Community Health Assessment Tools Adoptable in Nursing Practice: A Scoping Review

The WHO European Region defined the role of a new central professional for primary care, the Family and Community Nurse (FCN). The introduction of an FCN in the framework of health policies highlights a key role of nurses in addressing the needs of families and communities. A scoping review was conducted in order to identify and describe the available tools which have been adopted for the assessment of community health needs by FCNs. A comprehensive literature review on the Embase, Cochrane Library, PubMed, CINAHL, Scopus and PsycInfo databases was conducted including all studies up to May 2021. A total of 1563 studies were identified and 36 of them were included. The literature review made it possible to identify studies employing twelve different community assessment tools or modalities. Referring to the WHO framework proposed in 2001, some common themes have been identified with an uneven distribution, such as profiling the population, deciding on priorities for action and public healthcare programs, implementing the planned activities, an evaluation of the health outcomes, multidisciplinary activity, flexibility and involving the community. To the best of our knowledge, this work is the first attempt to provide an overview of community assessment tools, keeping the guidance provided by the WHO as a reference.


Introduction
During 2020, the whole world had to face, and is still fighting, the consequences of the pandemic caused by COVID-19, which led to an unprecedented health crisis, not only due to the organic shortages of health professionals, procurement materials and personal protective equipment, but also due to the organization of Western health systems that are built around the concept of patient-centered care. The concept of patient-centered care does not allow for addressing the changes that an epidemic requires as an approach based on community-centered care [1].
These two care models do not express alternative concepts, but rather a cross planning and organizational approach; therefore, these are complementary concepts. Ideally, the patient-centered model responds more to the individualistic-paternalistic ethics, while the community-centered model responds to the ethics of public assistance systems, oriented to the fairest possible effort to meet the needs of the entire population, therefore of each person. This second model integrates more easily with the possible decision-making and organizational synergies between health, society and the environment. − To identify community strengths and areas for improvement; − To identify and understand the state of the community's health needs; − To define areas for improvement to guide the community towards the implementation and support of policies, systems and environmental changes around healthy living strategies (e.g., physical activity, nutrition, tobacco and chronic disease management); − To help prioritize community needs and to consider the appropriate allocation of available resources.
The community needs assessment enables local stakeholders to work together in a collaborative process to analyze the community itself; offer suggestions and examples of change policies, systems and strategies; provide feedback to communities as they institute local changes for healthy living [9]; ensure resources allocation where there is the greatest health benefit; and adopting the principle of equity in practice [4].
Increasing healthcare demands, limited resources and growing health inequalities require governments across the European community to guarantee the right to health of all citizens [1], resulting in a paradigm shift away from historic "wait-and-see" healthcare in Europe and towards one already prevalent in other countries [10]. The issue of the assessment of community health needs, or rather socio-health needs, fits into this context, not only in European health services but in those around the world. The "health needs assessment" process plays, in fact, a central role: it allows professionals and policy-makers to identify priority health needs in the population and to ensure that social and health resources are used to maximize health and well-being; however, despite the centrality of this issue, there is not currently a standardized tool which reflects the framework proposed by the WHO in 2001 [9].
A scoping review was conducted in order to identify and describe the available tools which have been adopted for the assessment of community health needs by FCNs, without geographical restrictions.

Materials and Methods
The scoping review allows researchers to examine the extent and nature of research activities on a specific topic, to summarize and disseminate research findings and to identify research gaps in the existing literature [11].
A comprehensive literature review on the Embase, Cochrane Library, PubMed, CINAHL, Scopus and PsycInfo databases was conducted including all studies up to May 2021 in the English or Italian languages. The following inclusion criteria were adopted: The full text articles of all potentially eligible studies were retrieved and, after removing the duplicates, reviewed independently by four reviewers (CC, CP, NVU and YL) Any disagreement was resolved by a majority vote with the support of a tiebreaker (SS).
Data of the included studies were extracted and synthetized, in particular: authors, year, title, setting, study design and methods, purpose, sample and adopted tool and main findings. Any disagreement in the data extraction was resolved by a consensus of two experts (YL and SS). The study authors or investigators were contacted when additional information was necessary [12].

Study Selection and Charting the Data
After the removal of duplicates, articles were screened in order by titles, abstracts and then full text. A total of 1563 studies were identified and, after the removal of the duplicate studies, 610 abstract and 312 free-full-text studies were evaluated and then a total of 36 studies were identified (Figure 1).
The characteristics of primary studies are heterogeneous, also in the adopted design. A synthesis of the results is reported in Table 1. The most widespread tool, although only officially recognized in the USA, is the Community Health Needs Assessment (CHNA), reported by Akintobi et al. [13]; Carlton
The characteristics of primary studies are heterogeneous, also in the adopted design. A synthesis of the results is reported in Table 1.
The CHNA is a systematic process involving the community to identify and analyze community health needs. The process provides a way for communities to prioritize health needs and to plan and act upon unmet community health needs.
The Patient Protection and Affordable Care Act [22] has demanded that nonprofit hospitals must conduct a CHNA once every three years. The purposes are to adapt health services, implement strategies to address health priorities and improve population health.
Another tool, used in South Korea, is the Comprehensive Health and Social Needs Assessment (CHSNA) by Park et al. [23]. This validated system is characterized by userfriendly images and can be used by healthcare professionals, social workers and community residents to evaluate the reasoning underlying health and social needs, to facilitate the identification of more appropriate healthcare plans and to guide community residents to receive the best healthcare services. In detail, the assessment covers three areas: a basic health assessment, a life and activity assessment and an in-depth health assessment.
Through the literature research, another measurement method has been identified, such as the Community-Based Collaborative Action Research (CBCAR) by Van Gelderen et al. [24] and Krumwiede et al. [25]. This tool seems to facilitate community engagement and promote critical dialogue.
The Community-Based Participatory Research (CBPR) [13] is a partnership approach to research that equitably involves community members, organizations and researchers in all aspects of the research process. All partners shared expertise, decision-making and ownership. The aim of this tool is to increase the knowledge and understanding of a given phenomenon and to integrate the knowledge gained with interventions for policy or social change benefiting the community members.
The Precede-Proceed Model [26] is a cost-benefit evaluation framework proposed in 1974 by Green that could help health program planners, policy makers and other evaluators to analyze situations and design health programs efficiently. It provides a comprehensive structure for assessing health and quality of life needs, and for designing, implementing and evaluating health promotion and other public health programs to meet those needs.
The Participatory Rural Appraisal (PRA) [27] is an approach used by nongovernmental organizations (NGOs) and other agencies involved in international development that incorporates the knowledge and opinions of rural people in the planning and management of projects and programs.
Other tools, specific for certain categories of the population or patients, are used; for example, the Carer Support Needs Assessment Tool (CSNAT), used by Horseman et al. [28], Alvariza et al. [29], Ewing et al. [30] and Aoun et al. [31] is an evidence-based tool that enables the comprehensive assessment of carers' support needs, facilitating tailored support for the family members and friends of adults with long-term, life-limiting conditions (palliative care, motor neuron disease, etc.). It comprises 14 areas of need in which carers commonly request support. Carers may use this tool to state what they need both to allow them to care for their family member or friend and to preserve their own health and well-being within the caregiving role.
The Questionnaire for Assessing Community Health Nurses' Learning Needs [32] is destined for community health nurses.
The EASY-care [33], is a comprehensive geriatric assessments (CGA) instrument designed for assessing the physical, mental and social functioning and unmet health and social needs of older people in community settings or primary care.
The SPICE assessment tool [34], a shorter version of the Camberwell Assessment of Need for the Elderly, has been developed for routine use in primary care, focusing on five domains: Senses, Physical ability, Incontinence, Cognition, and Emotional distress (SPICE).
The University of Kansas Community Tool Box and the HRSA Compliance Manual have been used by Burns et al. [35] to conduct a needs assessment aimed at enhancing the service delivery of African-American adolescents and young adults at an urban federally qualified health center.
Finally, a modified version of the Patient Centered Medical Home Assessment (PCMH-A) has been developed by Kimble et al. [36] to assess primary care nurses' perceptions of their practice.
Some other tools reported in literature are: the Community Health Assessment toolkit [37], Mobilizing for Action through Planning and Partnerships (MAPP) [38], State Health Improvement Planning (SHIP) Guidance and Resources [39], Community Health Assessment and Group Evaluation (CHANGE) [40], Needs Assessment, Resource Guide [41], Healthy People 2030 and MAP-IT [42].
Among these methods, those that deserve further exploration for their flexibility, innovativeness, effectiveness in identifying a community's needs and for the involvement and empowerment of citizens are listed below.
− The elaboration, with the help of a local artist, of a "visual tool" [27], similar to a board game, submitted to citizens in order to identify and quantify the different needs of the population. − The creation of a short video [15] in which some citizens are interviewed with the purpose to "give voice" to the minorities of the community. These videos have been used not only as a source of data for the assessment but also as a proposal to integrate the point of view of the community to the CHNA process through their direct participation. − The use of applications and technological devices for community needs assessments [46]. − The planning of tools for needs assessments of people with low literacy skills [46].
Another important source of information which requires dedicated deepening, with transversal value at the international level, is the Community Health Needs Assessment-An introductory guide for the family health nurse in Europe [9]. It is a tool designed for services planning at the level of families, communities and populations, highlighting the importance of the nurses' contribution in the process. It describes how the evaluation of needs can identify priorities, directing resources to address inequalities and to activate a mechanism of involvement and participation of the local population.
The first part of the tool provides practical and user-friendly guidance to nurses through some general definitions and more specific advice regarding the needs assessment, dividing the process into three sections: profiling of the population, how do you find out and what to do with the information. The second part is a training pack written for trainers involved in nursing education about community health needs assessments.
Lastly, 'A Framework for Community Health Nursing Education' is a document produced by WHO [51] representing a possible approach to analyzing the community context through a participatory process between the reference stakeholders of the territory.
An overview of the common aspects of these tools with the WHO framework is reported in Table 2. Community-based experiences are reported (Ecuador, Japan, Los Angeles and Kenya) which support the thesis that the process of assessing needs is conducted with an approach and a tool that is as specific as possible and that allows communities to identify their own healthcare needs. This approach develops trust and therapeutic education between professionals and the community. Different types of assessment are reported including questionnaires, semi-structured interviews in person, by post or telephone and the participatory rural appraisal (PRA). The assessment process is adapted to the context and a combined approach of the different methodologies may be used. Nineteen themes emerged from interviews analysis; an innovative approach was adopted with the involvement of a local artist which allowed the construction of a graphic tool (visual tool) similar to a board game to be submitted to the population in order to identify and quantify the different needs of the community itself.
Strengths: -It emphasizes the importance of a cross-cultural approach; -The study is based on Leininger's theories of cross-cultural nursing and the process of community involvement in Hildebrandt's model of health empowerment; -The importance of using an approach and tools for health assessments that at the same time involve the population and are specific to the community in question; -An innovative approach that analyzes the assessment process and emphasizes nursing. Weaknesses: -It is a relatively dated study (2007); -The study was conducted in a setting different from the national one (rural island of Honduras). The CSNAT implementation led to an improvement in caregiver strain during the caregiving period within the research context. Effective implementation of an evidence-informed tool represents a necessary step towards helping palliative care providers better assess and address caregiver needs.
Strengths: -Demonstrates the usefulness of CSNAT and identifies it as a priority for caregivers.
-CSNAT was positively rated by both caregivers and nurses. Weaknesses: -Study conducted in Australia; -CSNAT is a useful assessment tool but very specific one (although it can be used by the nurse). The study was carried out in four phases (and specific methodologies) to carry out an assessment process as complete as possible (interviews, focus groups, interviews with key informants, reviews of public data in the database and the creation of questionnaires). Among the results emerged: improving awareness of a culturally specific, feasible and accessible action for primary care. The study shows that CHNAs offer to family and community medicine an opportunity to gain a greater understanding of the issues affecting the health of patients that goes beyond just a medical examination. In addition, it is considered a useful tool for training.
Strengths: -It is a recent study (2016); -The CHNA is considered a useful tool for training within the community; -Although this study involves doctors with extensive experience in the field of primary care, postgraduates and students, the CHNA approach is used, which is considered a useful tool especially if it allows the involvement of the largest number of professions, in addition to the medical ones, such as nursing. Weaknesses: -The nursing role is not analyzed; -The study was conducted in the USA with a specific CHNA process.  (2017); -It offers an innovative way of assessment (recording of interviews); -It supports, through a qualitative study, the contribution of the population to the identification of strategies for improving health and activates a process for involving the population; -Culture is considered an essential element to be integrated into the care process. Weaknesses: -The study was conducted in the USA; -The nursing role is not analyzed. Student assessments indicated an emerging appreciation for the social determinants of health, the power of partnerships and the importance of diversity. The integration of healthcare and public health system perspectives on assessments meets both public health and nursing accreditation standards and extends student leadership experiences. This integration also improves the regional capacity to improve the population's health state.
In conclusion, federal mandates for a community health needs assessment provide opportunities to advance leadership roles for nursing graduates throughout the health system and to confirm the importance of community assessments as an essential nursing competence.
Strengths: -It is a recent study (2017); -Nurses and nursing students are examined and importance is given to the community needs assessment process as a core competence of community/public health nurses (C/PHN). Weaknesses: -The study was conducted in the USA, with a cultural context different from the Italian one. Unmet needs corresponded to 7% of the total needs and "emotional distress" was the most frequent. The SPICE tool helped identify undisclosed needs, it was well accepted and its importance in clinical evaluation was recognized by GPs and patients, despite concerns about time constraints.
Strengths: -It is a recent study (2018); -It investigates the needs of a part of the population that is considered more fragile in the context of primary care; -The tool (SPICE) is considered easy to use for assessing the elderly population. Weaknesses: -The study was conducted in Portugal and not on a community but on a target population (the frail elderly belonging to the primary care department). The study participants accepted the CSNAT and perceived it as useful but used it as an 'add on' to current practice, rather than as a new approach to carer-led assessments. The barriers to CSNAT use include carers' self-deprecating attitudes and feeling that their own needs are much less important than those of the person they are caring for.
Strengths: -The CSNAT is a useful but very specific assessment tool, and it can be used by the nurse. Weaknesses: -The CSNAT is validated but can only be used in the specific target of caregivers of people at the end of their life. Purpose: To clarify the process by which community health needs can be structured through public health nurses' (PHNs) daily practice.
Sample: A total of 29 PHNs (inclusion criteria: work experience of at least 3 years).
Participants "used their five senses to understand the relationship between people's health and life" and some key themes were identified: -Learning from the community; -Visiting communities frequently; -Giving importance to minorities; -Comparing the subjective and objective.
Strengths: -It is an attempt to reconcile theoretical knowledge with daily practice; -It pays attention to the training process of professionals in PHC; -It is a recent study. Weaknesses: -The study was conducted in Japan, with a care setting and characteristics of nursing different from the Italian ones; Applying the results to continuing education systems can not only help to appropriately improve community health assessment methods, but can also help improve daily practice assessments and contribute to professional development.
-A very general study and, at the same time, specific results obtained for the setting in which the study was conducted; -The assessment process is not investigated; -No specific tool for the assessment has been evaluated. A tool was created to assess the needs of the resident population in South Korea, validated by a group of experts. The tool features user-friendly screenshots and images. The assessment concerns: 1. A basic health assessment. 2. A life and activity assessment. 3. An in-depth health assessment. The developed CHSNA system can be used by healthcare professionals, social workers and community residents to assess processes underlying health and social needs, to facilitate the identification of the most appropriate health plans and to guide community residents to receive the best health services.

ICT-Based
Strengths: -It is a recent study (2019) which uses innovative methods for community assessments; -There are many different professionals involved in the creation of the ICT system; -The International Classification of Functioning, Disability and Health (ICF) was used as a reference model. Weaknesses: -The nursing role is not specified; -The study was conducted in South Korea; -There are no specific details on the tool structure or the response of the population. Interviews and focus groups were conducted and decision-making needs studied based on the Ottawa Decision Support Framework. Decision-making needs are numerous, varied and different from those of the general population, including 26 decision-making needs grouped into five themes. The most frequent decisions concern access to the emergency room, transfer to a nursing home and adherence to a plan or treatment. In addition, issues such as patients' fear and distrust of healthcare professionals, differences of opinion between healthcare professionals and preconceived views of healthcare professionals about patients were identified.
Strengths: -It is a recent study (2019); -The study links many important aspects for the assessment process including the information needs of people and the needs of professionals; -It emphasizes the importance of shared-decision-making. Weaknesses: -The study was conducted in Canada; -The role of the nurse is not specified. In this study, the community needs assessment process (CNA) is a useful tool to identify the community's strengths and resources in order to address the social and healthcare needs of its members and must be culturally sensitive. In particular, FQHCs must perform a CNA every 3 years to accurately document the needs of the communities. This study made it possible to identify the priorities for the AYAs community (mental health, obesity and sexual health).
Strengths: -It is a recent study (2020); -The methodology and tools used; -It supports the importance of conducting the assessment, especially among the less represented categories within the community. Weaknesses: -It is a very specific study including only the target population of AYAs in Detroit; -The role of nurses is not analyzed.

Discussion
Community health assessments are the basis to defining, implementing and evaluating the services and educational programs necessary to reach public health, through the definition of the main health problems and the factors influencing them, the identification of the community's resources, the development potential and the involvement and empowerment of the people belonging to the community [9].
By identifying research using various community assessment tools, this review was able to find several recurring themes.

Education and Skills of the Family and Community Nurse
The relevance of education to improving how community health is assessed has been highlighted in numerous papers [19,24,25,44,47,49]. Education should be advanced [43,52] and specific to some professional fields, such as palliative care [53,54].
Evans-Agnew et al. [16] stated that the assessments of community health needs through academic and practical partnerships offer new opportunities for skills development, not only for professionals, but also for nursing students.
For education planning, it is necessary to determine the areas of competence development of family and community nurses through the assessment of learning needs [16,25,32,36,50].

Shared Decision Making and Nursing Role
The assessment process is defined as a core competence for the community/public health nurse (C/PHN) [9]. Nevertheless, among the selected studies, there is a limited number of those that refer to nurses, both as responsible for the assessment and as a processes member with other professionals [16,27,29,32,33,47,49,50,52].
In Cho et al.'s [47] work, it is argued that nurses play a key role in identifying the needs of the population and in reducing health inequalities.
Running et al. [27] consider nurses as professionals who can establish a real trust relationship with community members, the main actors in the assessment process [16,29,32,33,50].
Wilder et al. [19] offers a different point of view: the assessment process is carried out exclusively by doctors. Their work states that conducting a CHNA in a primary care training program can helps the next generation of family physicians become culturally competent and community-focused.
Yoshioka-Maeda et al. [50] found that providing support from PHNs to citizens considered as "difficult clients" was the starting point for identifying community health problems and the need for new services in their daily practice. The results showed that PHNs first took care of their "difficult clients" and, after, gradually identified the existence of community health problems. This is different from a traditional community assessment, in which the identification of community health problems is considered the first step in the development of a new service or action and is necessary to gather sufficient information to understand the community and to clarify its specific health problems.
In addition, community/public health nurses (C/PHN) during their daily practice make choices based on their responsibility and professional authority, determining if the different needs identified and/or problems may be addressed independently or in teams or, in general, with other professionals on an interdisciplinary level [47,50].
This perspective recognizes the usefulness of teamwork in assessment and planning: shared decision making (SDM) is an interpersonal and interdependent process in which the healthcare provider, the person and his or her family members relate to and influence each other, collaborating in healthcare decisions.
The SDM focuses on the evidence-based experiences of healthcare professionals and the unique attributes of the "patient" and her/his family [57]. This allows people to improve their knowledge of available options and clarify which ones are more important, taking into account your own values.

Community Engagement and Empowerment
The data produced by community assessments are as important as the process itself, because it allows a population's engagement to be activated which leads to the empowerment of the individual and the community. The assessment process, therefore, depends on the underpinning methodological and theoretical orientation. Sharma [21] examined two possible types with different outcomes. The first has been described as a directive assessment, characterized by goals and subject matters defined by the professional, service delivery-focused, centralized decision-making, a focused task definition, a community as an object and with an expert practitioner that sees him/herself as having whole knowledge of the problem and whole responsibility for results. The second has been defined as a nondirective assessment where community members are involved in the decision-making process and play a vital role in defining their priority health needs and in taking action to meet them, with decentralized decision-making, open-ended task definitions, community as the subject and with a reflective practitioner that spends more time studying the problem and engaging the community in a dialogue regarding problems and their possible solutions.
Community engagement has a positive impact on health, particularly if supported by strong organizational and community processes [55].
The systematic review by Haldane et al. [55] argues that community participation is a key element of an equitable, rights-based approach to health that has been shown to be effective in optimizing the health interventions for positive public health outcomes in a wide range of health areas and on multiple levels: organizational, community and individual.
Indeed, engagement makes it possible to establish trusting partnerships, to collect human and financial resources, to enhance communication processes and to improve health outcomes [24].
A theme closely related to engagement is empowerment; in fact, the participation of community members in decisions about their health reflects the process of empowerment itself [27] and is considered, along with the establishment of trusting relationships between citizens and professionals, to be a key element of health.
Furthermore, the citizens themselves express their willingness to be actively involved by health organizations [15]. Nevertheless, CHNAs often use quantitative data, revisions of the public data in databases and rarely incorporate directly the "voices" of the local community members. Then, what emerges is only an average of the data and not the specific, actual needs of the community, leading to an increasing risk to not identify and/or to underestimate the needs of some minority groups, such as ethnic minorities [15], or to not recognize the needs at the family/individual level, keeping in too-general terms.

"Culturally Competent" Approach
Among the examined studies, Running et al. [27] grounds its theoretical foundations on Leininger's theories of transcultural nursing and the process of community involvement of Hildebrandt's model of health empowerment. Several studies show the importance of using an approach and tools for the assessment that at the same time involve the general population [15,27,54] and the specific community considered, keeping a high sensitivity to the local community and minorities' culture [15,27,31,35,45,46,48,54].
The population itself [15] asks that social health organizations treat culture as a useful resource for health.

Development of Social Policies
Conducting a health needs assessment can guide policies and systems, approaches to environmental change, community-administered grants and job creation [13]. Furthermore, it improves hospital community continuity [14] and reshapes the path of care of elderly or end-of-life patients [56]. All of the above requires attention to community stakeholder involvement in collaborative assessment and planning, an understanding of the etiology of diseases, identification and intervention on the broader determinants of health, adopting a public health assessment and planning model and, finally, emphasis on improving population health [18].

Flexibility and Local Adaptability of Tools
The CHNA may be conducted by a variety of organizations thanks to its adaptability and the possibility to customize. Every community and hospital is different in terms of resources, demographic data, health issues, partners, history and other contextual factors that contribute to the manner in which organizations and community members work together, make decisions, identify and address problems and resources. Therefore, although the tool refers to the American context, thanks to these features, it could also be applied in other countries.
However, without more specific guidance or evaluation criteria, the usefulness, the applicability and the potential improvement of community outcomes are difficult to identify [17]. For this reason, Pennel [18] gives some recommendations to improve assessments and outcomes on a population's health.
In addition, organizations may carry out the CHNA using different methodologies, producing results that cannot be compared effectively. In fact, many authors have demonstrated information gaps [14,17,20].
The WHO [9] suggested that for several contexts, the tools can be adapted, up to the use of different tools combined each other, in order to create one that is effective and suitable for the considered community, the social and health characteristics of the citizens and for the network of services present.
The tool and the adopted approach need to be multidisciplinary and allow community engagement and empowerment [9,15,23,46].
To the best of our knowledge, this scoping review is the first attempt to provide an overview of community assessment tools, keeping the guidance provided by the WHO as a reference.

Limitations
This study has some limitations. First, this article does not perform a critical assessment of the literature included. However, as a scoping review, the aim of this study was not to synthetize evidence, but to pool together elements and core concepts from a various body of knowledge. The literature review was performed until May 2021, exposing this work to a publication bias. Nevertheless, the COVID-19 pandemic may also have led to differences in perspectives among studies conducted from 2020 onward compared with those from previous years.

Conclusions
Community assessments are a core competence for nurses but their role must be better defined, both as an autonomous and a collaborative one. According to Friedman [5], nurses work with individuals, families and communities at different levels and degrees.
From the literature review and the analysis of regulatory references emerges a multiprofessional approach, both in assessing the health needs of the community and in the treatment of identified needs. It means that the global assessment of the community and the definition of programs and services are carried out by a multi-professional team, with the equal participation of the community members.
When nurses work with families and communities, their goal is to guide them in the identification of problems and strengths, supporting analysis and decision-making. Community health can, in fact, be defined as the satisfaction of the collective needs of its members through the identification of problems and the management of interactions within the community [58].
The multidisciplinary approach in "individuals' and communities' health needs identification" must not, however, leave behind the fundamental and widespread role of every nurse involved in the everyday care of individuals, as: a source for activity data collection, which will then be aggregated; indirect community health promotion, supporting the individual health; the reinforcement of the social responsibility of each citizen, through health education.