scores in the first round

The subindicators of I_AB, I_MRS, I_SE and I_CM obtained 100% frequency of agreement for inclusion, with some reservations of adjustments in the descriptions of the formulas and weightings.

In the I_ES subindicators, only two experts (7.1%) did not agree with the inclusion, justifying that it would not be necessary to separate sanitary sewage into excreta and wastewater. However, studies applied in rural areas¹³13. Bernardes C, Bernardes RS, Gunther WMR. Proposta de índice de salubridade ambiental domiciliar para comunidades rurais: aspectos conceituais e metodológicos. Eng Sanit Ambient. 2018;23(4):697-706. https://doi.org/10.1590/S1413-41522018141631
https://doi.org/10.1590/S1413-4152201814... considered this separation relevant. Therefore, we kept these subindicators for the next round, with only minor changes in the formulas and scores, according to the suggestions.

Regarding I_MAP, half of the subindicators (I_APV, I_IA and I_E) obtained 100% agreement, and the other half obtained 87.5% frequency of agreement for I_UV, 91.7% for I_CES and 95.8% for I_US. The justification was the irrelevance of these indicators, also influencing the answers obtained in the formulas and scores.

As for I_Services, only the subindicators I_EE and I_TP did not obtain inclusion agreement in 100%, with 88.9%. In the descriptions of the formulas, the disagreement (11.1%) occurred in the I_E, I_S, I_EE, and I_TP subindicators, among which the suggestion was that the criterion of service attendance was included in the I_E and I_S subindicators.

The subindicators of I_Health, despite having an inclusion concordance of more than 80%, presented several considerations in the formula descriptions. One of them was the modification of the sampling form, from household to inhabitants, obtaining the occurrence of the disease. Because it changes the whole calculation form, we presented the changes suggested for evaluation in the 2nd round of the 3rd stage to the experts. For the other indicators, we present only the subindicator weighting option.

In the last round, we weighted all the subindicators with the average of the assigned weights and also obtained the frequency of agreement of the changes in the formulas of the I_Health subindicators. Only one expert disagreed with the home water treatment subindicator (I_PTA); the others fully agreed. Table 2 shows the final formulas for the indicators and their respective subindicators and scores.

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Table 2
Formulas for calculating indicators IAB, IES, IMRS, IMAP, IHealth, ISE, IServices and ICM, that make up the ISARural and its subindicators, with description and scoring.

When comparing ISA_Rural’s final proposition with studies found in the specific bibliography, we found that none of them contemplates, in an integral way, all the indicators. The separation of the specialists by area of expertise brought the formulation of essential subindicators with specificities, requiring easily obtainable data for calculation. Public authorities require some of them by means of PNSR¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. , and it is possible to obtain the others using questionnaires applied and used by the community health agents, improving them, as suggested in Bernardes, Bernardes and Gunther¹³13. Bernardes C, Bernardes RS, Gunther WMR. Proposta de índice de salubridade ambiental domiciliar para comunidades rurais: aspectos conceituais e metodológicos. Eng Sanit Ambient. 2018;23(4):697-706. https://doi.org/10.1590/S1413-41522018141631
https://doi.org/10.1590/S1413-4152201814... .

ISARural application

The application of the proposed ISA_Rural has found that only 14% of the communities are of medium salubrity, with the agglomerations occupying five of the top six places. In the remaining communities (86%), there is low salubrity ( Table 3 ), with 61.9% of the quilombola communities below average. Table 3 presents the decreasing position of the rural communities of Goiás, according to the results of the ISA_Rural and its indicators.

Analyzing the I_AB separately, only the community Povoado Veríssimo (77.23%) received the classification of salubrious, and 48.84% of the communities received the classification of medium salubrity. The others, 39.5%, presented low salubrity conditions and 9.3% insalubrity. In the PNSR¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. diagnostic, for the less densely populated isolated agglomerations, 46.3% of the inhabitants are adequately served in the water supply component, being close to the average value of 49.35 points ( Table 3 ) obtained for I_AB. The low salubrity occurred mainly due to the quality of the water supply, with the presence of E. coli in most of the water samples analyzed, resulting in disagreement with Annex XX of Consolidation Ordinance no. 5 of the Ministry of Health¹⁹19. Ministério da Saúde (BR). Portaria de Consolidação Nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de saúde do Sistema Único de Saúde. Brasília, DF; 2017. . The presence of E. coli in the water consumed by the population in rural communities has been reported in national and international scientific papers²⁰20. Scalize PS, Barros EFS, Soares LA, Hora KER, Ferreira NC, Baumann LRF. Avaliação da qualidade da água para abastecimento no assentamento de reforma agrária Canudos, Estado de Goiás. Rev Ambien Água. 2014;9(4):696-707. https://doi.org/10.4136/ambi-agua.1386
https://doi.org/10.4136/ambi-agua.1386... , ²¹21. Rowles LS III, Alcalde R, Bogolasky F, Kum S, Diaz-Arriaga FA, Ayres C et al. Perceived versus actual water quality: community studies in rural Oaxaca, Mexico. Sci Total Environ. 2018;622-623:626-34 https://doi.org/10.1016/j.scitotenv.2017.11.309
https://doi.org/10.1016/j.scitotenv.2017... , being something recurrent that requires attention from the public authorities. In most situations, disinfecting the water indoors with sodium hypochlorite solution would considerably decrease contamination²²22. Solomon ET, Robele S, Kloos H, Mengistie B. Effect of household water treatment with chlorine on diarrhea among children under the age of five years in rural areas of Dire Dawa, eastern Ethiopia: a cluster randomized controlled trial. Infect Dis Poverty. 2020;9(1):64. https://doi.org/10.1186/s40249-020-00680-9
https://doi.org/10.1186/s40249-020-00680... and consequently improve healthiness. Among the indicators that make up the ISA_Rural, the I_ES presented the worst results, present in 90.7% of the communities in unhealthy situations, requiring greater attention from the public authorities. This condition results from the use, in the vast majority of households, of a rudimentary cesspool as a solution for sanitary sewage. This result confirms the data presented in the PNSR, that only 15.2% of the inhabitants dispose of their effluents properly¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. , and the study by Roland et al.²³23. Roland N, Tribst CCL, Senna DA, Santos MRR, Rezende S. A ruralidade como condicionante da adoção de soluções de saneamento básico. Rev DAE. 2019;67(220):15-35. https://doi.org/10.4322/dae.2019.053
https://doi.org/10.4322/dae.2019.053... A study conducted in riverside communities in Amazônia concluded that one of the characteristics that most contribute to the situation of insalubrity and low salubrity is the precariousness of the houses in relation to the adequate disposal of excreta and grey waters¹³13. Bernardes C, Bernardes RS, Gunther WMR. Proposta de índice de salubridade ambiental domiciliar para comunidades rurais: aspectos conceituais e metodológicos. Eng Sanit Ambient. 2018;23(4):697-706. https://doi.org/10.1590/S1413-41522018141631
https://doi.org/10.1590/S1413-4152201814... . Only two communities (4.65%) received the classification of medium salubrity, and another two (4.65%) as low salubrity.

Another worrisome basic sanitation component is solid waste management, represented by I_MRS, present in only 6.98% of the communities served, in more than 80% of the households by direct or indirect solid waste collection. Although the great majority of the households in the communities separate their waste, they do not have adequate disposal, and burning is the main form of disposal, similar to the situation presented in the PNSR¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. diagnostic and other studies²⁴24. Fidelis-Medeiros FH, Lunardi VO, Lunardi DG. Proposta de gestão adequada de resíduos sólidos domiciliares em comunidades rurais utilizando análise espacial. Rev Bras Geogr Fis. 2020;13(2):527-43. https://doi.org/10.26848/rbgf.v13.2.p527-543
https://doi.org/10.26848/rbgf.v13.2.p527... . The article 47 of the National Solid Waste Policy²⁵25. Brasil. Lei Nº 12.305 de 2 de agosto de 2010. Institui a Política Nacional de Resíduos Sólidos; altera a Lei Nº. 9.605, de 12 de fevereiro de 1998, e dá outras providências. Diário Oficial da União. 3 ago 2010. p.2 forbid this practice. Depending on the composition of the waste, it can release toxic gases, and does not reduce all types of waste, contributing to the proliferation of diseases and influencing the quality of life of the population²³23. Roland N, Tribst CCL, Senna DA, Santos MRR, Rezende S. A ruralidade como condicionante da adoção de soluções de saneamento básico. Rev DAE. 2019;67(220):15-35. https://doi.org/10.4322/dae.2019.053
https://doi.org/10.4322/dae.2019.053... . In view of the above about the I_MRS, 53.49% of the communities fit as insalubrious, 39.53% with low salubrity and 6.98% medium salubrity.

In relation to the I_MAP, we classified only the riverside community Arraial da Ponte, representing 2.33% of the analyzed communities, as salubrious. The presence of pavement, curbs, and manholes (a device that allows rainwater drainage) characterized this condition, serving 50% of the community. We classified the others, 76.74% as medium salubrity, and 20.93% as low salubrity. Rainwater management is the only sanitation component for which it was not possible to diagnose the current situation in rural areas of Brazil by PNSR¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. , because IBGE²⁶26. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: IBGE; 2011. does not have enough data for such an analysis. For this reason, it is one of the biggest barriers to conducting studies on this component of basic sanitation, which stops the proper direction of public policies to solve problems related to infrastructure²³23. Roland N, Tribst CCL, Senna DA, Santos MRR, Rezende S. A ruralidade como condicionante da adoção de soluções de saneamento básico. Rev DAE. 2019;67(220):15-35. https://doi.org/10.4322/dae.2019.053
https://doi.org/10.4322/dae.2019.053... .

I_Health was the third indicator to present the best results in the survey. We verified the salubrious situation registered in 30.2% of the communities and medium salubrious in 69.8%. This is mainly because the inhabitants of the communities have not been diagnosed by a health professional with schistosomiasis and/or leptospirosis, with the exception of one inhabitant of the Julião Ribeiro community, and no deaths of children under one year of age have occurred in these communities. However, many residents of the communities tested positive for hepatitis A, corroborating another study on rural agglomerations in the southwest of Goiás in which 82.20% of the residents had antibodies to the virus²⁷27. Pinheiro RS, Araújo LA, Caetano KAA, Matos MA, Carneiro MAS, Teles SA. Intermediate endemicity of hepatitis A virus infection in rural settlement projects of southwest Goiás, Brazil. Arq Gastroenterol. 2015;52(3):200-3. https://doi.org/10.1590Caracterização/S0004-28032015000300009
https://doi.org/10.1590Caracterização/S0... , the main factor in the decrease in salubrity in this indicator.

The I_SE was the second indicator to present the worst salubrity results. Thus, 48.84% of the communities presented an insalubrity situation and 51.16% presented low salubrity due to the low education and monthly per capita income of the inhabitants. This consolidated the data presented in the PNSR¹⁶16. Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019. and the analyses that the lower the levels of education and income, the worse the solutions adopted in basic sanitation²⁸28. Sales BM. dos determinantes da exclusão sanitária nos domicílios rurais brasileiros [dissertação]. Belo Horizonte, MG: Universidade Federal de Minas Gerais; 2018. .

In general, I_Services showed the best results, with salubrity of 65.12% of the communities and 34.88% with medium salubrity. This is because 100% of the communities have basic education services, 69.77% have health services, and, in more than 90% of the households, 93% and 62.8% have access, respectively, to electricity and means of communication. The Programa Nacional de Universalização do Acesso e Uso da Energia Elétrica ²⁹29. Brasil. Decreto Nº 9.357. Altera o Decreto n. 7.520, de 8 de julho de 2011, que institui o Programa Nacional de Universalização do Acesso e Uso da Energia Elétrica. Diário Oficial da União. 30 abr 2018:1, col 2. (National Program for the Universalization of Access to and Use of Electric Energy), responsible for the evolution of the universalization of access to energy, with a deadline of 2022, was extended several times. Therefore, it produces, and certainly will produce, improvements in social and economic dynamics for the communities not yet fully served by this fundamental service³⁰30. Jeronymo ACJ, Guerra SMG. Caracterizando a evolução da eletrificação rural brasileira. Redes Santa Cruz do Sul. 2018;23(1):133-56. https://doi.org/10.17058/redes.v23i1.9816
https://doi.org/10.17058/redes.v23i1.981... .

Finally, the I_CM was the second indicator to show the best salubrity results, with 67.44% of the communities in a salubrious situation, 25.58% with medium salubrity, and 6.98% with low salubrity. In general, the communities have houses with adequate walls, floors and roofs, including the bathroom. However, their water reservoirs are in inadequate conditions, which may be one of the factors contributing to the low quality of the water and for being places of contamination³¹31. Cavalcante RBL. Ocorrência de Escherichia coli em fontes de água e pontos de consumo em uma comunidade rural. Rev Ambient Água. 2014;9(3):550-8. https://doi.org/10.4136/ambi-agua.1301
https://doi.org/10.4136/ambi-agua.1301... .

CONCLUSIONS

The proposed ISA_Rural is in line with the concept of environmental salubrity. It is useful in the context of public policies, as a conditioner for the prioritization of actions necessary to improve the salubrity conditions in rural agglomerations, aiming to contribute to the health level of their populations. In addition, it allows an evaluation of the evolution of the goals in the PNSR and the Municipal Sanitation Plan. It is possible to apply this index in its totality or in the evaluation of each indicator that composes it.

The results of the application of ISA_Rural in the communities studied in the state of Goiás indicate that the public authorities should devote priority attention to implement actions aimed at the universalization of sanitary sewerage, followed by the improvement of socioeconomic conditions, particularly in quilombola communities, which presented the worst environmental salubrity conditions among the communities studied.

REFERENCES

¹
Brasil. Lei Nº 12.864, de 24 de setembro de 2013. Altera o caput do art. 3º da Lei n. 8.080, de 19 de setembro de 1990, incluindo a atividade física como fator determinante e condicionante da saúde. Brasília, DF; 2013.
²
São Paulo (Estado). Lei Nº 7.750, de 31 de março de 1992. Dispõe sobre a Política Estadual de Saneamento e dá outras providências. Diário Oficial Estado de São Paulo.1 abr 1992; Executivo:1
³
Dias MC, Borja PC, Moraes LRS. Índice de Salubridade Ambiental em áreas de ocupação espontâneas: um estudo em Salvador - Bahia. Eng Sanit Ambient. 2004;9(1):82-92.
⁴
Batista MEM, Silva, TC. O modelo ISA/JP – indicador de performance para diagnóstico do saneamento ambiental urbano. Eng Sanit Ambient. 2006;11(1):55-64. https://doi.org/10.1590/S1413-41522006000100008
» https://doi.org/10.1590/S1413-41522006000100008
⁵
Ministério da Saúde (BR), Fundação Nacional de Saúde. Manual de saneamento. 5. ed. Brasília, DF: Funasa. 2019.
⁶
Conselho Estadual de Saneamento. ISA - Indicador de Salubridade Ambiental: manual básico. São Paulo: Conesan; 1999.
⁷
Lima ASC, Arruda PN, Scalize OS. Indicador de salubridade ambiental em 21 municípios do estado de Goiás com serviços públicos de saneamento básico operados pelas prefeituras. Eng Sanit Ambient. 2019;24(3):439-52. https://doi.org/10.1590/S1413-41522019188336
» https://doi.org/10.1590/S1413-41522019188336
⁸
Teixeira DA, Prado Filho JF, Santiago AF. Indicador de salubridade ambiental: variações da formulação e usos do indicador no Brasil. Eng Sanit Ambient. 2018;23(3):543-56. https://doi.org/10.1590/S1413-41522018170866
» https://doi.org/10.1590/S1413-41522018170866
⁹
Braga DL. Construção e aplicação de índice de salubridade ambiental em aglomerados rurais [dissertação]. Goiânia, GO: Universidade Federal de Goiás; 2021.
¹⁰
Pedrosa RN, Miranda LIB, Ribeiro MMR. Avaliação pós-ocupação sob o aspecto do saneamento ambiental em área de interesse social urbanizada no município de Campina Grande, Paraíba. Eng Sanit Ambient. 2016;21(3):535-46. https://doi.org/10.1590/S1413-41522016146176
» https://doi.org/10.1590/S1413-41522016146176
¹¹
Costa RVF. Desenvolvimento do Índice de Salubridade Ambiental (ISA) para comunidades rurais e sua aplicação e análise nas comunidades de Ouro Branco – MG [dissertação]. Ouro Preto, MG: Universidade Federal de Ouro Preto; 2010
¹²
Teixeira DA, Prado Filho JF, Santiago AF. Construção da equação do Indicador de Salubridade Ambiental (ISA/OP) da cidade de Ouro Preto (MG) para o gerenciamento do saneamento municipal urbano. Rev Nac Gerenc Cidades. 2020;8(60):1-23. https://doi.org/10.17271/2318847286020202403
» https://doi.org/10.17271/2318847286020202403
¹³
Bernardes C, Bernardes RS, Gunther WMR. Proposta de índice de salubridade ambiental domiciliar para comunidades rurais: aspectos conceituais e metodológicos. Eng Sanit Ambient. 2018;23(4):697-706. https://doi.org/10.1590/S1413-41522018141631
» https://doi.org/10.1590/S1413-41522018141631
¹⁴
Linstone HA, Turoff M, editors. The Delphi method: techniques and applications. Newark, NJ: University Heights, New Jersey Institute of Technology; 2002.
¹⁵
Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2020: manual do recenseador – Parte 1. CD-1.09. Rio de Janeiro: IBGE; 2019.
¹⁶
Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019.
¹⁷
Brasil. Ministério de Desenvolvimento Regional. Secretaria Nacional de Saneamento. Plano Nacional de Saneamento Básico. Brasília; 2019.
¹⁸
Brasil. Lei Nº 11.445, de 5 de janeiro de 2007. Estabelece as diretrizes nacionais para o saneamento básico; cria o Comitê Interministerial de Saneamento Básico; altera as Leis nos 6.766, de 19 de dezembro de 1979, 8.666, de 21 de junho de 1993, e 8.987, de 13 de fevereiro de 1995; e revoga a Lei nº 6.528, de 11 de maio de 1978. Diário Oficial da União. 5 jan 2007.
¹⁹
Ministério da Saúde (BR). Portaria de Consolidação Nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de saúde do Sistema Único de Saúde. Brasília, DF; 2017.
²⁰
Scalize PS, Barros EFS, Soares LA, Hora KER, Ferreira NC, Baumann LRF. Avaliação da qualidade da água para abastecimento no assentamento de reforma agrária Canudos, Estado de Goiás. Rev Ambien Água. 2014;9(4):696-707. https://doi.org/10.4136/ambi-agua.1386
» https://doi.org/10.4136/ambi-agua.1386
²¹
Rowles LS III, Alcalde R, Bogolasky F, Kum S, Diaz-Arriaga FA, Ayres C et al. Perceived versus actual water quality: community studies in rural Oaxaca, Mexico. Sci Total Environ. 2018;622-623:626-34 https://doi.org/10.1016/j.scitotenv.2017.11.309
» https://doi.org/10.1016/j.scitotenv.2017.11.309
²²
Solomon ET, Robele S, Kloos H, Mengistie B. Effect of household water treatment with chlorine on diarrhea among children under the age of five years in rural areas of Dire Dawa, eastern Ethiopia: a cluster randomized controlled trial. Infect Dis Poverty. 2020;9(1):64. https://doi.org/10.1186/s40249-020-00680-9
» https://doi.org/10.1186/s40249-020-00680-9
²³
Roland N, Tribst CCL, Senna DA, Santos MRR, Rezende S. A ruralidade como condicionante da adoção de soluções de saneamento básico. Rev DAE. 2019;67(220):15-35. https://doi.org/10.4322/dae.2019.053
» https://doi.org/10.4322/dae.2019.053
²⁴
Fidelis-Medeiros FH, Lunardi VO, Lunardi DG. Proposta de gestão adequada de resíduos sólidos domiciliares em comunidades rurais utilizando análise espacial. Rev Bras Geogr Fis. 2020;13(2):527-43. https://doi.org/10.26848/rbgf.v13.2.p527-543
» https://doi.org/10.26848/rbgf.v13.2.p527-543
²⁵
Brasil. Lei Nº 12.305 de 2 de agosto de 2010. Institui a Política Nacional de Resíduos Sólidos; altera a Lei Nº. 9.605, de 12 de fevereiro de 1998, e dá outras providências. Diário Oficial da União. 3 ago 2010. p.2
²⁶
Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: IBGE; 2011.
²⁷
Pinheiro RS, Araújo LA, Caetano KAA, Matos MA, Carneiro MAS, Teles SA. Intermediate endemicity of hepatitis A virus infection in rural settlement projects of southwest Goiás, Brazil. Arq Gastroenterol. 2015;52(3):200-3. https://doi.org/10.1590Caracterização/S0004-28032015000300009
» https://doi.org/10.1590Caracterização/S0004-28032015000300009
²⁸
Sales BM. dos determinantes da exclusão sanitária nos domicílios rurais brasileiros [dissertação]. Belo Horizonte, MG: Universidade Federal de Minas Gerais; 2018.
²⁹
Brasil. Decreto Nº 9.357. Altera o Decreto n. 7.520, de 8 de julho de 2011, que institui o Programa Nacional de Universalização do Acesso e Uso da Energia Elétrica. Diário Oficial da União. 30 abr 2018:1, col 2.
³⁰
Jeronymo ACJ, Guerra SMG. Caracterizando a evolução da eletrificação rural brasileira. Redes Santa Cruz do Sul. 2018;23(1):133-56. https://doi.org/10.17058/redes.v23i1.9816
» https://doi.org/10.17058/redes.v23i1.9816
³¹
Cavalcante RBL. Ocorrência de Escherichia coli em fontes de água e pontos de consumo em uma comunidade rural. Rev Ambient Água. 2014;9(3):550-8. https://doi.org/10.4136/ambi-agua.1301
» https://doi.org/10.4136/ambi-agua.1301

a
Supplementary material available from: https://files.cercomp.ufg.br/weby/up/780/o/Arquivo_complementar_proposicao_e_aplicacao_ISA_Rural.pdf
b
Only the form referring to the I_Healthsubindicators obtained one more stage for presentation and analysis of the changes suggested by the experts.

Funding:Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes - Brazil - Funding Code 001) and Fundação Nacional da Saúde (Funasa), via the project entitled Saneamento e Saúde Ambiental em Comunidades Rurais e Tradicionais de Goiás (SanRural – Sanitation and Environmental Health in Rural and Traditional Communities of Goiás) – Decentralized execution term – TED 05/2017.

Publication Dates

Publication in this collection
13 June 2022
Date of issue
2022

History

Received
30 Jan 2021
Accepted
21 June 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

[1] ¹
Brasil. Lei Nº 12.864, de 24 de setembro de 2013. Altera o caput do art. 3º da Lei n. 8.080, de 19 de setembro de 1990, incluindo a atividade física como fator determinante e condicionante da saúde. Brasília, DF; 2013.

[2] ²
São Paulo (Estado). Lei Nº 7.750, de 31 de março de 1992. Dispõe sobre a Política Estadual de Saneamento e dá outras providências. Diário Oficial Estado de São Paulo.1 abr 1992; Executivo:1

[3] ³
Dias MC, Borja PC, Moraes LRS. Índice de Salubridade Ambiental em áreas de ocupação espontâneas: um estudo em Salvador - Bahia. Eng Sanit Ambient. 2004;9(1):82-92.

[4] ⁴
Batista MEM, Silva, TC. O modelo ISA/JP – indicador de performance para diagnóstico do saneamento ambiental urbano. Eng Sanit Ambient. 2006;11(1):55-64. https://doi.org/10.1590/S1413-41522006000100008
» https://doi.org/10.1590/S1413-41522006000100008

[5] ⁵
Ministério da Saúde (BR), Fundação Nacional de Saúde. Manual de saneamento. 5. ed. Brasília, DF: Funasa. 2019.

[6] ⁶
Conselho Estadual de Saneamento. ISA - Indicador de Salubridade Ambiental: manual básico. São Paulo: Conesan; 1999.

[7] ⁷
Lima ASC, Arruda PN, Scalize OS. Indicador de salubridade ambiental em 21 municípios do estado de Goiás com serviços públicos de saneamento básico operados pelas prefeituras. Eng Sanit Ambient. 2019;24(3):439-52. https://doi.org/10.1590/S1413-41522019188336
» https://doi.org/10.1590/S1413-41522019188336

[8] ⁸
Teixeira DA, Prado Filho JF, Santiago AF. Indicador de salubridade ambiental: variações da formulação e usos do indicador no Brasil. Eng Sanit Ambient. 2018;23(3):543-56. https://doi.org/10.1590/S1413-41522018170866
» https://doi.org/10.1590/S1413-41522018170866

[9] ⁹
Braga DL. Construção e aplicação de índice de salubridade ambiental em aglomerados rurais [dissertação]. Goiânia, GO: Universidade Federal de Goiás; 2021.

[10] ¹⁰
Pedrosa RN, Miranda LIB, Ribeiro MMR. Avaliação pós-ocupação sob o aspecto do saneamento ambiental em área de interesse social urbanizada no município de Campina Grande, Paraíba. Eng Sanit Ambient. 2016;21(3):535-46. https://doi.org/10.1590/S1413-41522016146176
» https://doi.org/10.1590/S1413-41522016146176

[11] ¹¹
Costa RVF. Desenvolvimento do Índice de Salubridade Ambiental (ISA) para comunidades rurais e sua aplicação e análise nas comunidades de Ouro Branco – MG [dissertação]. Ouro Preto, MG: Universidade Federal de Ouro Preto; 2010

[12] ¹²
Teixeira DA, Prado Filho JF, Santiago AF. Construção da equação do Indicador de Salubridade Ambiental (ISA/OP) da cidade de Ouro Preto (MG) para o gerenciamento do saneamento municipal urbano. Rev Nac Gerenc Cidades. 2020;8(60):1-23. https://doi.org/10.17271/2318847286020202403
» https://doi.org/10.17271/2318847286020202403

[13] ¹³
Bernardes C, Bernardes RS, Gunther WMR. Proposta de índice de salubridade ambiental domiciliar para comunidades rurais: aspectos conceituais e metodológicos. Eng Sanit Ambient. 2018;23(4):697-706. https://doi.org/10.1590/S1413-41522018141631
» https://doi.org/10.1590/S1413-41522018141631

[14] ¹⁴
Linstone HA, Turoff M, editors. The Delphi method: techniques and applications. Newark, NJ: University Heights, New Jersey Institute of Technology; 2002.

[15] ¹⁵
Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2020: manual do recenseador – Parte 1. CD-1.09. Rio de Janeiro: IBGE; 2019.

[16] ¹⁶
Ministério da Saúde (BR), Fundação Nacional de Saúde. Programa Nacional de Saneamento Rural (PNSR). Brasília, DF: Funasa; 2019.

[17] ¹⁷
Brasil. Ministério de Desenvolvimento Regional. Secretaria Nacional de Saneamento. Plano Nacional de Saneamento Básico. Brasília; 2019.

[18] ¹⁸
Brasil. Lei Nº 11.445, de 5 de janeiro de 2007. Estabelece as diretrizes nacionais para o saneamento básico; cria o Comitê Interministerial de Saneamento Básico; altera as Leis nos 6.766, de 19 de dezembro de 1979, 8.666, de 21 de junho de 1993, e 8.987, de 13 de fevereiro de 1995; e revoga a Lei nº 6.528, de 11 de maio de 1978. Diário Oficial da União. 5 jan 2007.

[19] ¹⁹
Ministério da Saúde (BR). Portaria de Consolidação Nº 5, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de saúde do Sistema Único de Saúde. Brasília, DF; 2017.

[20] ²⁰
Scalize PS, Barros EFS, Soares LA, Hora KER, Ferreira NC, Baumann LRF. Avaliação da qualidade da água para abastecimento no assentamento de reforma agrária Canudos, Estado de Goiás. Rev Ambien Água. 2014;9(4):696-707. https://doi.org/10.4136/ambi-agua.1386
» https://doi.org/10.4136/ambi-agua.1386

[21] ²¹
Rowles LS III, Alcalde R, Bogolasky F, Kum S, Diaz-Arriaga FA, Ayres C et al. Perceived versus actual water quality: community studies in rural Oaxaca, Mexico. Sci Total Environ. 2018;622-623:626-34 https://doi.org/10.1016/j.scitotenv.2017.11.309
» https://doi.org/10.1016/j.scitotenv.2017.11.309

[22] ²²
Solomon ET, Robele S, Kloos H, Mengistie B. Effect of household water treatment with chlorine on diarrhea among children under the age of five years in rural areas of Dire Dawa, eastern Ethiopia: a cluster randomized controlled trial. Infect Dis Poverty. 2020;9(1):64. https://doi.org/10.1186/s40249-020-00680-9
» https://doi.org/10.1186/s40249-020-00680-9

[23] ²³
Roland N, Tribst CCL, Senna DA, Santos MRR, Rezende S. A ruralidade como condicionante da adoção de soluções de saneamento básico. Rev DAE. 2019;67(220):15-35. https://doi.org/10.4322/dae.2019.053
» https://doi.org/10.4322/dae.2019.053

[24] ²⁴
Fidelis-Medeiros FH, Lunardi VO, Lunardi DG. Proposta de gestão adequada de resíduos sólidos domiciliares em comunidades rurais utilizando análise espacial. Rev Bras Geogr Fis. 2020;13(2):527-43. https://doi.org/10.26848/rbgf.v13.2.p527-543
» https://doi.org/10.26848/rbgf.v13.2.p527-543

[25] ²⁵
Brasil. Lei Nº 12.305 de 2 de agosto de 2010. Institui a Política Nacional de Resíduos Sólidos; altera a Lei Nº. 9.605, de 12 de fevereiro de 1998, e dá outras providências. Diário Oficial da União. 3 ago 2010. p.2

[26] ²⁶
Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: IBGE; 2011.

[27] ²⁷
Pinheiro RS, Araújo LA, Caetano KAA, Matos MA, Carneiro MAS, Teles SA. Intermediate endemicity of hepatitis A virus infection in rural settlement projects of southwest Goiás, Brazil. Arq Gastroenterol. 2015;52(3):200-3. https://doi.org/10.1590Caracterização/S0004-28032015000300009
» https://doi.org/10.1590Caracterização/S0004-28032015000300009

[28] ²⁸
Sales BM. dos determinantes da exclusão sanitária nos domicílios rurais brasileiros [dissertação]. Belo Horizonte, MG: Universidade Federal de Minas Gerais; 2018.

[29] ²⁹
Brasil. Decreto Nº 9.357. Altera o Decreto n. 7.520, de 8 de julho de 2011, que institui o Programa Nacional de Universalização do Acesso e Uso da Energia Elétrica. Diário Oficial da União. 30 abr 2018:1, col 2.

[30] ³⁰
Jeronymo ACJ, Guerra SMG. Caracterizando a evolução da eletrificação rural brasileira. Redes Santa Cruz do Sul. 2018;23(1):133-56. https://doi.org/10.17058/redes.v23i1.9816
» https://doi.org/10.17058/redes.v23i1.9816

[31] ³¹
Cavalcante RBL. Ocorrência de Escherichia coli em fontes de água e pontos de consumo em uma comunidade rural. Rev Ambient Água. 2014;9(3):550-8. https://doi.org/10.4136/ambi-agua.1301
» https://doi.org/10.4136/ambi-agua.1301

Community name and typology	I_AB	I_ES	I_MRS	I_MAP	I_Health	I_SE	I_Services	I_CM	ISA_Rural
Julião Ribeiro^a	64.55	65.92	32.59	75.27	82.99	36.50	55.70	85.69	62.71
Povoado Veríssimo^c	77.23	5.26	65.18	48.30	74.88	50.37	98.48	80.51	58.41
Tarumã^a	70.22	55.93	22.09	59.93	70.02	29.73	71.36	80.85	57.81
Monte Moriá^a	60.67	48.09	19.70	52.97	71.47	37.70	56.66	75.68	52.72
Itajá II^a	57.45	25.12	32.70	58.60	79.48	34.60	71.09	82.89	51.97
João de Deus^a	75.10	0.00	33.07	60.07	78.97	27.13	84.72	83.54	51.49
Vazante^b	42.12	18.91	64.24	61.01	65.28	36.92	84.72	82.63	50.87
Mesquita^b	55.18	7.38	38.54	64.04	75.36	46.92	71.60	76.43	49.20
Extrema^b	70.01	2.65	34.91	44.34	71.23	30.25	83.89	79.86	48.77
Povoado Vermelho^b	64.88	19.52	18.72	62.36	69.14	22.96	80.83	73.92	48.52
Engenho da Pontinha^a	64.88	0.00	31.85	55.56	74.97	19.03	84.72	91.42	48.16
Lageado^a	64.88	4.23	24.16	48.51	67.98	23.96	100.00	79.97	46.89
Castelo, Retiro e Três Rios^b	53.69	3.63	23.41	60.28	79.37	28.38	97.62	80.03	46.71
Fio Velasco^c	46.84	37.64	46.24	28.72	64.30	14.34	56.66	74.44	46.08
Registro do Araguaia^c	49.49	6.57	42.09	57.32	65.25	26.13	84.72	82.87	46.03
Fortaleza^a	64.88	0.00	24.86	53.96	70.20	21.50	84.72	82.36	45.90
Santa Fé da Laguna^a	56.46	1.81	24.70	69.48	68.08	31.48	83.89	79.46	45.81
Arraial das Pontes^c	49.71	0.00	56.51	78.21	59.77	18.89	56.66	88.08	45.71
Forte^b	64.88	0.00	17.57	57.72	70.50	32.70	84.72	70.97	45.21
Fazenda Santo Antônio da Laguna^b	53.50	0.00	22.19	58.56	80.06	16.57	83.52	88.87	44.64
Queixo Dantas^b	61.88	0.00	19.70	60.28	72.53	13.45	84.72	80.79	44.48
Landi^c	69.28	0.00	19.70	48.66	70.08	23.65	56.66	84.80	44.42
Povoado Moinho^b	40.61	6.80	33.56	60.08	75.13	28.44	84.72	78.78	44.21
Sumidouro^b	51.93	2.44	30.84	57.55	75.37	26.74	56.66	84.75	44.03
Rochedo^a	37.26	0.00	29.98	57.87	77.70	34.77	100.00	80.19	43.44
Céu Azul^a	43.43	0.00	22.88	52.65	73.95	43.32	100.00	76.32	43.43
São Lourenço^a	44.71	0.00	27.66	57.48	78.33	21.05	99.24	75.32	43.20
Piracanjuba^a	42.12	0.00	37.52	47.25	76.01	31.73	84.72	79.33	43.19
Almeidas^b	58.01	0.00	31.05	51.99	64.06	18.02	84.72	71.90	42.96
São Sebastião da Garganta^a	42.04	0.00	29.62	64.73	66.55	33.46	84.72	80.81	42.60
Madre Cristina^a	51.30	3.97	28.05	50.46	68.45	27.76	74.17	65.89	41.87
Olhos d’água^c	49.14	0.00	19.70	50.74	79.33	4.92	84.72	84.33	41.26
Água Limpa^b	51.30	0.00	24.35	51.87	75.44	23.11	55.76	76.12	40.96
Rafael Machado^b	35.64	0.00	30.84	54.94	70.21	36.60	83.18	77.27	40.84
Taquarussu^b	37.68	0.00	19.70	54.06	77.48	31.75	81.09	60.42	38.59
São Domingos^b	49.99	3.53	19.15	60.26	76.53	18.08	64.13	39.13	38.16
Canabrava^b	24.69	0.00	19.70	55.39	80.48	25.45	83.21	78.95	37.39
Quilombo do Magalhães^b	36.10	0.00	16.89	59.75	73.29	6.27	53.80	84.33	36.02
José de Coleto^b	32.76	0.00	17.51	65.81	63.96	24.48	83.12	42.40	34.24
Arraial da Antas^a	34.80	0.00	24.16	52.76	69.20	6.27	100.00	37.27	34.24
Baco Pari^b	7.02	2.44	20.09	50.01	72.92	14.18	84.72	59.69	29.86
Porto Leucádio^b	8.42	0.00	19.70	56.96	74.59	20.52	56.66	67.14	29.86
Pelotas^b	5.52	0.00	19.70	63.58	83.84	14.68	56.66	51.69	28.96
Mean	49.35	7.49	28.78	56.75	72.90	25.92	78.46	75.30	44.23

Stages of the Delphi method		Number of invited experts	Feedback from the experts (%)	Period (days)	Participation of UF representatives (%)	UF without answer back
1ª	1st round for choosing and suggesting indicators and suggesting subindicators	168	38.1	52	85.2	MT, MS, PA and PE
1ª	2nd round for choosing the indicators	64	84.4	46	77.8	MT, MS, PA, PE, AM and RS
2ª	Weighting of indicators	54	87.0	37	70.4	MT, MS, PA, PE, AM, RS, ES and SE
3ª	1st round for analysis, choice and weighting of subindicators	66	60.6	60	74.1	MT, MS, PA, PE, AM, AL and ES
3ª	2nd round for analysis and weighting of subindicators	40	87.5	40	70.4	MT, MS, PA, PE, AM, AL, ES and RS

IAB=0.4212IAA+0.3512IQA+0.2277IFA
Subindicator	Formula	Score	Description
Adequate water supply at home (I_AA)	IAA=DraaDrt×100%	By formula	D_raa = number of households in the rural agglomeration supplied by a water distribution network, with indoor plumbing at the residence or on the property, or by a well, water source, or rainwater collection cistern, with indoor plumbing D_rt = number of households in the rural agglomeration
Water quality (I_QA)	IQA=NAANRA×100%	IQA=100%−Score=100IQA=95to100%−Score=80IQA=85to95%−Score=60IQA=70to85%−Score=40IQA=50to70%−Score=20IQA<50%−Score=0	N_AA = quantity of samples in accordance with acceptable water quality values for colimetry, chlorine and turbidity N_RA = number of samples performed
Frequency of water supply (I_FA)	IFA=DrfaDrt×100%	By formula	D_rfa = number of rural households that never or rarely lack water (1 time per month) D_rt = number of households in the rural agglomeration
IES=0.6349IDE+0.3651IDAS
Subindicator	Formula	Score	Description
Adequate disposal of excreta (I_DE)	IDE=DreDrt×100%	By formula	D_re = number of households in the rural agglomeration served by a collecting system followed by treatment, septic tank or sewage treatment technologies in the rural area for excreta D_rt = number of households in the rural agglomeration
Adequate disposal of wastewater (I_DAS)	IDAS=DrasDrt×100%	By formula	D_ras = number of households in the rural agglomeration served by a collecting system followed by treatment, septic tank or rural sewage treatment technologies for wastewater D_rt = number of households in the rural agglomeration
IMRS=0.2817ICRS+0.2985IDRS+0.1970ISRS+0.2228IDEA
Subindicator	Formula	Score	Description
Adequate collection of solid waste (I_CRS)	ICRS=DrcDrt×100%	By formula	D_rc = number of households in the rural agglomeration served by direct or indirect solid waste collection systems with a frequency of at least once a week D_rt = number of households in the rural agglomeration
Adequate disposal of solid waste (I_DRS)	IDRS=1−DrdDrt×100%	By formula	D_rd = number of households in the rural agglomeration that bury, burn or dispose openly solid waste D_rt = number of households in the rural agglomeration
Separation of solid waste (I_SRS)	ISRS=DrSDrt×100%	By formula	D_rs = number of households in the rural agglomeration that separate their solid waste D_rt = number of households in the rural agglomeration
Proper disposal of pesticide packaging (I_DEA)	IDEA=DreaDrta×100%	By formula	D_rea = number of households in the rural agglomeration that return their pesticide packages to the producer, the seller of the product, or to a voluntary delivery point D_rta = number of households in the rural agglomeration using pesticides
IMAP=0.1639IAPV+0.1308IUV+0.1580ICES+0.2133IIA+0.1721IE+0.1619IUS
Subindicator	Formula	Score	Description
Adequate rainwater management on roads (I_APV)	IAPV=DrvpDrt×100%	By formula	D_rvp = number of households in the rural agglomeration located on roads with pavement, curbs, and manholes D_rt = number of households in the rural agglomeration
Difficult or impossible to use access roads (I_UV)	IUV=DracDrt×100%	By formula	D_rac = number of households in the rural agglomeration that did not experience access difficulties to their homes in the last five years D_rt = number of households in the rural agglomeration
Control of surface runoff (I_CES)	ICES=DrceDrt×100%	By formula	D_rce = number of households in the rural agglomeration with excess runoff control devices, such as contour lines, channels or ditches, or others D_rt = number of households in the rural agglomeration
Occurrence of flooding and inundation (I_IA)	IIA=DriaDrt×100%	By formula	D_ria = number of households in the rural agglomeration without flooding in the last five years and inundation D_rt = number of households in the rural agglomeration
Erosions (I_E)	IE=DreDrt×100%	By formula	D_re = number of properties in the rural agglomeration that did not show erosion D_rt = number of households in the rural agglomeration
Soil use (I_US)	IUS=CuS×100%	By formula	Predominant soil use of rural agglomeration (C_us), criteria: native vegetation: 1; pasture: 0.5; agriculture: 0.25; exposed soil: 0
IHealth=0,1557IDD+0,1292IDH+0,1038IVD+0,1018IVE+0,0941IVL+0,1710IMI+0,1414IPTA+0,1030IPHM
Subindicator	Formula	Score	Description
Diarrhea occurrence (I_DD)	IDD=1−HrddHrt×100%	By formula	H_rdd = number of inhabitants living in the rural agglomeration with diarrhea in the last month. H_rt = number of inhabitants living in the rural agglomeration
Hepatitis A Occurrence (I_DH)	IDH=1−HrdhHrt×100%	By formula	H_rdh = number of inhabitants living in the rural agglomeration diagnosed with hepatitis A H_rt = number of inhabitants living in the rural agglomeration
Dengue (I_VD)	IVD=1−HrvdHrt×100%	By formula	H_rvd = number of residents in the rural agglomeration diagnosed with dengue, zika, chikungunya or yellow fever H_rt = number of inhabitants living in the rural agglomeration
Schistosomiasis (I_VE)	IVE=1−HrveHrt×100%	By formula	H_rve = Number of inhabitants living in the rural agglomeration diagnosed with schistosomiasis H_rt = number of inhabitants living in the rural agglomeration
Leptospirosis (I_VL)	IVL=1−HrvlHrt×100%	By formula	H_rvl = number of inhabitants living in the rural agglomeration diagnosed with leptospirosis H_rt = number of inhabitants living in the rural agglomeration
Infant Mortality (I_MI)	IMI=1−CrmiCrt×100%	By formula	C_rmi = number of children under 1 year old living in the rural agglomeration with death in the last year C_rt = total number of children under 1 year old residing in the rural agglomeration
Domestic water treatment (I_PTA)	IPTA=DrtaDrt×100%	By formula	D_rta = number of households in the rural agglomeration performing some treatment on their drinking water, such as filtration, boiling or disinfection D_rt = number of households in the rural agglomeration
Hand hygiene (I_PHM)	IPHM=HrmrHrt+HrmbHrt2×100%	By formula	H_rmr = number of residents in the rural agglomeration who always wash their hands with soap and water before meals H_rmb = number of inhabitants living in the rural agglomeration who always wash their hands with soap and water after using the toilet H_rt = number of inhabitants living in the rural agglomeration
ISE=0,4389IRF+0,2556IECF+0,3056IED
Subindicator	Formula	Score	Description
Per capita family income (I_RF)	IRF=DrrfDrt×100%	By formula	D_rrf = number of households in the rural agglomeration with monthly per capita family income greater than or equal to one minimum wage D_rt = number of households in the rural agglomeration
Education of the head of household (I_ECF)	IECF=DrecfDrt×100%	By formula	D_recf = number of households in the rural agglomeration whose head of household has at least completed elementary school D_rt = number of households in the rural agglomeration
Education (I_ED)	IED=Epa∗Fpj24	By formula	Schooling of the adult population (E_pa) = percentage of the rural agglomeration’s inhabitants aged 18 years or more with complete elementary education School attendance rate of the young population (F_pj): arithmetic mean (1) of the percentage of children between 5 and 6 years old attending school; (2) of the percentage of young people between 11 and 13 years old attending the final years of regular elementary school; (3) of the percentage of young people between 15 and 17 years old with complete elementary school, and (4) of the percentage of young people between 18 and 20 years old with complete high school
Iservices=0,2222IE+0,2806IS+0,2000IEE+0,1444IMC+0,1528ITP
Subindicator	Formula	Score	Description
Education (I_E)	IE=E×100%	By formula	Basic education in the rural agglomeration (E), criterion: rural agglomeration is served by basic education service (school in the rural agglomeration or availability of school transport to a basic education unit) = 1; rural agglomeration is not served by public education service = 0
Health (I_S)	IS=Sx100%	By formula	Health in the rural agglomeration (S), criterion: rural agglomeration is served by a health service (health center or community health workers) = 1; rural agglomeration is not served by a public health service = 0
Electric power (I_EE)	IEE=DreeDrt×100%	By formula	D_ree = number of households in the rural agglomeration with electric power. D_rt = number of households in the rural agglomeration
Means of communication (I_MC)	IMC=DrmcDrt×100%	By formula	D_rmc = number of rural agglomeration households with access to telephone, radio, television or internet D_rt = number of households in the rural agglomeration
Public Transportation (I_TP)	ITP=Tp×100%	By formula	Public transport in the rural agglomeration (T_p), criterion: rural agglomeration is served by public transport service = 1; rural agglomeration is not served by public transport service = 0
ICM=0,1430Imp+0,1505IPA+0,1555ICA+0,3125IB+0,2385IRA
Subindicator	Formula	Score	Description
Material used on the wall (I_MP)	IMP=DrmpDrt×100%	By formula	D_rmp = number of households in the rural agglomeration with masonry and plaster walls D_rt = number of households in the rural agglomeration
Adequate flooring (I_PA)	IPA=DrpaDrt×100%	By formula	D_rpa = number of households in the rural agglomeration with an impermeable floor or one that facilitates adequate cleaning D_rt = number of households in the rural agglomeration
Adequate Coverage (I_CA)	ICA=DrcaDrt×100%	By formula	D_rca = number of households in the rural agglomeration with tile roofing or other adequate rainwater insulation and thermal insulation D_rt = number of households in the rural agglomeration
Bathroom (I_B)	IB=DrbDrt×100%	By formula	D_rb = number of households in the rural agglomeration that have a bathroom with toilet and shower D_rt = number of households in the rural agglomeration
Adequate Internal Water Reservation (I_RA)	IRA=DrraDrt×100%	By formula	D_rra = number of households in the rural agglomeration with an internal water reservoir (water tank) that is capped and sanitized every six months mD_rt = number of households in the rural agglomeration with an internal reservoir

Saúde Pública

Saúde Pública

Proposition and application of an environmental salubrity index in rural agglomerations

ABSTRACT

OBJECTIVE

METHODS

RESULTS

CONCLUSIONS

INTRODUCTION

METHODS

Phase One: Preliminary Analysis to Propose an ISARural

Phase Two: ISARural Proposition

Selection of Experts

Phase Three: Applying ISARural

RESULTS AND DISCUSSION

Preliminary Analysis for the Proposition of an ISARural

ISARural Proposition

ISARural application

CONCLUSIONS

REFERENCES

Publication Dates

History