Skip to main content
  • Research article
  • Open access
  • Published:

Cross-cultural adaptation of an environmental health measurement instrument: Brazilian version of the health-care waste management • rapid assessment tool

Abstract

Background

Periodic assessment is one of the recommendations for improving health-care waste management worldwide. This study aimed at translating and adapting the Health-Care Waste Management - Rapid Assessment Tool (HCWM-RAT), proposed by the World Health Organization, to a Brazilian Portuguese version, and resolving its cultural and legal issues. The work focused on the evaluation of the concepts, items and semantic equivalence between the original tool and the Brazilian Portuguese version.

Methods

A cross-cultural adaptation methodology was used, including: initial translation to Brazilian Portuguese; back translation to English; syntheses of these translation versions; formation of an expert committee to achieve consensus about the preliminary version; and evaluation of the target audience’s comprehension.

Results

Both the translated and the original versions’ concepts, items and semantic equivalence are presented. The constructs in the original instrument were considered relevant and applicable to the Brazilian context. The Brazilian version of the tool has the potential to generate indicators, develop official database, feedback and subsidize political decisions at many geographical and organizational levels strengthening the Monitoring and evaluation (M&E) mechanism. Moreover, the cross-cultural translation expands the usefulness of the instrument to Portuguese-speaking countries in developing regions.

Conclusion

The translated and original versions presented concept, item and semantic equivalence and can be applied to Brazil

Peer Review reports

Background

The promotion of environmental health and the proper management of waste, especially the most dangerous types, are worldwide issues. Environmental contamination and occupational accidents caused by improper health-care waste management (HCWM) are on-going challenges [13], especially in less developed countries [4, 5]. To address these concerns, a number of political and legal mechanisms have been developed, to protect both the environment and human health against the risks associated with health-care waste (HCW) [47].

The hazardous nature of HCW is associated not only with blood-borne infections, mainly caused by sharps injuries, but also with diseases related to the contamination of soil, water and air caused by the inadequate treatment and/or final disposal of HCW [13, 812]. In less developed countries these problems are recurrent [4, 13] due to the poor access and precarious situation of health basic services, urban infrastructure, water supply, sewage system and waste collection, among others. In relation to HCWM, many health-care facilities (HCF) wrongly dispose their hazardous waste with the ones similar to household waste, others burn them in open dumps or in incinerators without the necessary devices for environmental contamination control, exposing the nearby communities to their toxic emissions (dioxins, mercury and particulate matter, for example) [4].

Aware of the local problems and global dimensions in the last few decades, both national and international organizations have been intensifying the effort to improve management practices [4, 14] aimed at global disease burden reduction. Health-care organizations have committed to finding solutions to the challenge of continually improving their environmental performance and to achieving measurable results [15].

Regulatory organizations, such as the Brazilian Health Surveillance Agency (Anvisa) [16], the National Environmental Council (Conama) [17] and the National Nuclear Energy Commission (Cnen) [18], are based on a mediator and regulator model, and are responsible for national policies concerning HCWM, from its inception to its final disposal (“cradle to grave” or “cradle to cradle” for recyclable waste).

These organizations have political, financial, regulation and management autonomy and through two main Federal Acts (Anvisa 2004 and Conama, 2005) [16, 17] determine that HCW generators are responsible for their correct waste management and must elaborate a free public access document relating to HCW management including the monitored indicators. The technological information center (databases) [19] of the Unified Health System – SUS (Public health care system for Brazilians and foreigners travelers over the country) [20] has an available field [21] where HCF managers must inform the category and amount of HCW generated by them.

The National Solid Waste Policy [22] is guided by the principles of sustainability and environmental protection. Although it does not deal specifically with healthcare waste, it increases the responsibility of every waste generator to provide proper final disposal. According to this policy, hazardous waste generators must develop specific waste management plans, taking the wastes’ inherent risks into consideration [23].

In this context, the main Brazilian legal regulations for HCWM [16, 17, 24] establish guidelines regarding the elaboration, and request the implementation and development of a Health-care Waste Management Plan (HCWMP) in every HCF. The HCWMP is part of an integrated management system for environmental health, and must include aspects related to all stages of waste management, professional awareness and qualifications, and occupational health and safety, as well as monitoring and evaluation (M&E) methods for proper health-care waste management [16, 24].

As a consequence of the HCWMP, researchers, interlocutors and managers have demonstrated an increasing interest in developing an integrated system for HCWM assessment [15]. Nonetheless, to our knowledge, in Brazil, no assessment tools for the straightforward evaluation of an integrated HCWM plan, adapted to various data collection modes and scopes, have yet been developed.

Among the international proposals identified, the Health-Care Waste Management – Rapid Assessment Tool (HCWM-RAT) [25] is considered the best for satisfying the evaluation criteria: scope, field investigation, methodology, robustness, origin and adaptability to the Brazilian context. This tool is part of an overall strategy developed by WHO to achieve a reduction in the disease burden attributed to inadequate health-care waste management. Assessment-in-context reviews are recommended by the WHO as a requirement for improving HCWM systems, since their implementation is unsatisfactory in health care institutions in many countries throughout the world [4, 25].

The (HCWM-RAT) [25] structure is based on a Rapid Evaluation Method (REM) and methodological triangulation: that is, a combination of qualitative and quantitative methods for collecting and analyzing data [26, 27]. This structure makes the HCWM-RAT distinct from other commonly used standard tools for gathering information on HCWM, which are based only on a check-list survey, and lack the perspective of a participative and emancipatory assessment [28].

Research in the field of environmental health evaluation, particularly for HCWM, is critical, because of the need for improving control of the spread of pollutants [29]. Cross-cultural adaptation of measuring instruments for HCWM, however, is scarce, and this study found none regarding Brazilian instruments. Furthermore, Brazil has been receiving thousands of Colombian refugees [30, 31], as well as immigrant workers from Africa and Haiti, and tourists, due to recent sports events. Brazilian health facilities must therefore be prepared not only for foreign visitors’ health assistance but also for the safe management of any HCW that might be produced.

Brazilian political structure is aligned with the principles of the World Health Organization (WHO) [4] to achieve safe and sustainable HCWM. Moreover, underlines the importance of periodic assessment to generate reliable information that will support interventions focused on ensuring best practices and waste reduction. However, through a large consensus from the literature, the use of such measuring instrument (questionnaire) made in other nations should be preceded by cross-cultural investigation (cross-cultural adaptation process) [3237].

So, as this tool was originally developed in the U.S., cross-cultural research has been recognized as essential, to ensure the quality of translation and the cultural adaptation process [3237], as well as to ensure equivalence between the original and the target language. This study aimed to promote a Brazilian cross-culturally adapted version of the English HCWM-RAT tool proposed by WHO [25]. It focused on equivalence of concepts, items and technical and semantic aspects, between the English and Brazilian Portuguese versions.

Methods

Instrument

The HCWM-RAT [25] is an assessment instrument consisting of a questionnaire with 85 items distributed over eight sections (toolboxes) containing 14 analysis criteria. It is structured as an electronic spreadsheet and has 8 supplementary sections: introduction, preparation, planning, contacts, glossary and abbreviations, personal observations, rating at the national level, and an inventory of all the questions.

The instrument contains five different options for answers: 1) multiple choice (C), which allows more than one option; 2) text (T),which allows open-ended answers; 3) numerical (N), which refers to the amount of generated waste and the size of the budget allotted to HCWM; 4) qualitative (Q), which allows ranking from 0 (nonexistent) to 5 (excellent); and 5) Boolean [B]: yes/no answers. The tool also provides space for the interviewer’s personal observations, to facilitate information matching. HCWM-RAT follows a logical and chronological frame, and can cover areas from the national level (ministries) to the local level (individual healthcare facilities) and considers all stakeholders involved in the issue of waste management [25].

Cross-cultural adaptation

The universal approach of Herdman, Fox-Rushby and Badia [35], was chosen because that method “emphasizes the possibility of cross-cultural variations in the nature of multidimensional concepts” [p.324]. In addition, the approach of Beaton, Guillemin and Bombardier [32] was applied to carry out the cross-cultural adaptation. To assess both conceptual equivalence and items using the cross-cultural adaptation method, a thorough literature review was carried out. A theoretical reference was built and, subsequently, constructs related to an integrated system of HCWM were analyzed [6, 8, 10, 11, 38, 39]: “sustainable development”, “safe management”, “health-care waste”, “safe handling”, “environmental health”; and political, legal, technical and operational concepts in both cultures [4, 14, 16, 17, 22, 24, 40]. Moreover, the terms adopted by the major Brazilian databases of HCWM, such as the National Register of Health Care Facilities (CNEN) [21], the National Information System on Sanitation (SNIS) [41] and the Brazilian Institute of Geography and Statistics (IBGE) [42] were verified.

As suggested in the literature, the evaluation of conceptual equivalence and items was complemented by structural analysis of the original instrument, to determine whether its various dimensions would be relevant in the Brazilian context [32, 35]. The participation of a committee of experts and a target population of the study were used to improve this process [32, 33, 36]. The committee evaluated the semantic equivalence, which involved the formal analysis of all stages of the cross-cultural adaptation process [32, 33, 36].

Conceptual questions, shown in Fig. 1, were formulated to guide the study and to help the analysis, through the following steps:

  • Step 1 (Translation): Two independent translations of the HCWM–RAT to Brazilian Portuguese (T1 and T2) were made by different certified bilingual professionals, named as Translator A and Translator B: one with previous knowledge of the theme and the other without it. This step was aimed at strengthening the possibility of finding badly formulated questions or linguistic ambiguities [32, 3436].

  • Step 2 (Translation synthesis): Discussions of translation differences were conducted during a meeting between the translators and the author of this study, using the Nominal Group Technique (NGT) [43] to produce a synthesis of the two translations (T1-2). This process of comparison was carried out taking into consideration the original instrument, the theoretical framework, and the political and regulational context in both languages and cultures. Because the original instrument contained a large number of sections and had a complex structure, a source spreadsheet incorporating translations T1 and T2 was created, to compare the translations, in order to produce a synthesis of the two. In this source spreadsheet, the lines were identified by different background colors, identifying the two translations, while the consensual synthesis was identified by a third color pattern. The main issues and the method for achieving consensus were described in reports produced by the author of this study, using methods recommended in the literature [32].

  • Step 3 (Back translation): The back translation was performed to generate another version of the questionnaire (T1-2) in its original language (English). This process was conducted totally blind of the original version by two other different translators, whose mother tongue was English, named here Translator C and Translator D (native English-speaking back-translator, with a Doctorate in Public Health concluded in Brazil) as indicated in the methodology [32].

  • Step 4 (Back translation synthesis): The two back translations (BT1 and BT2) were systematized into a consensual version during a meeting following the same methodology explained previously, producing a synthesis (BT1-2).

  • Step 5 (Expert judgment): The semantic equivalence (connotative and denotative) [35, 36] was rated by a committee of experts, based on the three versions — the original (HCWM-RAT), T1-2, and BT1-2 — along with respective reports produced in the translation and synthesis steps [32].

    Representatives of different areas of healthcare waste management made up the committee of experts: researchers, and professionals in the fields of biosafety, hospital quality and management, occupational health, and the physics and hygiene of radiation. Translator D also took part in this group, since he was the only native speaker specialized in public health with a Doctorate in Brazil. There were also members of municipal hospitals, cleaning and hygiene staff, representatives of a municipal garbage collecting company, statistical experts, and representatives of the Sanitary Surveillance Agency, the General Coordination for Environmental Surveillance (Health Ministry) and the Brazilian Environmental Council (Environmental Ministry).

    A 2-day meeting was conducted, and since the HCWM system to be used is regulated by the government, participation from all aspects of HCW had to be obtained, to contribute positively and productively. The meeting employed a nominal group technique with audio recording [43]. The group evaluated the clarity, coherence and pertinence of all the items and sections in the tool, with respect to the Brazilian context. After analyzing the material and coming to consensus, the committee of experts, along with the author of this study, created the preliminary version to be submitted for a pre-test.

  • Step 6 (pre-test): The pre-test was presented to 39 individuals [32], who were selected for their positions as representatives of government or of one of the nine public health care facilities of the Municipality of Niteroi, Rio de Janeiro; at least one individual was selected from each of the nine facilities. An individual could be included in the sample if he or she: performed a function in a governmental sector involved with health or the environment; was a health-care facility director or manager, or a nursing supervisor; was an HCWM commissioner; or was a worker involved with health-care waste handling.

Fig. 1
figure 1

Steps of cross-cultural adaptation and guideline questions

The pre-test was conducted with a heterogeneous group of targeted interviewees in 3 different meetings (March 2011) of 3 h each; the interviewee had to analyze as well as answer the items. A single interviewer conducted this pretest.

To answer the preliminary version of the translated instrument, the individuals had to complete a form with two questions, to evaluate the quality of the items: 1) Is it easily understood? (Y/N); 2) Is it appropriate for collecting information on an HCWM system? (Y/N). For both questions, the interviewee was also asked to rate the comprehensibility of the item and to suggest changes for improvement. When the number of “no” answers to either question for a given item exceeded 5 %, that item was included in a list for further analysis and discussion among the experts. Because a number of confusing, ambiguous or inconsistent items were identified by the sample group, a second test was conducted 2 weeks later, by a single interviewer, asking the same questions of the revised item. This second test (re-test) occurred with 83 participants [32], including HCF professionals, government representatives, and others directly or indirectly involved in HCWM systems.

Results

After analysis of the literature and regulations, and further discussions among the experts, the constructs in the original instrument were considered relevant and applicable to the Brazilian context. The concepts and dimensions were consistent with Brazilian HCWM policies, and included occupational health and safety, biosafety, ecology, and sanitation [16, 17, 24]. The 14 criteria of the original instrument were identified in the Brazilian Version of the HCWM-RAT and were grouped into five dimensions (Table 1).

Table 1 Dimensions and criteria of the health-care waste management – rapid assessment tool (HCWM-RAT) Brazilian version

After adjustment, the original instrument could be considered applicable to Least Developed Countries (LDCs) [13] and those without regulations or policies on HCWM. Both the committee and the target population recommended the cross-cultural adaptation as being useful in Brazil. Such a cross-cultural adaptation of HCWM-RAT [25] was new and unknown in Brazil.

The aim of the committee of experts was to make the instrument suitable for use in a monitoring and evaluation program in Brazil. Changes and adequacies have followed semantic equivalence to concepts, terms and expressions from the original WHO instrument [32, 35, 36].

After evaluation of the semantic equivalence, two different translations (T1 and T2) were obtained. There were no discrepancies between the two back-translations (BT1 and BT2). During the synthesis elaboration of the translated and back-translated versions (T1-2 and BT1-2), terms such as scope, feedback, checklist, stakeholders were maintained because of their current use in Brazil, in the same cultural context.

The introduction (basic assumptions and objectives) to the Brazilian instrument included a guidance statement from, and the electronic addresses, of the Brazilian regulatory authorities (Table 2). Table 3 shows the acronyms and terms used in three official databases: the Brazilian Institute of Geography and Statistics [42]; the National Register of Health Care Facilities [21]; the National Sanitation Information System [41].

Table 2 Evaluation of conceptual, technical and semantic aspects between the Brazilian Portuguese version of the health-care waste management tool - rapid assessment tool (HCWM-RAT) and its original English version
Table 3 Inclusion of terms, acronyms and assessment requirements: conceptual, technical and semantic evaluation

Additional sections (e.g., glossary) provided the standardized terminology used by the health system and the Brazilian regulatory agencies. For example, terms related to health-care-waste handling were included according to the Brazilian regulatory systems, e.g.,: “Temporary storage”; “Similar to the solid urban waste” (RSU in Brazilian Portuguese); “Internal transportation” (Table 2).

Terms and items that made no sense in the Brazilian context or culture were replaced by ones commonly applied in the national information system database for health (CNES). For example, the item referring to healthcare facilities (HCF) “category” had to be changed to either “type of establishment” or “level of hierarchy” (Item 200, shown in Table 4) in accordance with HCF registration nomenclature in the Brazilian health-system database.

Table 4 Evaluation of item equivalence between the Brazilian HCWM-RAT version and the original HCWM-RAT version

According to the committee of experts, all the items that could be answered through research in databases were listed in a separate data sheet to be collected prior to the interviewer’s field visits.

The dimension “Capacity building, safety and health” (Table 1) was included with some extra terms (Table 3, e.g., Item 304) to refer to the HCW handlers’ level of risk awareness; the original instrument did not offer parameters to classify this awareness level.

The dimension “Handling steps” was also changed to adapt to Brazilian culture. In Criteria 4 (generation) and 10 (treatment) the term “anatomical waste” was changed to “anatomical parts” (“peças anatômicas” in Brazilian Portuguese) because in the target culture the term “waste” has a negative connotation (equivalent to “garbage”), which would be considered offensive when related to human body organs or parts.

In addition, after a preliminary field version of the test, some items — for example, those referring to budget allocations for HCWM (found in Criterion 13 “Policy and budgets”) — were directed to multiple actors from different levels, a difference from the original version. The aim here was to better understand the difficulties that the HCWM staff and decision makers usually face when trying to interpret or verify rules, especially when they are not included in the decision-making processes. The suggestions and observations made by the people interviewed during the test phase were extremely helpful in producing the final version of the instrument.

Discussion

Despite the conventions signed by Brazil, such as the Basel Convention [29], the Stockholm Convention [44] and the Minamata Convention [45], and their associated regulation structures and databases (CNES; SNIS; IBGE), the segregation and collecting of health-care wastes are still primitive in most Brazilian cities.

This lack of development contributes to the paucity of knowledge about the total amount of waste generated in health-care facilities, and its real destination, in Brazil [46].

Some studies have identified the importance of training programs directed to health workers, HCW management teams and waste handling workers in order to improve the global approach on HCWM [47, 48]. However, this has been neglected in Brazil [23] and may be one of the reasons behind the difficulties on HCWM faced by this country.

The use of periodic assessments supported by a comprehensive instrument that is adapted to Brazilian context and validated in the target country (Brazil), helps not only to identify problems but also to explain its causes providing decision makers with the necessary evidence to reorient strategies.

The cross-cultural adaptation process is an approach that can be applied to many instruments developed in other cultural and linguistic settings. For Brazil, it may help to fill the data gap about the critical knots for HCWM improvement as well as to provide feedback on HCW to DATASUS database.

The objective of the adaptation is to achieve equivalence between the original measurement instrument and its adapted version [32, 35]. Therefore, the Brazilian Portuguese version of the HCWM-RAT was obtained through careful cross-cultural adaptation steps, recommended in the literature. In contrast with other cross-cultural adaptation studies that focused on epidemiological measurement instruments, this research considers an equivalence study on an environmental health measurement instrument that, as applied, will help identify and make comprehensible the HCWM framework in Brazil.

In this cross-cultural research, the constitution of a committee of experts was shown to be fundamental for the achievement of equivalence, as well as the validity of the construct, the content and the face (apparent) of the adapted instrument [32, 34, 35, 37].

While it is recognized that additional tests for evaluating the instrument’s psychometric properties are highly recommended, they are not compulsory for the validation of the translated version [32]. However, to reinforce the process of version evaluation, a 16-member committee of experts was put together, composed of researchers, one of the translators, and representatives from one of the Brazilian HCWM regulation agencies. Using the NGT [43] with the support of a moderator, this evaluation was aimed at maximizing information compilation and encouraging experts to express their opinions, while avoiding any particular expert’s domination in the discussion.

Throughout the experts’ meeting, items were examined with the goal of reaching a consensus on each item before moving on to the following one. During this process, a theoretical construct coherent with universal principles [4] yet specific to the HCWM status investigation practice [4, 16, 17] was observed.

For both the conceptual and the item-level equivalence, a consensus of keeping the original structure and items prevailed, based on the instrument modus operandi: that is, it must be used only by trained interviewers — HCWM and M&E professionals. This recommendation was also stated in the introduction to the original instrument. For instance, the maintenance of item 1400 in the Brazilian version (“Do all patients have access to/use of toilets in the healthcare facility?”) drew a great deal of attention during the expert discussion, motivating 3 rounds using the NGT [43]. Ultimately, however, the experts decided that this item should be kept as it is, and as the Brazilian instrument is applied, the interviewers would evaluate the condition of the toilets provided by each facility. This decision was attained after the group agreed that Brazil is a huge country with 283,434 health-care facilities [21], in many different socio economic and cultural scenarios, and that therefore this item would be useful for identifying infrastructure shortcomings.

The preliminary version that was obtained after 2 days of expert meetings was tested with 39 individuals [32] from the target population, with the aim of adjusting the instrument to achieve equivalence between the original source and the target version (Brazilian) in different aspects involving clarity, coherence and pertinence of the questions. The test showed that some items still received more than 5 % of negative answers for quality evaluation (again using Step 6 of the method). In other words, although the preliminary version of the Brazilian HCWM-RAT had been thoroughly evaluated by experts, eight (8) individuals of the target population considered that some items were not clear, coherent or pertinent. Consequently, some questions were modified. For example, the item referring to “national HCWM regulations,” with the question “Does their application cause any problems?” was changed to “Does the application of the established rules generate any issues?" (“a aplicação da regulamentação gera algum tipo de situação-problema?” in Brazilian Portuguese): Item 1202 in the Brazilian Portuguese version, shown in Table 4). The experts claimed that the word “problem” could not be applied to the Brazilian context since it has a negative connotation and a regulation is not designed to cause negative effects but to help guide the population.

Another example raised by the target population was in Criterion 10, where it is asked how “urban solid waste” (in place of “domestic waste,” in the original instrument) is usually treated in a health-care facility. For this population the term “treated” was not coherent because it implied the need for a method, technique or process to reduce or eliminate any inherent contamination risk, occupational accident, or environmental damage. Therefore, in order to avoid semantic discrepancies between the original and translated versions, this item was changed to “how the waste is handled - organic and recyclable” (“como são manejados – orgânicos e recicláveis” in Brazilian Portuguese), as shown in Table 4.

After the modifications applied from the testing of the preliminary version, all items received a positive evaluation, indicating that interviewees had no difficulties in understanding the questions. Table 4 shows the original items and the translated and adapted ones, in the field tests and from the committee of experts’ analysis.

Reports of the revisions were written and sent to the WHO, explaining the rationale behind the decisions that resulted in changes in the adapted version: a necessary step for the official recognition of the Brazilian version of HCWM-RAT.

Operational equivalence was evaluated during both the test and the retest; but the method of administration and the estimated time for application of the tool remained the same as for the original instrument. With emphasis on the modus operandi, equivalence refers to a comparison between the characteristics of an instrument for use in target populations (Brazilian version) and of one for use in the original population source (source instrument) [36].

The Brazilian version of HCWM-RAT has the potential to generate indicators and official database feedback, and to subsidize political decisions at different political levels among decision makers. However, an investigation of the psychometric properties of the instrument should be performed in the future [32, 33, 36].

Although a Brazilian version of HCWM-RAT has been approved, there is no guarantee that the cross-cultural adaptation was effective without the assessment of measurement equivalence, therefore, sophisticated statistical methods such as item response theory model (IRT) can be used to confirm the results of this study and it can be considered as a limitation of the study.

From this study arises the possibility for the application of the instrument to be expanded to other Portuguese-speaking countries, considering the results of Step 2 (Translation synthesis, T1-2) of the cross-cultural adaptation process.

For countries that already have guidelines and regulations on HCWM, this study may at least reduce the effort required for the research and development of their own adapted versions.

Conclusion

The results of this study show that developing a Brazilian version of HCWM-RAT can open new research paths and possibilities for expanding the comprehension of the HCWM system, as well as the critical factors to achieve proper HCW management. These factors are considered essential for the success of any HCWM Plan.

It thus supports decision-making and stimulates innovation in evaluation, for this specific field.

From this study also raises the possibility for the application of the instrument (Translation synthesis, T1-2) to other Portuguese-speaking countries. For countries that already have framework directive on HCWM, this study may at least reduce the effort required for the research and development of their own adapted versions.

Abbreviations

CNES:

National register of health care facilities

HCF:

Health-care facility

HCW:

Health-care waste

HCWM:

Health-care waste management

HCWMP:

Health-care waste management plan

HCWM-RAT:

Health-care waste management-rapid assessment tool

IBGE:

Brazilian Institute of Geography and Statistics

NGT:

Nominal group technique

REM:

rapid evaluation method

SNIS:

National information system on sanitation

SUS:

Unified health system

WHO:

World Health Organization

References

  1. Forastiere F, Badaloni C, Hoogh K, Kraus MK, Martuzzi M, Mitis F, Palkovicova L, Porta D, Preiss P, Ranzi A, et al. Health impact assessment of waste management facilities in three European countries. Environ Health. 2011;10:53.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Prüss-Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med. 2005;48:482–90.

    Article  PubMed  Google Scholar 

  3. Saia M, Hofmann F, Sharman J, Abiteboul D, Campins M, Burkowitz J, Choe Y, Kavanagh S. Needlestick injuries: incidence and cost in the United States, United Kingdom, Germany, France, Italy, and Spain. Biomedicine International. 2010;1(1):41–9.

    Google Scholar 

  4. Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, Townend W, Wilburn S, Zghondi R. Safe management of wastes from health-care activities. 2nd ed. Geneva: World Health Organization; 2014. p. 329.

    Google Scholar 

  5. Nascimento TC, Januzzi WA, Leonel M, Silva VL, Diniz CG. Occurrence of clinically relevant bacteria in health service waste in a Brazilian sanitary landfill and antimicrobial susceptibility profile. Rev Soc Bras Med Trop. 2009;42(4):415–9.

    Article  PubMed  Google Scholar 

  6. Fuerhacker M. EU Water Framework Directive and Stockholm Convention: can we reach the targets for priority substances and persistent organic pollutants? Environ Sci Pollut Res Int. 2009;16 Suppl 1:592–7.

    Google Scholar 

  7. Koloutsou-Vakakis S, Chinta I. Multilateral environmental agreements for wastes and chemicals: 40 years of global negotiations. Environ Sci Tech. 2011;45(1):10–5.

    Article  CAS  Google Scholar 

  8. Singh S, Prakash V. Toxic Environmental Releases from Medical Waste Incineration: A Review. Eviron Monitor Assess. 2007;132(1–3):67–81.

    Article  CAS  Google Scholar 

  9. Porta D, Milani S, Lazzarino AI, Perucci CA, Forastiere F. Systematic review of epidemiological studies on health effects associated with management of solid waste. Environ Health. 2009;8:60.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Hossain MS, Santhanam A, Nik Norulaini NA, Omar AK. Clinical solid waste management practices and its impact on human health and environment – A review. Waste Manag. 2011;31(4):754–66.

    Article  CAS  PubMed  Google Scholar 

  11. Harhay MO, Halpern SD, Harhay JS, Olliaro PL. Health care waste management: a neglected and growing public health problem worldwide. Trop Med Int Health. 2009;14(11):1414–7.

    Article  PubMed  Google Scholar 

  12. Georgescu C. Report of the Special Rapporteur on the adverse effects of the movement and dumping of toxic and dangerous products and wastes on the enjoyment of human rights. Geneva: United Nations Human Rghts - Officie of the High Commissioner for Human Rights; 2011. p. 11.

    Google Scholar 

  13. UNCTAD. World Investment Report 2013. Global Value Chains: Investment and Trade for Development. United Nations Conference on Trade and Development. 2013.

  14. Prüss-Üstün A, Giroult E, Rushbrook P. Safe management of wastes from health-care activities. Switzerland: World Health Organization; 1999. p. 230.

    Google Scholar 

  15. Karliner J, Guenther R. Global green and healthy hospitals: a comprehensive environmental health agenda for hospitals and health systems around the worl. Buenos Aires: Global Green and Healthy Hospitals/Health Care without Harm - NoHarm; 2011. p. 44.

    Google Scholar 

  16. Ministry of Health, Brazilian Health Surveillance Agency. Regulation about health-care waste management. In: Brazilian Health Surveillance Agency, Regulation no. 306/2004, Dec 7th, editor. 306/2004. 2004th ed. Brasília: Ministry of Health; 2004.

  17. Ministry of the Environmental, National Environment Council. Regulation about health-care waste treatment and disposal. In: National Environment Council, Regulation no. 358/2005, Apr 29th, editor. 358/2005. 2005th ed. Brasília: Ministry of the Environment; 2005.

    Google Scholar 

  18. Ministry of Science Technology and Innovations. Brazilian Nuclear Energy Commission. Radioactive waste management in radioactive facilities. In: Brazilian Nuclear Energy Commission, Norm CNEN-NE.6.05/1985. Brasília: Ministry of Science Technology and Innovations; 1985.

  19. DATASUS. Health information database from SUS. Brasília: Ministry of Health. http://datasus.saude.gov.br/informacoes-de-saude. Accessed 1 Sept 2015.

  20. Becerril-Montekio V, Medina G, Aquino R. Sistema de salud de Brasil. Salud Publica Mex. 2011;53(sup 2):s120–31.

    Google Scholar 

  21. Secretaria de Atenção à Saúde. Cadastro Nacional de Estabelecimentos de Saúde. Brasília: Ministry of Health; 2014. http://cnes2.datasus.gov.br/Mod_Ind_Unidade.asp. Accssed 1 Sept 2015.

  22. Brazil. Política Nacional de Resíduos Sólidos. In: Environment Mot, 12.305/2010, editor. 12305. Brasília: Minitry of the Environment; 2010. http://www.planalto.gov.br/ccivil_03/_ato2007-2010/2010/lei/l12305.htm. Accessed 1 Sept 2015.

  23. Moreira AMM, Günther WMR. Assessment of medical waste management at a primary health-care center in São Paulo, Brazil. Waste Manag. 2013;33:162–7.

    Article  CAS  PubMed  Google Scholar 

  24. Brazilian Health Surveillance Agency, Ministry of Health. Manual de gerenciamento de resíduos de serviços de saúde, Série A - Normas e Manuais Técnicos. Brasília: Ministry of Health; 2006. http://www.anvisa.gov.br/servicosaude/manuais/manual_gerenciamento_residuos.pdf. Accessed 1 Sept 2015.

  25. Health-care waste management - Rapid assessment tool for country level. [http://www.who.int/water_sanitation_health/medicalwaste/ratupd05.pdf]. Accessed 1 Sept 2015.

  26. Mcnall M, Foster-Fishman PG. Methods of Rapid Evaluation, Assessment, and Appraisal. Am J Eval. 2007;28(2):151–68.

    Article  Google Scholar 

  27. Anker M, Guidotti RJ, Orzeszyna S, Sapire SA, Thuriaux MC. Rapid evaluation methods (REM) of health services performance: methodological observations. Bull World Health Organ. 1993;71(1):15–21.

  28. Rossi PH, Freeman H, Lipsey MW. Evaluation – a systematic approach. 6th ed. Michigan-USA: Thousand Oaks: Sage Publications - University of Michigan; 1999.

    Google Scholar 

  29. UNEP. Basel convention on the control of transboundary movements of hazardous wastes and their disposal. United Nations Environmental Program. 2014. Accessed 1 Sept 2015.

  30. Stelzig S. Country Profile: Brazil. Focus Migration. 2008;15:1–11.

  31. IOM. Migration Initiatives 2015: Regional Strategies. Migrants and Cities. International Organization for Migration. 2015.

  32. Recommendations for the crosscultural adaptation of the DASH & quickDASH outcome measures. [http://www.dash.iwh.on.ca/assets/images/pdfs/X-CulturalAdaptation-2007.pdf]. Accessed 1 Sept 2015.

  33. Gjersing L, Caplehorn JRM, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Med Res Methodol. 2010;10:13.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Guillemin F. Cross-cultural adaptation and validation of health status measures. Scandinavian Journal of Rheumatolology. 1995;24(2):61–3.

    Article  CAS  Google Scholar 

  35. Herdman M, Fox-Rushby J, Badia X. A model of equivalence in the cultural adaptation of HRQoL instruments: the universalist approach. Qual Life Res. 1998;7(4):323–35.

    Article  CAS  PubMed  Google Scholar 

  36. Reichenheim ME, Moraes CL. Operationalizing the cross-cultural adaptation of epidemological measurement instruments. Rev Saude Publica. 2007;41(4):665–73.

    Article  PubMed  Google Scholar 

  37. Sperber AD. Translation and validation of study instruments for cross-cultural research. Gastroenterology. 2004;126(Suppl):124–S128.

    Article  Google Scholar 

  38. Silva ENC. Resíduos de Serviços de Saúde: aspectos conceituais, legais e técnico- operacionais. In: Costa MAF, Costa MFB, editor. Biossegurança geral para cursos técnicos da área de saúde. Rio de Janeiro: Publit; 2009. p. 269–84.

    Google Scholar 

  39. Morelli J. Environmental Sustainability: A Definition for Environmental Professionals. Journal of Environmental Sustainability. 2011;1(1):1–9. Article 2.

    Article  Google Scholar 

  40. IPEN. International POPs Elimination Network. International POPs Elimination Project. Mobilizing Brazilian Civil Society for Stockholm Convention Implementation. Brazil: International POPs Elimination Network. 2006. Accessed 1 Sept 2015.

  41. Sistema Nacional de Informações sobre Saneamento. [http://www.snis.gov.br]. Accessed 1 Sept 2015.

  42. Demographic census 2010. [http://ces.ibge.gov.br/base-de-dados/metadados/ibge]. Accessed 1 Sept 2015.

  43. Totikidis V. Applying the nominal group technique (NGT) in community based action research for health promotion and disease prevention. The Australian Community Psychologist. 2010;22(1):18–29.

    Google Scholar 

  44. United Nations Environmental Program - UNEP. Stockholm Convention on Persistent Organic Pollutants. In: ONU, editor. Promulgated by Federal decree n° 5.472, on June 20th, 2005. Stockholm: ONU; 2001. p. 28.

    Google Scholar 

  45. UNEP. Minamata Convention on Mercury. United Nations Environmental Program. 2013. Accessed 1 Sep 2015.

  46. ABRELPE. Panorama dos Resíduos Sólidos no Brasil. São Paulo: Associação Brasileira de Empresas de Limpeza Pública e Resíduos Especiais -; 2013. http://www.abrelpe.org.br/panorama_edicoes.cfm. Accessed 1 Sept 2015.

  47. Kumar R, Somrongthong R, Shaikh BT. Effectiveness of intensive healthcare waste management training model among health professionals at teaching hospitals of Pakistan: a quasi-experimental study. BMC Health Serv Res. 2015;15(81):1–7.

    Google Scholar 

  48. Thakur V, Ramesh A. Healthcare waste management research: A structured analysis and review (2005–2014). Waste Manag Res. 2015;33(10):855–70.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

Our acknowledgments go out to the researchers from the social sciences, and to the policy makers (Ministry of Health and the Ministry of the Environment), who participated as experts in the theoretical analysis of the instrument and its items; and to the managers and partners: Municipal Foundation of Health from Niteroi/RJ; Department of Health and Civil Defense of the State of Rio de Janeiro, who authorized the participation of their health-care facilities, located in Niteroi.

The authors also acknowledge the professionals of all the health-care facilities who donated their time to answer and evaluate the quality of the items, contributing to the improvement of the Brazilian version of HCWM-RAT. We also thank Michael Eduardo Reichenheim for his comments and suggestions on the manuscript. Humberto N. C. da Silva helped with English editing and we are very grateful.

ENCS is thankful to the Visiting Researcher Program of FIOCRUZ/CNPq, who granted a fellowship supporting the present work (process #104080/2014-0). Presently, ENCS is supported by a Post-doctoral Grant from the Brazilian Federal Agency for Support and Evaluation of Graduate Education; CAPES (process # PNPD20131082-31010016015P0). JCW is thankful to CNPq for a Productivity Fellowship (process # 306714/2013-2).

Funding

This research was not supported by any funding agency.

Availability of data and materials

All the data underlying the findings is contained within the manuscript.

Authors’ contributions

ENCS participated in the conception and design of the study, carried out the data collection, analyzed and interpreted the data, drafted the manuscript and critically revised it for intellectual content. CRS participated in the analysis and interpretation of the data and critically revised the manuscript. ALL participated in the analysis and interpretation of the data and critically revised the manuscript. JCFAW participated in the analysis and critically revised the manuscript for intellectual content. BR participated in the conception and design of the study and critically revised the manuscript. LRT participated in the design of the study, participated in the interpretation of the data, and critically revised the manuscript for intellectual content. All the authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

The research was conducted with the written permission of the WHO. The study protocol was approved (including the informed consent process) by the Research Ethics Committee of the Sergio Arouca National School of Public health, Oswaldo Cruz Foundation (ENSP/FIOCRUZ) under protocol number 0231.0.031.031-10.

Written informed consent was obtained from each participant before any study procedure was initiated.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Eliana Napoleão Cozendey-Silva.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cozendey-Silva, E.N., da Silva, C.R., Larentis, A.L. et al. Cross-cultural adaptation of an environmental health measurement instrument: Brazilian version of the health-care waste management • rapid assessment tool. BMC Public Health 16, 928 (2016). https://doi.org/10.1186/s12889-016-3618-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-016-3618-4

Keywords