Environmental health in public health community practice : An integrative review of the literature

It is understood that the performance of Public Health Nursing is indispensable for the development of sustainable health communities, with regard to sub-standard living conditions in environments that include physical, chemical and biological factors influencing these conditions. This work is in an integrative review which aims to characterize how Environmental Health appears in scientific Public Health Nursing production, for the development of community health. Out of 442 articles, 30 met the search criteria. The publications covered contamination and exposure to environmental risks; strengthening of community groups for environmental health and workforce development of public health nursing for community practice in environmental health. The results summarized in the present study support the growing trend of interest in Environmental Health as knowledge which is essential to Public Health Nursing practice in the community.


INTRODUCTION
The Millennium Development Goals of the United Nations include the relationship between human health and environmental health (EH) sustainability [1].In this perspective, it is understood that the performance of Public Health (PH) Nursing becomes indispensable, through its theoretical and practical skills and commitment to social justice, with the aim of minimizing inequalities in relation to sub-standard living conditions in environments which include physical, chemical and biological factors [2] which influence these conditions.
The aim of this review is to characterize how EH appears in PH Nursing scientific production, for the development of community health.According to the World Health Organization (WHO), [3] community health corresponds to a combined science of values, beliefs and skills directed towards the maintenance and development of health for all people through collective and social action.Programs, services and institutions involved prioritize disease prevention and the needs of the population as a whole [3].We are of the belief that PH Nursing is a sub-area of nursing knowledge which is building a body of knowledge tied to environmental sciences.In other words, PH Nursing has in its production, scientific evidence which is included in the interdisciplinary field of EH, which is the desired relationship with the health of communities.
The aim is to explain the themes and forms of apprehension about EH which are included in the cataloging of peer reviewed articles, defining the scope and limits of the findings presented here.Future potential for other research review is also highlighted.

METHODS
To achieve this goal, the integrative review method was preferred, which allows for complete synthesized research and for obtaining evidence from the theme, EH in the sub-area of PH Nursing.For this operational review there were six stages: defining the guiding question; establishment of criteria for inclusion/exclusion for the selection of scientific articles; definition of the information to be extracted from selected articles; analysis of the included studies; interpretations of the results and; presentation of an integrative review [4].The quality of the evidence of the texts selected were classified into seven levels: 1 evidence from a systematic review or meta-ana-lysis of randomized controlled trials or derived from clinical guidelines based on systematic reviews of randomized controlled trials; level 2 evidence from at least one well delineated randomized controlled Trial; level 3 evidence from well-designed clinical trials without randomization; level 4 evidence from cohort and case-control well delineated trials; level 5 evidence from a systematic review of descriptive and qualitative studies; level 6 evidence from a descriptive or qualitative study and; level 7 evidence from opinion of authorities and/or report of expert committees [5].
The guiding question was: How does Environmental Health appear in the scientific production of Public Health Nursing, for the development of community health?
The selection of studies was focused on EH and as a collective object and study and intervention in the subarea of PH Nursing.Thus, studies of interest sought to address communities in need of EH.To help standardize the research, the definition of EH from WHO [2] was adopted.EH is related to the physical, chemical and biological external factors, which may interfere with human behavior.EH is comprised of the evaluation and control of those environmental factors which have the potential to adversely affect health.This is achieved through disease prevention and healthy environments.It should be noted that this definition excludes behavior not related to the environment, social and cultural environments and genetics [2].The choice of a social-historical scope of the definition in different areas of knowledge, which makes the multi-disciplinary knowledge productive and which is the particularity of PH Nursing, is explained.

Study Selection Criteria
The peer reviewed literature was screened to identify articles documenting the production of PH Nursing in relation to the EH community, as aforesaid.The EH includes any external factor related to people living in particular surroundings (that which is around people), understood as a community setting.Therefore, it is reiterated that the review was restricted to studies that highlight EH in relation to the collective object and community of the study and intervention in the sub-area of PH Nursing.Dissertations, theses and texts without abstracts were not included.Studies that did not show at least one nurse as an author were excluded.The study was limited to articles that were available in English, Portuguese or Spanish.Only studies which constitute research with empirical data in relation to EH as the collective object and in relation to the community of the study with intervention in the sub-area of PH Nursing were considered in this review.

Search Strategy
The following electronic databases were searched for the period January 1992 to December 2012: CINAHL, Medline, Web of Science, Cochrane Library and Science Direct.The choice of this period is justified, due to the relationship with EH Nursing as an object of study and intervention, from the socio-temporal context of the United Nations Conference on Environment and Development.In addition to this milestone justifies the reported evidence that the formal description of the technical and scientific skills of PH Nursing is not explicit in the scientific community until 1990 [6].
To search the peer reviewed texts, recourse was made to the National Library of Medicine, Medical Subject Headings (MeSH ® ), for confirmation of keywords required, namely: Environmental Health (the science to control or modify conditions, influences or forces that surround men/women and that relate to the promotion, establishment and maintenance of health); Public Health Nursing (the area of nursing with a focus on community health through preventive and educational programs, as well as providing treatment services and diagnosis); and Community (elements that characterize a population; apply in determining the need for and use of health services).
The inclusion or exclusion of studies was conducted by two independent evaluators.There is an agreement among evaluators in all the stages.

Inclusion, Exclusion and Presentation of Studies
Throughout the researched literature, 442 publications were identified.Most publications were indexed in Medline (n = 130), followed by CINAHL (n = 124), Cochrane Library (n = 179) and Science Direct (n = 9).After identification of the results, duplicated articles were removed and 57 publications were eliminated.Publications which did not have at least one nurse as an author were also withdrawn, eliminating 26 publications and five publications which appeared in German, Greek, Slovenian, Chinese and Japanese.In the first screening encountered in the title, 359 publications were analyzed.Such analysis enabled the identification of 114 relevant references.Of the 245 articles excluded after reading the titles, 59 did not respond to the study theme and 186 had no empirical research methodology.The second screening encountered in the summary of the articles, identified 30 relevant references.The 84 excluded articles were not appropriate to the study theme (Figure 1).
Of the 30 included studies, eighteen (60%) addressed contamination and exposure to environmental risks; four (13%) addressed the strengthening of community groups for EH and eight (27%) addressed the workforce development of PH Nursing for community practice in EH (Table 1).
Concerning the publication years, most articles were published in 2010 (n = 5) (Figure 2).
Regarding the articles, analyzed quality of the evidence in the first subset, "Contamination and exposure to environmental risks", 18 articles (94.4%) had levels of evidence 6 and 1 article (5.55%) level 2. In the second subset, "Strengthen community groups for environmental health", 3 articles (75%) had levels 6 and 1 article (25%) level 7.In the third subset, "Workforce development of public health nursing for community practice in environmental health", all eight articles analyzed showed level 6.In all of the analyzed articles, the majority, 28 texts (93.35%), presented evidence level 6.
Concerning the impact factor of the journals containing the analyzed publications, the highest was 3.926 of the American Journal of Public Health.The lowest impact factor was the journal Annual Review of Nursing Research (0.182).
Characteristics of studies included in the review, grouped by subject are present in Table 2.

Contamination and Exposure to Environmental Risks
In this subset studies were found which had been developed in a rural setting, in the home and at school.This latter is related to environmental pollution produced by tobacco smoke in the school environment [12].The contamination and exposure of the rural environment include, for example, contamination by asbestos [9]; rural environment contamination by the concentration of animals and their effect on human health; exposure to secondhand smoke in a rural school; [21] the rural home environment as the focus of PH nurse intervention [11].It should be noted that explicit means for EH were included in these studies, as, for example, the use of parks for adolescents [19] as a positive element in the construction of EH.Another study related to environmental exposure to smoke from vulnerable groups, is the case of the child whose parents smoke at home [17] as an intervention object for PH Nursing practice.Such studies indicate the different areas that are present in the EH practice of PH nursing, highlighting the need for preparation of professionals to work with such diversity.

Strengthen Community Groups for Environmental Health
Positive evidence of PH Nursing interventions was In this study of parks uses by youths there was no association between organized activity participation after school and team identification as a source of motivation for the young becoming active.

Continued
Sowing the seeds for sustainable change: a community-based participatory research partnership for health promotion in Indiana, USA and its aftermath [20] United States Communitybased participatory research (CBPR).
Analyze the development of the partnership originated from CBPR, the methods and findings and environmental changes that sought to promote healthier lifestyles.
The study argues that participatory research on the impacts on health initiatives, such as the analyzed program (CBPR), have often been disappointing in their ability to explain the likely impacts on community health through the collaborative efforts of confidence on the individual, community, institutional or policy sectors.From the evidence, the following observation for the long term arises.
Environmental health effects of concentrated animal feeding operations: implications for nurses [21] United States Self-reported exposure to environmental hazards for workers' environments of concentrated feed and neighboring farms.
Identify evidence of exposure risks to workers' health, the environment for concentrated animal feeding.
The adverse health effects have been found in workers and neighbors.A number of respiratory effects were noted for workers and neighbors, some of which are severe enough to cause workers to leave the industry.The mental health of neighbors seems to suffer as well, mainly because of noxious odors and stress.
The role of the community health nurse in environmental health [22] United Analyze two communities and describe the interpretation of environmental risk of its residents In an evaluation of nursing in a contaminated community, the nurse is critical as a source of social facts and the nurse can be qualified to be an agent of an official or scientific information agency for residents of contaminated sites.This is because the communication needs to be conducted with mutual trust, through a collaborative process of building skills within the community in order to empower residents and leaders to independently verify the safety of their community.Present a methodology and conceptual framework based on the results of programs used to evaluate the performance and impact of a coalition of local community.

Comprehensive
The analysis of co-development alliance in Douglas County, with regard to the final results of the smoking prevention program; the authors emphasize that comparative measurements must be performed every year.Identify that there are strong reasons for the co-alliance to continue, citing among these: the federal program is in decentralization and community is the focus for local and state governments; funding favoring collective community work and strengthen alliance application programs in co-covenant co-alliances to represent are media health programs.Thus, the public health nurses represent excellent resources for the evaluation of services, due to their clinical experience, their knowledge of community resources and their education focused on community groups and individuals.
"The People Know What They Want" An Empowerment Process Of Sustainable, Ecological Community Health [27] United States Ethnographic.
The study was conducted with 33 participants in a community.
Explore the relationships between health, environment and culture from the cultural context of a community.
The results presented allowed for reflection on the story of overcoming (winning over) the community.Through the process of empowerment of individuals in the community, the people of San Jose had voice, structure and action.
Evidence-based advocacy: using Photovoice to identify barriers and facilitators for community participation after spinal cord injury?[28] United States

Communitybased participatory research (CBPR)
Describe the photovoice method applied to individuals with spinal cord injury in order to gather evidence of the environmental factors that affect their community involvement.
The Photovoice is effective to empower individuals with spinal cord injury to address the environmental factors that affect their participation in the community.

Workforce development of the public health nursing for community practice in environmental health
Knowledge of nurses about the Family Health Strategy about health service waste [29] Brazil Qualitative Analyze the knowledge of nurses working in the Family Health Strategy refers to the problem of waste mismanagement of health services, the need to adequately meet the relevant standards and even including the professionals involved in the management process.
The results showed that nine of the ten nurses interviewed were able to diagnose the situation in which the residues are within their unit.However, despite the existence of a significant knowledge on the subject, there is still need to work on awareness and development of best practice waste management of health services.
Developing the community environmental health role of the nurse [30] Scotland Focus group with community nurses and community members Investigate the environmental health concerns of community members from a town in Scotland.
The community nurses believe they have an underdeveloped role.In order to maximize their role, nurses need to be recognized as partners to promote environmental health.To assist in this recognition, it is necessary that the practice of nurses includes the prevention of environmental health.

Continued
Incorporating environmental health into nursing practice: a case study on indoor air quality [31] United Framing personal risk in public health nursing [36] Canada Qualitative (thematic analysis).56 public health nurses were interviewed.

Conduct thematic analysis of the risks present in the workplace of public health nursing
The authors presented four categories to determine the environmental risks of the work of public health nursing, which are: become aware of and recognize influences; make comparisons and know your rights and freedom.The results also showed that 62% of nurses questioned, were not concerned about the risks of the workplace.The authors believe that it is disturbing to think that the same workers who promote health do not care about their own.found, first to reduce contamination and exposure to environmental risks and second, to develop interventions with communities to create and strengthen the EH community One of the statements found a link to risk perception of social groups present in the particular surroundings of a community (environment).Study conducted in two different communities in Arizona/USA [25] identifies that the experiences of resi-dents with contamination and exposure to environmental hazards coincide with the degree of confidence in the public sector, (level of government) [26].This means that knowledge about specific conditions of contamination and exposure is associated with confidence that this fact is true and even when not living it as an event; it is true if you believe in who is advertising it as true fact.Confidence increases in direct relation to the truth of the clari-fied and believed social fact.The process of developing individual skills that focus on community health as an explicit element of the complexity of knowledge to work in EH [27,28].

Workforce Development of Public Health Nursing for Community Practice in Environmental Health
Studies addressing the contamination and exposure to risks in households conducted in the United States demonstrate the ability of the PH nurse to reduce risks in the home environment, linked to the training and institutional support and community development of these skills.They reinforce the fact that the PH nurse is properly positioned to promote the families' and communities' health through the reduction of risks in the home environment [30,31,34,35].
EH represents a challenge in the sub-area of PH Nursing, as a theoretical object and as an intervention object [10,30].In both cases a technical methodological contribution is required which is able to produce scientific evidence for the development of nursing actions [30,32,34,36].It is also assumed that it is a complex interdisciplinary field in which the nurse is included in the production of knowledge.
This review has revealed areas for future research.Future review studies could examine the relationship between the theory and what is applied in the EH community and in training PH Nursing.Studies [37][38][39][40][41] outside the scope of this review show the relevance of EH science as being indispensable for the formation of skills for nursing work in communities as a collective object of EH [37].For this a body of knowledge about contamination and exposure to environmental risks and their potential effects on human health is necessary, [38,39] as well as learning theoretical framework for the construction of EH as a form of social justice and reducing inequitable health conditions, [40] by building healthy environments in partnership with community groups [41].
The possible errors in identification and inclusion of articles were minimized by the inclusion of a second reviewer.As the studies were limited in number, used various methods and metrics and were conducted in several countries, the results cannot be generalized.There was no intent to carry a weight value of the findings of studies to establish the quality of the study.The development of PH actions to achieve social justice corresponds to the understanding that EH is a phenomenon and that nursing in PH is a workforce capable of producing healthy living conditions for different social groups.This means that nursing intervention with communities constitutes a workforce for the production of an EH community.

CONCLUSION
This review identified EH in PH Nursing scientific production related to problems of contamination and exposure to environmental risks (rural, home environment, school environment in relation to pollution caused by smoking), among others.The review shows that the PH nurse operates in EH, focused on problems traditionally recognized in this field with, however, participatory approaches in their community intervention.The results summarized in the present study support the growing trend of interest in EH as essential knowledge for the practice of the community PH nurse.

Figure 1 .
Figure 1.Results during each screening phase and final number of included documents.

Figure 2 .
Figure 2. Distribution of publication years of the articles included in the review (n = 30).

Table 1 .
Subjects addressed in articles included (n = 30).Percentages rounded to the nearest whole number.
SubjectsPercent (%)Contamination and exposure to environmental risks-18 60Strengthening of community groups for environmental health-4 13Workforce development of public health nursing for community practice in environmental health-8 27

Table 2 .
Characteristics of studies included in the review, grouped by subject.Dash marks indicate items not reported in the studies.The areas identified in this assessment represent a set of influences from the context of individual, group and environment in which people were motivated to participate in health screenings in a semi-rural community.The emergence of the three domains of motivators (self-care guidelines, interpersonal influence and accessibility) for participation in sessions in the community reflects an ecological individual, micro, and macro systems.Approaching community participation, from the intersections on the ecological model, is the intersection of intrapersonal and interpersonal dimensions, as well as the explicit macro for social accessibility.