Artigos

INTRODUCTION
In August of 2019, Brazil’s Northeastern Coast was afflicted by the largest orphan oil spill in the country’s history1. The event was considered an environmental crime and is the most extensive (2890 km) oil spill ever reported in tropical oceans, with 5 tons of waste collected2. Between August of 2019 and March of 2020, spilled oil was reported in 1009 distinct locations within 130 municipalities and 11 states, mainly affecting the coast of northeastern Brazil2,3. Although the oil was spilled in the open ocean, its presence was not reported until it reached the shoreline, hindering traditional mitigation techniques for oil spills, including containment in open water2,3.
In the 2019/2020 disaster, crude oil appeared on the Brazilian coast recurrently and across a large geographic area, with distinct volumes of oil appearing in a discontinuous pattern along the coast3. Figure 1 shows the affected locations, classified by the date of sighting of the oil and the amount of oil collected, first disaster response actions, and states that declared an emergency before the federal government issued a decree3,4.
Figure 1. Affected locations, classified by the date of oil sighting, the amount of oil collected, initial disaster response actions, and the states that declared an emergency before the federal government issued a decree.

The spilled oil affected more than 10 unique tropical ecosystems2, with the greatest number of oiled faunae reported in the state of Bahia3. The presence of oil-related contaminants, including polycyclic aromatic hydrocarbons (PAHs), was reported and quantified in seawater and fish2. In addition, heavy metals were measured in seawater from impacted sites at levels above those recommended by Brazilian legislation2. With the pollutant classified in Group 4 “Heavy Oils,” this disaster off the Brazilian coast is likely the only spill in the world with such a significant volume of oil and whose origin and polluter are unknown3.
Because of the lack of immediate response from the federal and state governments, fishers and other residents attempted to mitigate the effects of the spilled oil along the coastline. Thousands of volunteers responded, both individually and collectively, to remove oil from the beaches. Cleanup activities had a high potential for human exposure to oil, as most occurred without professional guidance or usage of personal protective equipment (PPE)5,6.
More than 360,000 artisanal fishers (AF) in Northeast Brazil faced increased financial vulnerability, health risks, and nutritional concerns in the months following the spill6. There was a documented increase in hunger and malnutrition in fishing communities7. These economic and nutritional challenges left fishers with the difficult choice between starvation or consumption of fish and shellfish from affected territories, even if this could aggravate toxicological health effects. In addition to the acute effects, environmental contamination by crude oil may also cause lasting impacts on the ecosystem and fishing territories5.
A study of fishers affected by the Prestige Oil Spill who took part in the clean-up process in Spain indicates that exposure to oil residues, even for short periods, can have harmful effects on health, such as an increase in respiratory symptoms and other changes suggestive of persistent airway damage8. In Brazil, artisanal fishers are exposed to overlapping chemical and physical hazards, as they reside near disaster sites, work in affected areas, and participate in the removal of oil.
Artisanal Fishing Background
Artisanal fishing communities play a major role in the food system, as well as coastal management, local economics, environmental protection, and sustainable use of marine and aquatic resources9. Despite artisanal fishing’s importance, it is a cultural and subsistence practice that remains undervalued and neglected. Global catch from fisheries totals 92 million tons, with small-scale fisheries contributing 37 million tons (40%)9.
Given the various existing global definitions of the term "small-scale fisher"9 and the predominance of their use in the international context, we have chosen to consider both terms as synonyms in the context of this article. The difference between small-scale fishers and artisanal fishers is generally related to the context and focus of their definitions, although both terms often overlap9.
In Brazil, AF are workers registered with the Ministry of Fisheries and Aquaculture who carry out their activity directly as professional fishers, autonomously or in collaboration with other community members, with their own means of production or through a partnership contract on small vessels10. Throughout this paper, we use the gender-neutral “fishers” to encompass fishermen, fisherwomen, and shellfish gatherers.
Artisanal fishing makes up 45% of Brazil's seafood production, with the Northeast Region, including Bahia, contributing 34% (415,723 tons). 75% of this comes from artisanal fishing11. Out of Brazil's 970,000 registered professional fishers, 957,000 (98%) are in artisanal fishing11. Artisanal fishing is physically demanding with, on average, 100-hour work weeks that include catching and processing seafood11, 12.
An epidemiological study carried out in a fishing population in Bahia shows that 95.9% of those interviewed declare themselves black and or brown, and 10.3% illiterate, evidence of a low educational level13. Fishing incomes are very low: Averaging 70 USD per month for shellfish gatherers and 117 USD per month for fishers, their earnings corresponded to 23.4% and 40.4% of the country's monthly minimum wage in 2017, respectively13. In addition, fishing communities have faced significant health disparities, the loss of collectively owned land, and environmental contamination of their homes and fishing territories by the growing petrochemical industry14.
During the oil spill, fish and shellfish consumption and sale in Northeast Brazil were halted, directly impacting artisanal fishers and worsening the spill's economic impact. Seafood sales plummeted by 80-100% in Pernambuco, Northeast Brazil, with farmed species like shrimp experiencing a 50% price drop. The decline in tourism and seafood sales severely impacted the Northeast's economy and the seafood production chain7,15. Thus, even areas without oil contamination faced social and economic impacts2.
Given the limited information on the short- and long-term effects of exposure to oil spills on human health and the magnitude of this disaster, this article aims to describe the design and the questionnaire validation of a cross-sectional epidemiological study. The questionnaire can be applied to cohort studies to examine the potential effects of the 2019 oil spill on human health among artisanal fishers.
Study Rationale
During the oil spill, there was no systematic assessment of human exposure to oil and minimal quantification or characterization of airborne or aquatic pollutants affecting coastal communities. The Entre Mares Research Project is a shortened name referencing the project Exposure and Health Effects Assessment Study in Fishers Affected by the 2019 Oil Spill in Brazil (EHEASFB). The project aims to estimate individual exposure to oil during the oil spill and the overall impacts of the oil spill on health, economic stability, and health-related quality of life (HRQOL) in artisanal fishing communities across the state of Bahia. The multidisciplinary team participating in the “Entre Mares Research Project” involved epidemiologists, toxicologists, biostatisticians, qualitative researchers, and fishing community leaders that designed and conducted the study. This paper describes the theoretical framework and methodology of the study design, as well as the implementation of the epidemiological questionnaire titled “Exposure and Health Effects Assessment Questionnaire in Fishers Affected by the 2019 Oil Spill in Brazil (QESP-DP19)”. This epidemiological study is one of few that evaluate the exposure and health impacts of oil spills, with a focus on artisanal fishers, and utilizes a community-engagement approach.
Theoretical Framework for the Entre Mares Study
The impacts of oil spills include environmental, public health, and economic consequences. Human health and the environment are interrelated, especially in fishing communities that have deep connections with coastal aquatic environments. In this way, the affected territories represent damage to the spaces where families live and work.
This study is inspired by the model proposed by Sandifer & Walker (2018)16 and Sandifer et al. (2021)17 to assess and identify the diversity of possible effects on human health in major oil disasters: individual (psychological, physical health, economic) and community (sociological, economic and cultural effects)17. Two theoretical frameworks were combined to guide the study. The first is the United States Academy of Science’s Exposure Science in the 21st Century Exposure Assessment Framework. Under this model, exposure precedes health impacts and an individual’s level of exposure is directly impacted by multiple factors including individual decisions, contaminant intensity, and upstream social and environmental factors. This model was combined with the Social-Ecological Framework approach, which is used to identify the key determinants of exposure and public health outcomes, including health, quality of life, and economic impacts. Figure 2 illustrates this combined framework, highlighting the numerous factors that may have an important role in determining the level of individual exposure, as well as the breadth of public health impacts for individuals and impacted artisanal fishing communities. This theoretical framework was used to guide the development of the epidemiological questionnaire.
Figure 2. Proposed Framework for Assessing Oil Spills Exposures for Artisanal Fishing Communities.

Health-Related Quality of Life and Oil Spills
Quality of life is an indicator of how well one perceives that he/she is functioning physically and mentally. An epidemiological study showed lower HRQOL of artisanal fisherwomen/shellfish gatherers from Bahia, in comparison to the general population in Brazil18. Some studies analyzing HRQOL and disasters caused by oil spills have identified worse scores related to the mental health domain19,20.
Objective of the Entre Mares Study
The study's objective is to assess the impact of the 2019 oil spill on fishing communities in the coastal region of the state of Bahia, Brazil. Our hypothesis is that exposure to the oil spill resulted in acute effects on the physical health and quality of life of AF exposed to the spill. The limited emergency response by the Brazilian government, coupled with the nuances of a community that relies on the ocean for their livelihood, primary source of nutrition, and cultural practices, created a unique challenge for assessing exposure and public health impacts. Community-engaged research methods, previously detailed elsewhere 21, were integral to the study design. This involved collaboration with affected fishers to ensure the project addressed community and research team interests. Several meetings were held with the fishing advocacy organizations Fishers’ Pastoral Council (CPP) and Movement of Fisherwomen and Fishermen (MPP) to develop the overarching research goals and ‘select study sites to increase visibility of the impacts of the oil spill on fishing communities.
METHODS
Questionnaire Design and Validation
The questionnaire is divided into the following topics: demographic information, involvement in activities related to oil exposure, confounding variables (such as work history, COVID-19, tobacco use), health information, and HRQOL22. Both health information and HRQOL will be used to assess outcomes in relation to oil exposures.
The Delphi Method was employed to validate the questionnaire using feedback from experts in toxicology, epidemiology, and environmental health. The Delphi approach describes a strategic process of seeking feedback from experts in a particular field to reach a consensus from a large group23. The six-phase process of the Delphi method was as follows:
1. Creation of Questionnaire Draft 1. Based on a literature review and contributions from fishing community leaders, a questionnaire was developed with the necessary questions to achieve the study's objectives.
2. Identification of expert participants. Researchers listed potential participants based on their expertise, seeking individuals with broad knowledge of the research topics. Eligible participants held a doctorate in public health, toxicology, or a related field, or had significant work experience in environmental health with a post-graduate degree. They were contacted via email to complete a consent form for the Delphi study; non-respondents were excluded after one week.
3. Delphi Round 1. Round 1 aimed to assess whether the first questionnaire draft aligned with the project's research goals. Participants received an abstract outlining the project's history and goals, along with Questionnaire Draft 1. Items were categorized by the intended research question. Additionally, participants received questions about each category to confirm that the questionnaire addressed all research goals.
4. Analysis of Round 1 Responses. The Entre Mares research team calculated several statistical measures with the Round 1 responses, including response rate, average score by category, average score as a percentage of the maximum score, and committee agreement rate. These values and any qualitative comments from participants were used to develop Questionnaire Draft 2.
5. Completion of Delphi Round 2. Participants received Questionnaire Draft 2 in the format that it would be provided to the target population. In addition to the questionnaire, they received a survey to provide commentary about specific questions, as well as the formatting and overall effectiveness of the questionnaire.
6. Analysis of Round 2 Responses. The Entre Mares research team analyzed the experts’ feedback using the same methodology followed in step 4. They edited the questionnaire accordingly to create Questionnaire Draft 3, which was used in pilot testing with the target community.
Questions focused on participant identification information, demographic characteristics, and the pre-validated HRQOL questionnaire (SF36 V2, discussed below) were excluded from the Delphi process to limit the burden on respondents.
Selection and Description of Study Sites
Study site selection prioritized highly exposed fisher communities and those facing reported health challenges. The following characteristics were used to select final study locations in Bahia:
1. Areas where Brazil’s Crisis Command reported the high volume of oil collected, proportionally, according to IBAMA maps3.
2. Presence of coastal mangrove forests. Based on the Atlas of Environmental Sensitivity to Oil on the coast of the state of Bahia24, crude oil is more difficult to remove from mangrove forests because of the increased surface area created by the flora. In addition, fishers would be more likely to have direct contact with the spilled crude oil while fishing in mangroves as they enter the water during fishing activities.
3. Presence of resident populations that were potentially exposed to oil during the disaster via direct dermal contact, respiration, or contaminated food sources.
4. Presence of a large vulnerable population due to reliance on subsistence fishing and/or shellfish gathering. This criterion considers that these populations may be exposed for longer periods of time, due to possible dermal and dietary contact with oil, as well as their economic vulnerability due to reduced opportunities for fishing due to ecosystem destruction.
5. Located in areas where molecular evaluations of marine life contamination and chemical analysis of water and sediment were conducted by other research teams.
Using these criteria, six municipalities were selected to be part of a cross-sectional epidemiological study between January and November 2021 (Table 1 and Figure 3).
Table 1. Characterization of the study sites by Unit of Conservation (UC) classification, municipality, and estimated population of fishers participating in the study, Bahia, 2021.


Figure 3. Localities and municipalities surveyed on the coast of Bahia: Epidemiological study on the oil spill in Brazil, 2019/2020.

Participant Recruitment and Community Engagement
Community leaders were contacted to assist with recruitment and survey administration. The project team described the study in meetings with leaders and representatives of fishing trade associations. During the meetings, questionnaire dissemination strategies were conceived alongside fishing leaders, according to the unique needs at each study site. A messaging application (Whatsapp) and hand-delivered invitations were used to schedule interviews. Videos to publicize the research were broadcast on social media networks, and the research coordinator appeared in interviews in the local media (radio and newspaper) to mobilize participants.
Artisanal fishers in Brazil are generally enrolled with one or more trade organizations in their community. The leaders of fishing trade organizations provided lists of program beneficiaries for participant recruitment. These lists were updated in the field with the help of fishing community leaders. All those present on the lists who fit the study selection criteria were invited to participate. Financial remuneration was not offered.
All participants were required to meet the following selection criteria: AF aged 18 or over, residing in one of the areas included in Table 1 and whose name was present on the list provided by a local fishing trade association; fishers who were active or retired, but still fishing regularly. Fishers over 18 years of age, included in the lists provided, but who were not working as fishers at the time of the oil spill period, were excluded from the study.
Fishers and children of fishers who had graduated from or were attending high school were invited to apply to serve on the questionnaire administration team alongside university-affiliated researchers. Members were selected based on the following criteria: communication skills, ease of handling electronic devices, research experience, engagement with social movements and artisanal fishing organizations, and affinity with the project themes. These field interviewers were provided a stipend and trained in research techniques and COVID-19 health and safety protocols. They played a key role in mobilizing participants, establishing community trust in the research team, and carrying out research activities.
Study Procedures
The questionnaire22 consists of 325 items, distributed in the following 13 blocks: Identification and control (4 Items (I); General information (16 I); Socioeconomic status and living conditions (9 I); Work history and work organization (37 I); Organization of fishing activities during the oil spill (51 I); Exposure associated with the oil spill clean-up (39 I); Seafood consumption (39 I); Perception of the impact of the oil spill (14 I); Clinical measures (5 I); Other health information (26 I); Lifestyle (20 I); Quality of Life (Medical Outcomes Study 36-Item Short-Form Health Survey - SF36 V225,26 (36 I); COVID-19 (16 I)22.
Responses were recorded in the Qualtrics (v2) offline research application on tablets used exclusively for data collection. The questionnaire requires between 40 and 60 minutes for each participant to complete. Anthropometric measurements, including height, weight, and waist circumference, were recorded using standardized protocols22,27.
Health and Safety Protocol
All questionnaires were administered in person due to inadequate internet and phone service coverage in the study locations. Additionally, anthropometric measurements required participants’ in-person attendance. A Health and Safety Protocol was developed in consideration of safety needs during the COVID-19 pandemic. All team members completed health and safety training. All health and safety procedures followed the Technical Standards of the State of Bahia Health Department 28.
This project was approved by the Research Ethics Committee of the Faculty of Medicine of the Federal University of Bahia, Brazil, (No. 4.444.084, CAAE:29570620.3.0000.5577), and in the Biodiversity Information Authorization System (SISBIO), (No. 76691).
RESULTS
Delphi Survey Validation and Survey Administration
A total of 33 experts were invited to participate in the Delphi review process. In round one, 15 participants completed the review, for a response rate of 45.5%. In round two, 14 participants completed the review, for a response rate of 42.4%. The first round showed strong consensus that the survey topics were well-matched to the study’s research objectives. The key concerns raised included the time between the crisis and the questionnaire application, as well as the length of the questionnaire. Experts recommended shortening the questionnaire where possible.
During the second round of the Delphi review process, the alcohol/tobacco consumption and COVID-19 sections of the questionnaire were identified as needing structural changes prior to questionnaire implementation. In other sections, wording adjustments were recommended for clarity, but adding or removing questions was not advised. All changes were made in accordance with the Delphi feedback prior to study implementation.
In total, sixteen scholarship recipients assisted in survey administration across five of the six communities, and at least one fishing trade organization supported the project in each municipality21.
Fisher Participation
The rates of participation in the study varied significantly between the five municipalities, as shown in Table 1. Canavieiras and Una provided a single shared estimate, as fishers from both sites are part of the same fishing trade organization, called AMEX. Using the provided estimates, participation rates varied from 13.8% in Belmonte to 87.3% in Conde. Overall, we estimate that 36.9% of fishers in the participating municipalities were interviewed, with a 100% completion rate. 959 individuals responded to the questionnaire (see supplementary document).
DISCUSSION
Research following a disaster can provide information to help mitigate health consequences, inform future recovery efforts, and improve resilience29. In this sense, the Entre Mares Project directly addresses the urgent research, social, and health needs arising from the largest oil spill in Brazilian history. Some authors indicate a significant gap in scientific research on oil spills and human health, with only 1% of spill-related studies addressing the consequences of these disasters on human health30. Additionally, this study represents an opportunity to prepare the health sector to respond to the disaster and support the healthcare needs of the exposed population.
The study was based on the need to construct a validated questionnaire specifically adapted to AF. Given this challenge, the theoretical framework of the study, as well as the questionnaires developed by the Gulf Study31, were utilized as references. The expertise of researchers from the Federal University of Bahia (UFBA)13 who were already engaged in studies targeting this population was also essential to the study design.
The effects of oil spills on human health have not been well studied32. This study is one of the first to focus exclusively on artisanal fishing communities and prioritize the inclusion of vulnerable communities. Brazil’s artisanal fishing communities, which are predominantly Black and Indigenous, are particularly vulnerable as they have been excluded from decision-making roles regarding environmental and health protections, as well as emergency preparedness and responses.
Many fishers volunteered through informally organized events to clear oil from the beaches without safety training, likely resulting in exposure to the oil6. Artisanal fishers are subject to overlapping exposure to oil. Because they live in communities affected by the disaster, fishers may be exposed through dermal or inhalation exposure to oil during oil containment activities at sea and/or beach oil removal; by ingesting contaminated shellfish and/or fish; and during work activity, both during the disaster period and months after the first sighting of oil stains on the beaches, when residues continued to be identified in fishing areas. The questionnaire identifies various forms, frequencies, and intensities of exposure, enabling comparisons among fishers based on location-specific exposure levels. These distinctions facilitate comparisons between groups of fishers with varying degrees of oil exposure.
A community-engaged approach is a strength of our study21. It was used to ensure that the research goals, approaches and results would be reflective of the experiences of the fishing communities. The research instruments were developed to address the concerns of our community partners and to assess commonly measured exposures for oil-impacted communities. Our questionnaire was based on questionnaires used in other studies31; however, as the AF is a unique and under-studied population, significant changes were necessary to ensure participation of the fishing community and the Delphi approach to building consensus.
Because of the population's characteristics, like low education and limited phone and internet access, face-to-face questionnaire administration was necessary. Additionally, three significant challenges for study planning were the lack of official data on the number of fishers, the absence of prior health information, and the ongoing COVID-19 pandemic. Official statistics on AF in Brazil are limited11, particularly regarding health data. Thus, the study's findings will enhance the understanding of this population.
Despite the study employing community-engaged methods and the broad dissemination of the questionnaire, the COVID-19 pandemic required the establishment of a specific protocol to protect researchers and interviewees, which may have resulted in delays in data collection and reduced response rates from fishers affected by the disaster.
One of the challenges in this study was selecting the areas for investigation. The starting point for this selection was the Atlas of Environmental Sensitivity to Oil24. This facilitated an alignment of interests between environmental and epidemiological impact studies, which is fundamental for studies in environmental epidemiology. The study also aims to consider the spatial and social variations of each investigated area, as well as the characteristics of the population, which contributes to comparing exposure levels between individuals.
Study participants were asked about the presence of health-related symptoms 1 to 3 months after the oil spill. The acute health effects could not be captured in real-time, having been reported in a self-reported manner with a delay of 17-26 months from the start of the disaster. Although this can cause memory bias, the traumatic effects of a disaster most often remain in the memories of those affected33. The persistence of symptoms can partly be captured through the questionnaire.
Despite the rigor and inclusive investigation techniques that are a central component of this research, this study has some limitations. First, the cross-sectional epidemiological study design has limited capacity to establish causal associations. Secondly, the conclusions of this study cannot be generalized to non-fisher populations that carried out oil waste cleanup activities, or to the general population living in the oil spill area. Third, there is a time delay between the beginning of the oil spill and the data collection period, which began approximately seventeen months after the beginning of the oil spill. This delay can impact our ability to interpret the initial impact of the oil spill and may result in a recall bias. In addition, COVID-19 and its impacts on local communities add a likely significant confounder in our analysis of the impact of the oil spill on the HRQOL of participants.
Another important point to highlight is that, to compare the upcoming results of this study with similar oil spill disasters, the differences related to the chemical components of the oil spilled in each of the disasters must be taken into account8.
The methodological design of the Entre Mares study presented in this article is the first step in carrying out a pioneering study investigating the health effects of the largest oil spill in the South Atlantic. This article aims to present the design of the study and the characterization of the population. The results related to health impacts are not included. The application of this questionnaire will allow for the creation of a baseline to assess associations between exposure and health effects, monitor the health effects in this population over time, and analyze occupational and socio-economic impacts, among other research topics. Despite the methodological and operational difficulties faced, we highlight the importance of the active participation of community members in all stages of the research, a fundamental element for the success of the study.
Although one million Brazilians are artisanal fishers, they remain under-studied in terms of health, as well as their importance for food security and the preservation of marine ecosystems. The results obtained from this research represent opportunities for the public health system to improve care for this population, for the scientific community to understand the importance of fishers in environmental preservation, and for the fishing population to claim their historically denied rights.
Acknowledgments: Thanks to Charlene da Silva for the final review.
REFERENCE
1. Mendes LF, Eichler PPB, Leite T, Bennemann ABA, Melo CS, Ferreira AL, Garcia KBL, Silva LLN, Barker CP, Vital H, Gomes MP, Lopes PFM. On the impact of Brazil’s largest recent oil spill on regional oceans. Sustain Mar Struct. 2021 Sep 9;3(2).
2. Soares MO, Teixeira CEP, Bezerra LEA, Rabelo EF, Castro IB, Cavalcante RM. The most extensive oil spill registered in tropical oceans (Brazil): the balance sheet of a disaster. Environmental Science and Pollution Research. 2022 Jan 21;29(13):19869–77.
3. IBAMA (2019) Manchas de óleo no litoral Brasileiro. Available from: https://www.gov.br/ibama/pt-br/assuntos/fiscalizacao-e-protecao-ambiental/emergencias-ambientais/manchasdeoleo/arquivos/2023/20230118_Of_Ext_30_279_2020_CM_MMA_An_Incidente_Poluicao_Oleo_Relatorio_final.pdf
4. Freitas CM, Peres MCM. O desastre tecnológico envolvendo derramamento de petróleo no Brasil – Diagnóstico preliminar sobre lições aprendidas e perspectivas futuras para o setor saúde - Relatório Técnico.CEPEDES/ENSP/FIOCRUZ. 2021. Available from: https://www.arca.fiocruz.br/handle/icict/56099
5. Soares EC, Bispo MD, Vasconcelos VC, Soletti JI, Carvalho SHV, Oliveira MJ, Santos MC, Freire ES, Nogueira ASP, Cunha FAS, Sandes FDD, Santos RAR, Leite Neta MTS, Narain N, Garcia CAB, Costa SSL, Santos JCC. Oil impact on the environment and aquatic organisms on the coasts of the states of Alagoas and Sergipe, Brazil - A preliminary evaluation. Marine Pollution Bulletin [Internet]. 2021 Oct 1;171:112723.
6. Pena PGL, Northcross AL, Lima MAG de, Rêgo R de CF. Derramamento de óleo bruto na costa brasileira em 2019: emergência em saúde pública em questão. Cadernos de Saúde Pública. 2020;36(2).
7. Araújo ME, Ramalho CWN, Melo PW. Pescadores artesanais, consumidores e meio ambiente: consequências imediatas do vazamento de petróleo no Estado de Pernambuco, Nordeste do Brasil. Cad. Saúde Pública, Cad Saúde Pública. 2020;36(1):230319
8. Rodri?guez-TrigoG. Health Changes in Fishermen 2 Years After Clean-up of the Prestige Oil Spill. Annals of Internal Medicine. 2010 Oct 19;153(8):489.
9. FAO, Duke University & WorldFish. Illuminating Hidden Harvests: The contribution of small-scale fisheries to sustainable development. 2023.
10. Brasil. Lei nº 11.959, de 29 de junho de 2009. Política Nacional de Desenvolvimento Sustentável da Aquicultura e da Pesca. Diário Oficial da União. 29 jun 2009. https://www.planalto.gov.br/ccivil_03/_ato2007-2010/2009/lei/l11959.htm
11. Rêgo RF, Müller JS, Falcão IR, Pena PGL. Vigilância em saúde do trabalhador da pesca artesanal na Baía de Todos os Santos: da invisibilidade à proposição de políticas públicas para o Sistema Único de Saúde (SUS). Rev Bras Saúde Ocup. 2018;43(suppl 1):1 9.
12. Pena PGL, Gomez CM. Health of subsistence fishermen and challenges for Occupational Health Surveillance. Ciência & Saúde Coletiva. 2014 Dec;19(12):4689–98.
13. Müller JS, Silva EM, Rego RF. Prevalence of Musculoskeletal Disorders and Self-Reported Pain in Artisanal Fishermen from a Traditional Community in Todos-os-Santos Bay, Bahia, Brazil. International Journal of Environmental Research and Public Health. 2022 Jan 14;19(2):908.
14. Barros S, Medeiros A, Gomes EB, organizadores. Conflitos socioambientais e violações de direitos humanos em comunidades tradicionais pesqueiras no Brasil: relatório 2021. Olinda, PE: Conselho Pastoral dos Pescadores, 2021. https://www.cppnacional.org.br/publicacao/relat%C3%B3rio-dos-conflitos-socioambientais-e-viola%C3%A7%C3%B5es-de-direitos-humanos%C2%A0em%C2%A0comunidades
15. Ferreira BMP, Bonfim CVD, Raposo IPA, Quinamo TS, Campos LHRD. Socio-environmental disasters and their impacts: socioeconomic consequences of the oil spill in the northeast region of Brazil. An Acad Bras Cienc 2022;94(suppl 2).
16. Sandifer PA, Walker AH. Enhancing Disaster Resilience by Reducing Stress-Associated Health Impacts. Front Public Health. 2018. 6: 373.
17. Sandifer PA, Singer BH, Colwell RR. The U.S. Needs a National Human Health Observing System. Front Public Health. 2021. 9: 705597.
18. Müller J, Falcão I, Couto M, Viana W, Alves I, Viola D, Woods CG, Rego, RF. Health-Related Quality of Life among Artisanal Fisherwomen/Shellfish Gatherers: Lower than the General Population. International Journal of Environmental Research and Public Health. 2016 May 5;13(5):466.
19. Lyons RA, Temple JM, Evans D, Fone DL, Palmer SR. Acute health effects of the Sea Empress oil spill. Journal of Epidemiology & Community Health. 1999 May 1;53(5):306–10.
20. Osofsky HJ, Hansel TC, Osofsky JD, Speier A. Factors Contributing to Mental and Physical Health Care in a Disaster-Prone Environment. Behavioral Medicine. 2015 Jul 3;41(3):131–7.
21. Machado LOR, Mota LSR, Larrea-Killinger C, Orsi PA, Nascimento JS, Northcross AL, Rego RCF. Dialogue of knowledge for the assessment of the impacts of the oil spill disaster on the Brazilian coast in 2019. In: Gomez S, Köpsel V, editors. Transdisciplinary Marine Research Bridging Science and Society. 1 ed. New York: Routledge; 2023. p. 320.
22. Rêgo RCF, Machado LOR, Mota LSR, Caldas WM, Lima VMC, Muller JS. Pesquisa para monitorar os possíveis efeitos à saúde da exposição ao petróleo na população atingida pelo desastre de derramamento de Petróleo na Costa brasileira no ano de 2019: Relatório de Execução. Salvador, Universidade Federal da Bahia. 2024. 1:147. https://repositorio.ufba.br/handle/ri/39922
23. Osborne J, Collins S, Ratcliffe M, Millar R, Duschl R. What ?ideas-about-science? should be taught in school science? A Delphi study of the expert community. Journal of Research in Science Teaching [Internet]. 2003 Aug 25;40(7):692–720.
24. Brasil. Atlas de sensibilidade ambiental ao óleo das bacias marítimas da Bahia. José Maria Landim Dominguez, organizador. Brasília: MMA, 2012.
25. Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. User's Manual for the SF-12v2TM Health Survey. Lincoln: Quality-Metric Incorporated; 2007.
26. Ciconelli, RM. Brazilian Portuguese version of the SF-36: A reliable and valid quality of life outcome measure. Res. Bras. Reumatolog. 1999, 39, 143–150.
27. IBGE. Pesquisa Nacional de Saúde: Manual de entrevista. 2013. Available from: http://biblioteca.ibge.gov.br/visualizacao/instrumentos_de_coleta/doc2963.pdf
28. Bahia, Secretaria Estadual de Saúde. Boletins epidemiológicos e notas técnicas [Internet]. Governo do Estado da Bahia 2020. Available from: https://www.saude.ba.gov.br/temasdesaude/coronavirus/notas-tecnicas-covid-19/
29. Kwok RK, Miller AK, Gam KB, Curry MD, Ramsey SK, Blair A, Engel LS, Sandler DP. Developing Large-Scale Research in Response to an Oil Spill Disaster: a Case Study. Current Environmental Health Reports [Internet]. 2019 Aug 2;6(3):174–87. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699641/
30. Murphy D, Gemmell B, Vaccari L, Li C, Bacosa H, Evans M, Gemmell C, Harvey T, Jalali M, Niepa TRH. An in-depth survey of the oil spill literature since 1968: Long term trends and changes since Deepwater Horizon. Marine Pollution Bulletin. 2016 Dec;113(1-2):371–9.
31. NIEHS - National Institute of Environmental Health Sciences. The GuLF STUDY. 2011. Available from: https://gulfstudy.nih.gov/en/index.html [accessed 20 mar. 2022]
32. Woodward C. Gulf oil spill exposes gaps in public health knowledge. Canadian Medical Association Journal. 2010 Aug 9;182(12):1290–2. https://doi?org.nuncio.cofc.edu/10.1503/cmaj.109?3329
33. Sandifer PA, Juster RP, Seeman TE, Lichtveld MY, Singer BH. Allostatic load in the context of disasters. Psychoneuroendocrinology. 2022 Jun;140:105725.