Building sustainability indicators in the health dimension for solid waste management 1

ABSTRACT Objective: to prepare a list of sustainability indicators in the health dimension, for urban solid waste management. Methods: a descriptive and exploratory study performed jointly with 52 solid waste specialists, using a three-steps Delphi technique, and a scale measuring the degree of importance for agreement among the researchers in this area. Results: the subjects under study were 92,3% PhD's concentrated in the age group from 30 to 40 years old (32,7%) and 51% were men. At the end of the 3rd step of the Delphi process, the average and standard deviation of all the proposed indicators varied from 4,22 (±0,79) to 4,72 (±0,64), in a scale of scores for each indicator from 1 to 5 (from "dispensable" to "very important"). Results showed the level of correspondence among the participants ranging from 82% to 94% related to those indicators. Conclusion: the proposed indicators may be helpful not only for the identification of data that is updated in this area, but also to enlarge the field of debates of the environmental health policies, directed not only for urban solid waste but for the achievement of better health conditions for the Brazilian context.


Introduction
The needs that derive from human development, change the environment and alter substantially the natural conditions. In the face of these shifts, there is a need of new and permanent investments to improve the sanitation conditions. The sanitation movement foster changes in the mindset about health and illness (1) and may help to minimize the rate of those illnesses linked to inadequate sewage. (2)(3) as these shortcomings in infrastructure impact in the health conditions of the populations (4)(5) .
Among the different areas of sanitation activities, waste management is considered a relevant and present problem for society as a whole, as it is an essential service for public health in developing countries (6) .
This area of concern is a constant in the political and administrative agendas in several countries. In Brazil, the debated around waste management were the origin of many studies in the last years (7)(8) and were the basis for the National Policy for Solid Waste that was enacted by Law 12.305 in August 2 nd 2010 (9) .
This policy was of great importance for the improvement of concept standardization in waste management, providing criteria about adequate and safe management and an integrated and sustainable administration. Additionally the policy mandates every state and municipal authority to establish a plan for integrated urban solid waste management, to optimize this management, in order to provoke several beneficial effects for the whole Brazilian society (10) .
The demand for having a waste management plan, proposed by the National Policy for Solid Wasteis also mandatory for the facilities that generate hazardous waste such as health services, that pose public health or environmental risks, because they have one or more characteristics e.g. flammability, corrosiveness, reactivity, toxicity, pathogenicity, carcinogenicity, teratogenicity and mutagenicity (9) . Around 25% of the health service waste is considered hazardous with potential risks to workers and that risk may extend also to the community (11) . This waste is classified in five groups: A -biologic, B -chemical, C -radioactive, D -common and E -sharps, being essential to develop studies to create protocols and new practices to manage these kind of waste (7) .
The National Policy for Solid Wastealso reaffirms the relevance of the rolling out of the management plan in the facilities that generate health services related waste (9) . to the respective generator, also state the different steps for its management, in order to reduce environmental pollution, and to protect the agents that work in all the phases of the process (7)(8) .
To cope with the new Brazilian legal requirements, new and permanent investments will be needed in order to have a accurate description of reality. In this context, building indicators is a useful tool to help in gathering a set of updated information to improve the waste management (12) , and minimize possible impacts in health and environment. This information is essential because it will support the managers for planning and interventions in the decision-making process. The sustainability indicators have different approaches, depending on the dimensions where they belong, such as environmental, economics, and social (13) as well as other relevant dimensions as institutional and health dimensions.

Methods
This is a descriptive and exploratory research, with the participation of specialists in the area of waste management. Due to the nature of the findings, the quantitative approach was used in the first three stages and then the qualitative one was used for the data collected in the first stage. Is noteworthy that the qualitative and quantitative approaches are not excluding each other (14) and may be complementary in the quest for better grasp of a certain context, contributing for analyses and proposals for solving problems in health (15) .  (17) .
Data collection was done through the Delphi technique in three steps with the participation of 52 subjects, followed by the quitting of one in the second Veiga TB, Coutinho SS, Andre SCS, Mendes AA, Takayanagui AMM.
step and another one in the third step. When the research was finished 50 subjects remained.
The technique is a methodological strategy for research including a wide group of subjects, that is oriented to frame the judgments of specialists for a maximum of agreement on the studied area, promoting the convergence of opinions (17) . This methodology tries to keep the anonymity to eliminate the influence of factors such as academic or professional status, allowing for a more active and less biased participation, non inhibited as may happen in face-to-face meetings (18) .
Following the steps of the Delphi technique, participants allocated a specific degree of importance to each indicator, using values from 1 "dispensable" to 5 "very important". In the first step, additionally to this allocation of importance to the five proposed indicators, the participants were asked to suggest the insertion of new indicators, according with a document review done by the researchers, or to propose changes in the texts of the indicators that were presented to them.
One of the key characteristics of the technique is the feedback, that allows the specialists to review the results of the previous step, and to weigh their judgments according to the results of the group (17) .
Using this procedure in an iterative process, some points of view were deleted, altered or added following the reflections of the participants.

Results
The profile of the 52 interviewees that participated    (Table 3).

Discussion
The issue of urban solid waste is considered a public health problem that involves multiple topics of collective interest, being crucial to adopt public policies to support the managers' decisions and the activities of the civil society around waste management (19) , in order to avoid harmful effects to the environment and human health (19) , In this context, the experts point to the need of larger investments for developing studies to promote building and using sustainability indicators in this particular area (6,20) and also concur in relating inadequate sanitation conditions with vector proliferation and expansion of several kind of diseases (2)(3) . In spite of this, the health dimension in waste management is still poorly discussed and disseminated.
Even though this debate is its early stages, it was possible to verify the interest that the researchers with Rev. Latino-Am. Enfermagem 2016;24:e2731. different backgrounds, put in the process of building the proposed indicators, arriving to higher level of agreement (82% to 94%) for the 12 indicators put to consideration. Another relevant factor is referred to the exclusion of factors, as just one of the indicators was deleted during the process because it did not reach the minimum agreement among the participants, something that underlines the need to incorporate of concepts that link the importance of health issues related to waste management.
The first four suggested indicators (Table 2) are related to working conditions, safety equipment and exposure to risks of the workers in urban solid waste management. Human exposure to risk factors present inn the environment is a outstanding issue in several research initiatives (10,21) .
In the case of people working in waste management, it is essential to adopt preventive measures and using personal protective equipment (22) , needed in every phase of work to avoid the chance of accidents and aiming for safety and occupational health standards.
In this way, the managers should include in their management plans, the conditions needed for having an integrated waste management (9) , including training courses and the use of adequate equipment to ensure safety for all persons working in this sector.

The fifth indicator proposes the enumeration of the
Dengue foci or proliferation of other vectors. A range of determinants foster the disease-transmitting mosquito proliferation, one of them is the inadequate disposal of waste such as bottles, tires, glasses and plastic bags, that are potential incubators for the vector (23) . In fact, in Dengue surveillance matters, inadequate waste management is considered a main factor for keeping this endemic disease going on (24) .
Inadequate storage and disposal of waste are contributors to the environmental determinants of several diseases, being a serious public health issue in developing countries (6) . In this way, new environmentally Handling this waste is a responsibility of the generator, that must have a plan for adequate management depending on the type of waste that is generated (9) , in spite of the fact that usually the municipal authority ends up performing the external handling.
A larger problem is the fact that frequently the municipal administration does not have a number of staff that are qualified and trained for performing the different phases of management in a safe way. Not withstanding this, and independently from the proposal elaborated by the institution, legal and technical principles should be observed, on the basis of an improved concern about its importance (19) . procedures for minimization of waste production, the preventive and corrective measures for its operationalization (9) .
During this process, investing in permanent training, upgrading the capacities of the workers acting directly or indirectly on the different stages of waste management, may imply an advance in the use of best practices in the waste area (10) .
The National Policy for Solid Waste states the requirements in terms of programs and actions for Environmental Education to be promoted, directed to avoid the generation, reduce, reuse and recycle solid waste. Another factor that emerges form this policy is the importance of the updated information recorded in the different sectors that are linked to waste management (9) .
According to the participating experts in this study, the difficulties in getting hold of information and the subjectivity were a few of the characteristics seen in the indicators that were prepared.