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Environmental risk: perception of nurses in the family health strategy in areas covered


Lívia Maria Vidal RomãoI; Evanira Rodrigues MaiaII; Grayce Alencar AlbuquerqueIII

INurse. Expert Degree in Assistance and Health Management in Family Health at  the Faculdade de Juazeiro do Norte, Crato, Ceará, Brazil. E-mail: liviamariavr@hotmail.com
IINurse. PhD in Nursing. Professor at the Medical Department at Universidade Federal do Ceará. Professorat the Nursing Department at the  Universidade Regional do Cariri. Crato, Ceará, Brazil. E-mail: evanira@bol.com.br
IIINurse. PhD in Health Sciences. Coordinator of the Graduate Program in Family Health Assistance and Managementand Professor of the Nursing School at the  Faculdade de Juazeiro do Norte. Ceará, Brazil. E-mail: geycy@oi.com.br

ABSTRACT: This research aimed at assessing nurses’ perceptions about environmental risks in areas covered by the family health strategy in a medium-sized municipality in the state of Ceará, Brazil. Research was conducted in Crato (CE), from January to March, 2011. We carried out a descriptive qualitative study with eight nurses. Data were collected through semi-structured interview, addressing the characterization of the target population, perceptions, and environmental health- related actions. Findings revealed that although those professionals are sensitive to environmental risk situations in their areas of coverage, andshow extensive insight into environmental health-related categories, concepts,and methods of intervention, they have faced particular difficulties in implementing coping measures. Actions on this issue were found to be limited. Attention from local managers across the theme and creation of environmental health indicators for primary care, with a view to monitoring are suggested.

Keywords: Environmental health; nursing; primary health care; risk.



The definition of health is primarily associated to one’s social environmental, family, and community contexts. That is a central perception to those acting in primary health care, for it presumes a more accurate understanding of the health-disease process, as well as the adoption of effective intervention in health advancement, prevention, and recovery on the basis of   identification and elimination of collective health risk factors.

Under this light, it is remarkable that Brazil has followed wealth-generating economic models favoring environmental degradation.  Environmental destruction by human action deriving from predatory exploitation of natural resources and generating pollution has an expressive effect upon health conditions and living standards. That setting brings forth a challenge to the health segment, which calls for reexamining environmental deterioration and ensuing effects on human health on both individual and collective fronts1.

Thus, a few strategies have been adopted worldwide by both the World Health Organization (WHO) and the Pan-American Health Organization (PAHO), for improvement of health conditions and living standards.  Along this line, Primary Health Care (PHC) and, more recently, Primary Environmental Care (PEC), stand out1,2.

Since the Alma-Ata Declaration, the concept of PHC entailed the formulation of official health policies in both developed and developing countries, in order to reach higher health levels by the year 2000.  However,the concept of Primary Environmental Attention - PEA, disseminated by PAHO/WHO since 1998, proves to be a strategy which acknowledges the citizen’s right to live in a healthy environment and to be informed of existing environmental risks. Within that scope, governments’ and citizens’ responsibilities and rights were also defined on the basis of environment and health so that higher living standards could be reached as a result of environmental protection and the strengthening of communities’ participationwithin the local sustainability sphere, especially by means of health advancement actions1.

Proposals for reorganization of the assistance model in Brazil require redirecting curative assistance to that in out-patient and home care, with focus on the individual, the family and the community, and on their insertion in the environment, in view of health advancement and community participation targets.

Therefore, health work process must be conducted on a basis where an interdisciplinary team and society make partners.  In Brazilthe Family Health Strategy (FHS) and the Community Health Agents Program (CHAP) stimulate bonds between the professionals in the area and the families involved. Further, they presume the development of a critical stand in the cross-sectional approach to local health problems3.

Despite the advances shown in the nineteen years after implementation, the FHS actions are still short of full incorporationof environmental concerns, especially if the groundsfor advancement of population’s health by means of the PEA principles are considered.

Despite a closer relation with families and territory where the FHS actions are effective, little is known about that professional’s expertise or about his/her action within the environmental health realm.

This research, therefore, aims at assessing the nursing professional’s perceptionof environmental risks within the area covered by the FHS, at a medium-sized municipality located in the backlands of the state of Ceará, Brazil. Effective contribution to the theme is expected out of this research, which addresses a relevant issue to the Single Health System (SHS)


To a better assessment of the environmental theme in the FHS, it is central to acknowledge the relevance of environmental risk concept, since it allows for an understanding of the problems affecting an area under the FHS influence which might jeopardize population’s health.

Risk assessment is based on the relation between reliability and criticism of complex systems, in which the dynamic behavior of countless variables must be identified against a selective set of indicators capable of monitoring interactions going on, in fact, at different time frames, that is, in the short, mid, and long term4.

In this light, environmental health in the FHS must be advanced by the team on an articulated, cross-sectional, and interdisciplinary basis, according to the environmental reality of social groups, so that humanized, democratic, and dynamic work is achieved to advance life quality5.

Among the health professionals integrating the FHS, the nurse stands out in face ofthe environmental issues affected by his/her actions within his/her area under FHS coverage. Close full-length health assistance to individuals’ and families’ in a broad range of community scenarios allows him/her to identify situations and users exposed to risks, so that planning, organization,andcoordinated actions can be assured6.

In addition, health professionals must develop skills to act with environmental responsibility in face of world crises. Assisting people, families, and communities with environmental issues involves revisiting concepts, methods, and practices, anchored in the debate on sustainable preservation of the planet, all of which in environmental and health interrelated aspects7.

That setting results from the fact that health and environmental issues intensify populations’ poverty and social vulnerability because communities experience low service coverage, feeble access to health, discontinuity, and low cross-sectional resolution8.


This piece of research had a descriptive nature and a qualitative approach to assess a set of specific meanings to meet interpretive and descriptive data concerns on the basis of subjects’ perceptions9.

The research was conducted with the FHS teams of Crato, Ceará, Brazil, from January to March, 2011. The municipality has twenty-seven FHS active teams, nine of which in rural areas and eighteen of which in urban areas. It is worth remarking that 27 nurses acted in those health units during data collection.

Participation was restricted to eight nurses on a random selection after inclusion criteria were applied: professional activity in FHS located in urban areas (resulting from higher environmental vulnerability faced by both the population and the professionals, on account of urbanization processes) and a minimum one-year on-going professional activity in the respective FHS(as this lapse is regarded as minimum time requirementto allow for better knowledge and stronger bondwith the population under the FHS area of coverage.).

Total number of respondents resulted from saturation criterion of the speeches collected in the interview upon application of semi-structuredquestionnaire with open and closed questionsrecorded in room conditions favorable to concentration and privacy of interviewees.

After listening and transcription, data were organized on the basis of contents analysis techniques. Material was explored by means of classification of speech extractsunder record units. Thus, considering research problems and objectives two categories were listed, according to similarities in the speeches obtained: Category 1 –nurses’ perceptions of environmental risks within their FHS area of coverage; and Category 2- actions taken by nurses in the realm of environmental health. It must be highlighted that subcategories were outstanding upon category analysis, generating further discussion.

Appropriate literature for establishing research grounds was used for data discussion. To ensure interviewees’ identification, nurses were identified by the letter E followed by the sequence number interviews were made (E1, E2, E3 etc.).

The research project was submitted to the Research Ethics Committee at the Universidade Regional do Cariri, under registration number CCAAE 5717.0.450.000-10, and received a favorable opinion registered under 43/2010.


The FHS are grounded on health advancement, prevention, and recovery. Core activities are thus community issues in health education,sanitation, contagious disease and vector control, interventions upon the environment – and more recently, prevention of risk factors, and health advancement2.

Therefore, the FHSaffects the development of new expertise as well as health practices beyond those in which individualistic stands used to define physician/hospital care - centered models. By means of FHS health professional bonds between the nurse and the individuals/families/communities are created, a fact which makes identification of health problems and assistance easier2.

Female nurses prevailed (seven) among the eight participants, their age ranging from 27 to 45 years old. As for the time they had held their degree, just one had obtained hers 4 years before whereas the others had held their degree for 5 years or longer. On the participants’ qualification, it is worth remarking that the eight held expert degrees in collective health.

Respondents’ speeches provided the means for setting up analytical categories and subcategories. In fact, by virtue of holding a degree for longer than 6 years in most cases, participants delivered rich speeches, a sign of professional maturity resulting from the association between their background and the time they have held a degree9. Data obtained reinforce research results on the nurses’ constant quest for qualification to improve work quality at FHS, especially by means of continuing education10.

Therefore, participants in the research knew about the environment families lived in. Arguments presented allow for claims on the relevance to assess research subjects, since they aremajor social actors in the development of health systems, and show strong commitment to public health in Brazil, especially by means ofhaving joined the FHS.

Category 1: Nurses’ perceptions of the environmental risks within the areas covered by FHS

It is known that planning in the health area requires health professionals to haveinherent knowledge of the health status of a given community, like the health conditions of a covered area. In this sense, it is relevant to identify nurses’ perceptions of existing environmental risks within their FHS area so that they can identify and cope with those risks.

Perception of existing environmental risks

Effects of environmental degradation over human health are undeniable, since they are directly related to deterioration of social conditions in the community, giving rise to epidemics and diseases11,12.

Risk is regarded as chances an expected or unexpected event might materialize. In this context, the term environmental risk turns out to be a situation related to what goes on around (environment), whether it is natural and/or built by man (social and technological)2. Likewise, environmental risks are still conceptualized as resulting from the association between natural risks and those stemming from the aggravation of natural processes by human action and by territory occupation.

Thus, investigation on the understanding of the term environmental risk in speechsignaledto a concept involving hazard and damage to human health and that of the community:

Environmental risk turns out to be any situation that might jeopardize society or community. (E2)

They are all risks involving the place people live, any situation or circumstance that might break life’s chain in that place, which might jeopardize community’s health. (E5)

I find environmental risk is everything, that is, all situations that might jeopardize my clients’ health. They are situations existing where they live, especially with inadequate infra-structure. (E6)

The concept of environmental risk was defined by respondentsas the presence of agents in the environment capable of jeopardizing population’s health. In fact, that definition is reinforced in a piece of research showing that environmental conditions, just like living, infrastructure, and accessibility conditions interfere substantially with living standards and health conditions of a given population11,13,14.

Approximately 80% of the Brazilian population are concentrated in urban areas, giving rise to the so-called constructed ecosystems, which generate multiple-front environmental problems with resulting decrease in environmental quality1. Thus, factors such as residential location and residence quality can considerably raise vulnerability to environmental risks1.

In face of this context, health can be regarded as a social product, that is, the result of relations between ongoing biological, ecological, cultural, and social economic processes in society that condition population’s living standards5.

Risk area: evaluation of conditioning and determining factors of the health process

The FHS must act from a given influence territory – and that means that the area in question should be under its coverage. In consequence, a health diagnostic to identify risk situations in the area covered must be made. Among other aspects, it must provide information on environmental conditions which might interfere with community health in positive or negative ways4.

In association with the given information, an area of environmental risk is that favoring people’s morbidity in a given community. A place with open sewage, for example, jeopardizes population as a result of their increasing vulnerability to vector-borne diseases4.

Therefore, participants’ speech referencesto definitions of environmental riskswere primarily anchored in the relation between urban occupation, ineffective primary sanitation, and violence , all of which integrating the FHS reality:

They are lodges on hillsides, where swamp areas were to be found in earlier days. (E3)

Open sewage, wasteland, difficult access, and non-treated area. (E1)

Inappropriate garbage collection, risk of landslide, lack of sanitation, and wasteland.(E4)

In the area I work, for example, there are houses at risk of collapse for landslide. (E8)

Violence, illicit drug consumption, lack of primary sanitation, demographic risk. (E5)

On environmental risk factors, which condition and determine health/disease processes, subjects showed environmental degradation results primarily from disorderly urban development in medium and large-sized cities, translated as lack of primary sanitation, open ditch garbage disposal, and high crime rates. In fact, places whose infra-structure is compromised by lack of planning by political spheres and increase in individuals’ health risks1.

It is important to highlight that research participants had broad awareness of the main environmental problems jeopardizing population’s health, since they approached wider themes such asviolence and drug consumption2,6. Such result translates the intensive training process conducted in the municipality, with the support of the Health Ministry by action of the General Coordination of Environmental Surveillance (Coordenação Geral de Vigilância Ambiental - CGVAM), in joint action with a Civil Society for Public Interest (Sociedade Civil de Interesse Público - OSCIP) and the Regional University of Cariri(Universidade Regional do Cariri - URCA), with the resulting  implementation, in 2005, of the Environment and Health Project in the Araripe Bioregion.

Identification of risk areas: the community health agent’s action

When inquired on how environmental risk areas are identified, most respondents stated the community health agent (CHA) was in charge of identifying and reporting  to the FHS team.

Through the mapping of the area conducted by the CHA. (E1)

Predominantly through the CHA, who visits families and identifies risk areas. (E2)

Through the CHA, who assists the families. (E3)

Primarily through the CHA’s work, in regular contact with the community.  (E4)

Respondents acknowledge the CHA’s presence in people’s daily health concerns, an on-going reality since the early 1990’s. For his/her insertion in the community, that agent must know all about the micro area under his/her action, identifying inherent environmental risk factors as well as reporting them to the team.

As for the agent’s professional qualification, the curriculum references issued by the Education Ministry and the Health Ministry for the Technical Course for CHA, in 2004, provided for a three-stage curriculum itinerary with 1,200 hours each. The third stage turns out to be a central axis, for it reinforces the CHA’s work in the environments and in health advancement. Therefore, nurses highlight the CHA’s job in developing competences in the realm of advancement, prevention, and monitoring situations of environmental and sanitary risks6,15,16.

That document underlines the concept of risk, pointing at facts and risk situations as one of the fundamental components in the work process to be undertaken by the CHA. The job emphasis lies on disease prevention and transmission/aggravation control – on environmental factors, and on the so-called social risks, such as poverty, violence, and migrations, among others10,11,17.

Furthermore, the CHA has preferential and close contact with population. The feeling of belonging in the workplace as well as themonthly home visits paid account for the agent’s bond with the community and ensures identification of main community’s problems2,3.

Despite the contact that agent has with the population, the other professionals, as well as the nurses, must also take up responsibility for identifying main risk situations involving the community. Team work is thus enhanced and actions affecting social and environmental context are operated. The supervisor nurse’s action must be innovating with mediating effects on decision-making and solution by means of discussion of creative and constructive sustainable practices18.

Category 2: Actions taken by nurses in the realm of environmental health

Once aware of the community’s health status, in which they belong as a health professional, it is up to the nurses and the primary care team to elaborate coping strategies for problems identified. In this respect, implementation of educational health-care actions have become a frequent  practice in order to qualify the FHS health team (continuing education) as well as to empower population in the exercise of their rights (popular education in health).

However, research on state of the art production in English on environment-related themes in nursing allowed for the identification of limited and punctual production inclusive of interviews and reflections on the following teams: environmental risks; perception of the environment and nursing actions; environment taken as work environment in nursing; individual-environment relation and effects on the health/disease process. Nursing professionalization and affinities with the environmental theme were also approached in those productions19.

Activities conducted for the decrease of environmental risks: health education

The approaches to the community for environmental risks described by the respondents were related to health education.

Directions, educational lectures in the unit. (E2)

Lectures in residents’ associations. (E3)

Home-delivered health training, through home visits and by means of volunteer collective work for dengue prevention. (E5)

Home-based directions turn out to be the best way to emphasize risks for the population. (E7)

According to the participants’ speeches, health education is regarded as the main intervention strategy in environmental risk factors to the population.

In the FHS context, health education implies going beyond curative assistance: it means ascribing priority to prevention and promotion-natured interventions3. Therefore, health education is a health-targeted teaching-learning process, and the professional in the area is the major mediator in that process.
Thus, the health professional is expected to go beyond education, as he/she must be trained to offer strategies todelineate transformation among people5.

Nursing professionals must take ecosystemic actions on a daily basis. Environmental education must be acknowledged for full care, ensuring integrating and ecological-wise environmental practices20.

Therefore, health education cannot be limited to information levels, because it is characterized as an important tool to stimulate principles ruling self-care notionsas well as the quest for healthy life. In addition to alternatives to care, health education also presumes training of subjects with self-awareness and critical skills to review concepts and values5.


Identification and elimination of environmental risks at the FHS proves to be a challenge to nurses. Although sensitive to environmental risks within their areas of coverageand despite their accurate perception of the theme, nurses had special difficulty with coping measures.

Investigation limitations are acknowledged on the basis of research conduction in a medium-sized municipality, preventing generalizations. Nonetheless, unveiling the scenario related to perceptions and actions by nurses in health advancement in the context of environmental risks at FHS prompts the need for amplifying discussion of this theme. Thus, this research is expected to contribute to the debate on environmental health issues at the FHS.

Findings showed wide concepts held by nurses on environmental risks within areas covered by the FHS, as well as compromised interdisciplinary and cross-sectional interventions on that care level. It is up to the FHS professionals to identify risk areas, a primary activity (but not exclusive) of the CHAs and of local agents. Additionally, they must develop projects targeted at the decrease of risk factors, implanting corrective measures by means of infra-structure work, educational services and care, which may affect a wide scope of environment-related activities.

To be able to act in face of situations involving environmental risks, the professional needs training for a specific interventive approach, which requires on-going professional development on the basis of permanent education. This way, nurses can promote transformations, becoming active subjects to necessary transformations in the health sector and in environmental care.


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Direitos autorais 2014 Lívia Maria Vidal Romão, Evanira Rodrigues Maia, Grayce Alencar Albuquerque

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