School and Community Relationship in the Perspective of Health Promotion : Integrative Review

Results: Nine studies were selected in Portuguese, Spanish and English, published from April 2006 to April 2016. Most of the rescued studies showed that the type of relationship between school and community has based on actions that are not linked to the principles of Health Promotion, mostly focused on the individual, without considering collective issues, risk factors that cause illness, disconnected from the social context. Few studies present advances in Health Promotion with a critical-citizen perspective and experiences with the potential for the necessary establishment of the school and community relation.


Introduction
The concepts and practices of Health Promotion (HP) became known and implemented worldwide in health systems and academic spaces after the First International Conference on Health Promotion in Ottawa in 1986 [1].Therefore the understanding of health expands and the HP becomes a transversal, integrated, inter-and intra-sectorial strategy for the creation of mechanisms that reduce situations of vulnerability [2,3].
In this perspective the intersectoriality provides the involvement and establishment of shared spaces, the exchange of experiences by the different actors, the sharing of ideas and the planning of the actions to be developed [4].
Based on this understanding, health interventions broaden their purpose, addressing health problems and needs and their determinants and constraints, while developing actions and services that operate in areas beyond the walls of health services [3].
Health Promotion spaces can be understood as all places where educational and human care activities are carried out, such as health units, or other collective spaces, such as schools, where there is the possibility of carrying out activities for the Promotion of People's Health [2].
The expansion of HP spaces allows promoting healthy choices by individuals and communities in the territory where they live, study and/or work, and enables the definition of policies for the preservation and protection of the physical and social environment.The school becomes a potential scenario for the development of personal skills that contribute to the creation and maintenance of healthy environments and that respond to an integral health conception [3].
The Health-Promoting Schools (HPS) serve the interfaces of the school space with society and the commitment to the living conditions of the populations.From this point of view, Health Promotion in schools comprises three main components: health education with an integral approach; creation of healthy environments and provision of health services [5,6].
The relevance of the thematic about the school as an opportune space for Health Promotion is undeniable, as well as the contribution of studies that seek to elucidate the way that the school and community partnership has been established in this perspective.In this context, the article aimed to analyze the national and international scientific production on the relationship between school and community in the perspective of Health Promotion.

Method
The used research methodology was the integrative review.This method allows gathering and synthesizing research results in a systematic and orderly manner, contributing to deepen the knowledge of certain investigated subject or question [7].This choice allowed analyzing, in the literature, how the relationship between school and community has occurred in the perspective of Health Promotion.
In an attempt to understand better this phenomenon, the following question was proposed for this study: How has the relationship between school and community occurred in Health Promotion?
In order to carry out the integrative review, a structured protocol, already validated, was used, which predicted its organization in six stages: elaboration of the guiding question and establishment of inclusion and exclusion criteria; definition of databases; definition of the information to be extracted from the selected studies; evaluation of the studies included in the integrative review; interpretation of results; and presentation of knowledge review/ synthesis [7].
The study included articles in English, Spanish and Portuguese, published in the last 10 years that presented descriptors based on the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS): health promotion, "school" and "community" and answered the research question.As a search strategy, we used the "and" feature between the descriptors.Were excluded articles that did not have in their title or abstract, for at least two of the descriptors used in the search; articles that were not available for-free, editorial letters, as well as monographs, dissertations and theses were excluded.
The articles were retrieved by bibliographic search from January to April, 2016, in the databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Literature in Health Sciences (LILACS), Spanish Bibliographic Index (IBECS) and Scientific Eletronic Library Online (Scielo) consulted through the CAPES Portal and the Virtual Health Library (VHL).
The initial search returned 1082 publications.The texts received a detailed reading of the abstracts, from which the inclusion and exclusion criteria were applied.After reading the titles and abstracts, there was exclusion of duplicate studies in different databases and studies that did not meet the in-clusion criteria.Of these, 36 articles were selected for complete reading, being four in LILACS, 21 in MEDLINE, three in IBECS and eight in Scielo.There was exclusion of 22 articles for not answering the guiding question and five, for not addressing the school-community relationship specifically.Thus, after complete reading, nine articles answered the guiding question and constituted the final sample of this review.(Figure 1) In the stage of results interpretation, thematic analysis was carried out.An overview of the articles for definition of the thematic categories was drawn from the information extracted from the texts, which answered the questions contained in the protocol used for the study.The information extracted from each article included: title, authors, periodic/year/ type of publication/publication medium/database,

Phase 01
How has the relationship between school and community occurred in Health Promotion?

Data collection
Phase 02 objective, type of study/methodology, main results, experiences and strategies that articulate the school and community in the promotion, factors that strengthened or hindered the health promotion at school.Next, the comparison and grouping of the obtained information were performed.
The classification of the scientific evidence from the studies [7] based on levels, as follows: Level 1systematic review or meta-analysis of relevant randomized controlled clinical trials or derived from clinical guidelines based on systematic reviews of controlled randomized controlled trials; Level 2well-delineated controlled randomized trial; Level 3 -evidence obtained from well-designed clinical trials without randomization; Level 4 -evidence from well-delineated cohort and case-control stu-dies; Level 5 -evidence originating from a systematic review of descriptive and qualitative studies; Level 6 -evidence derived from a single descriptive or qualitative study; Level 7 -evidence from the opinion of authorities and/or report of expert committees.

Result
Most of the rescued studies refer to texts produced in Brazil (four), followed by Spain (two), Vietnam (one), USA (one) and Canada (one).Regarding the chronology of publications, the year 2008 had (one) publication and the years 2009, 2010, 2013 and 2014 had two publications each, as shown in Table 1.The selected studies allowed capturing the reality of how the theme of the relationship between school and community in the perspective of Health Promotion has been approached.Table 2 describes the articles included in the integrative review and their characterization of objectives, methodology and results.
With regard to the relationship between school and the community in the perspective of Health Promotion, two thematic categories emerged: 1. [11] To identify and discuss the scientific production published on indexed bases on Health Promoting Schools in Latin America, through the understanding of the scope of the reported initiatives of health education in the programs or interventions

Literature review
There is little scientific production in the Latin American on HPS; Most studies emphasized the importance of effectiveness studies and half focused on reducing some specific morbidity without prioritizing the conceptual axes contained in the Ottawa Charter [12] To present a bibliographic review on school health in Latin America from articles published between 1995 and 2012, reflecting the theme from the possibilities of its effectiveness as a public policy

Literature review
Practical breakdowns and political referrals of the demands raised are not part of their guidelines and do not incorporate a basic element of health surveillance: information for action; Persistence of disease-centered initiatives focusing on screening and prevention actions.However, the election of HP as a strategic school health axis has driven changes [13] To know the characteristics of interventions aimed at education and health promotion in children and primary education, through studies published in scientific journals

Literature review
Health education programs have a more preventive perspective on the disease than on health promotion and are not frequent in primary and secondary education; The criteria of healthy schools were included in only 5 articles from the 26 that were part of the study; There was no acquisition of health skills that promoted individual and social exchanges; Although the interventions extend to the family and educational community, they develop fundamentally in the classroom

Refereces Objective
Methodology Result [14] To analyze the actions developed in the project Open school in five schools of the state education network of Rio Grande do Sul, trying to understand how the subjects participating in the actions perceived the project and the own participation in the activities developed in the weekends

Qualitative research
It was identified with the study that there is the desire, on the part of the populations that live in the surroundings of the schools, for the accomplishment of activities in the weekends, configuring the institution like space of leisure that serves at the same time for the amusement and for formation.
[15] Evaluate the partnership between school and community

Qualitative research
The responses of the students and community members showed differences of positions, in the public school there were complaints of lack of interaction, which resulted in feelings of non-belonging and indifference; Already in the agreed school the community feels responsible for the school, thanks to the opportunities of interaction established [16] Summarize the characteristics and effects of school interventions directed to different areas of conduct

Literature review
The activities were based on different theoretical models and were revealed in interactive lessons, peer mediations, environmental exchanges, activities with parents and community; In some cases they were moderate to large effects; The short and long term on behavioral variables Incipient school and community relationship; and 2. School and community relationship: advances in Health Promotion.

Discussion
This analysis bases on the understanding that a partnership relationship between school and community requires the involvement of all actors, belonging to the school community and its surrounding community in the discussion and formulation of strategies and actions that may, in fact, attend those problematic situations identified by both.Most of the rescued studies, contrary to this conception, showed that the type of relationship between school and community has based on actions that do not relate to the principles of Health Promotion, mostly focused on the individual, without considering issues of collective order, restricting to risk factors that cause illness, disconnected from the social context.Thus, actions carried out superficially and vertically and restricted to the physical space of the school stand out.
Nevertheless, there were few articles dealing specifically with the topic, of which two studies in Brazil provided a glimpse of some experiences, where the relationship between school and community were central themes, and how they may succeed in the establishment of the necessary school and community relationship, evidenced, among other points, by the community's genuine interest in approaching the school and performing, with it, actions for the improvement of people's living conditions [13,14].

Incipient school and community relationship
Most studies have presented results that show the experiences of the school and community in the perspective of Health Promotion as the development of actions, which occurred almost exclusively in the school environment, and included only the school community and members of the students' families.The studies did not adequately recognize or address the importance of the community in the school environment [11][12][13]16].
There were few experience reports with the community participation, such as the organization of workshop-type events and the dissemination of information through the media.However, this action focused on the prevention of risk behaviors such as: healthy nutrition, physical activity, aiming to achieve short-and long-term changes in behavioral variables [16].
In general, most experiences and strategies that related school and community in the perspective of HP found in the studies did not prioritize the conceptual axes of the Ottawa Charter.Nonetheless, even in a smaller number, some studies that presented programs that incorporate criteria of healthy schools had presented more effective results [11,13].
The Ottawa Charter is an essential document to understand the current context of development of the HP.Produced at the First International Conference on Health Promotion in Canada in 1986, the discussions resulting from this meeting pointed to five fields of action: creation of healthy environments; establishment of healthy public policies; development of personal skills; strengthening of popular participation and reorganization of health services [17].
The option to implement the new paths of Health Promotion at schools means adopting a broad and participative action proposal that can be developed in the school context, but also considering its surroundings.In this sense, it must articulate and involve the community in the discussion and planning of strategies and actions that bring resolution to everyday problems [15].
The operationalization of the Health Promotion policy requires the consolidation of practices aimed at individuals and collectives, in a multidisciplinary work perspective, integrated in a way that considers the health needs of the population in an articulated action among the various actors that work in certain territory [2].
In this perspective, the school has represented an important place for the meeting between these actors, constituted by both the student community, as health professionals and the population surrounding them, harboring various possibilities of initiatives that generate autonomy and critical participation of the authors, so that they can collectively construct viable HP proposals [11].
Studies in the USA and Canada [8,9] confirm that schools still tend to develop HP actions focused on the prevention of certain risk behaviors, remnants of a conception of health as an absence of disease, not linked to living conditions of the populations [18].Nevertheless, the results of these studies point to a better performance in healthy behaviors, such as the decrease in the percentage of overweight and obesity and decrease in the prevalence of smoking, explained by the application of policies and programs in the analyzed schools, which consider the multiple aspects of their context and some characteristics of the surrounding community.
The acquisition of healthy habits in childhood and adolescence has a potential predictor of awareness for a healthy lifestyle in adult life [6].Based on this knowledge, the Pan American Health Organization (PAHO), regarding Health Promotion, focuses on the adolescent population, considering that respect for health promotion and education in schools may include the operationalization of programs that promote the improvement of the quality of life of this population.
The personalized monitoring intervention of school health surveillance can be complementary to the execution of programs and projects directed at the priority health problems identified by the subjects themselves in their settings.Thus, HP at school should also play a role in acquiring healthy lifestyles and in preventing habits and behaviors considered harmful [3].
Thus, Health Promotion actions in and around the school should be able to develop knowledge, skills and abilities for health self-care and prevention of risk behaviors in all educational opportunities.Moreover, it should also foster opportunities for a critical analysis of determinant values, behaviors, social conditions, and lifestyles of the health-disease process [19].

School-community relationship: advances in health promotion
The search also resulted in the finding of studies that demonstrated that the approach of the school to the community has the potential for the changes in the relationship between the subjects and the school [14,15].Among the rescued articles, one specifically discussed this theme [15].The Brazilian text aimed to evaluate the partnership between school and community, comparing the performance of two schools, one that maintained a more active relationship with the community and the other, less active.
The comparative results revealed that, in the school where there is an active participation of the community, the pedagogical project periodically contemplates the community with courses and lectures related to the school and social inclusion.Because of these opportunities for rapprochement with the school, the community feels responsible for it and there are demonstrations of genuine interest in discussing more-productive interactions.Contrary to the assertive, in the school where there are no activities that contemplate the community, there were complaints of lack of interaction, which resulted in feelings of non-belonging and indifference [15].
The lack of recognition of school as a collective space, belonging not only to the subjects that make up the school community, but also to parents and the community in its surroundings, contributes to the distance between the subjects, generating feelings of non-belonging and lack of responsibility, difficulty in resolving conflicts that arise in their daily life and revealing extreme situations of indifference [20].
Conversely, paths that point to an openness to the relationship between school and community have revealed significant experiences, with good results and improvements in human interactions, in teaching, in the preservation of physical facilities and in combating violence in and out of school [15].
Another experience of approaching the school with the community was observed in a study also carried out in Brazil [14], which aimed to analyze the actions developed in the project "open school" in five cities of the state education network of Rio Grande do Sul.It sought to understand how the community perceived the project and its own participation in the activities developed in the school during the weekends.
The results reveal that the community surrounding the school desires to perform activities during the weekends, configuring the school as a space of leisure, which serves, at the same time, for amusement and formation.However, as a limitation of the project, there were no activities that would allow debating and reflecting the role of the project, the school itself, public policies, among others, that could contribute to the criticality of social inequalities [14].
Promoting the role of the school as a space for Health Promotion requires its articulation with the community surrounding it, either through actions and experiences that allow the participation and interaction of the subjects in the discussion about the social determinants of the health/disease in the surrounding population, or in the planning of possible solutions.This process calls for mobilizations on the right to health, which leads to the strengthening of community participation in health issues [21].
The partnership between schools and communities has its importance in HP because it represents as a scenario and tool of health education, since, by forming opinions of children, adolescents and their families, it becomes a social device that contributes to citizens conscious and responsible for their choices, behaviors that can effectively respond to the health needs of the population [22].
Health Promotion depends on both individual as social aspects, permeating the individual with autonomy over his/her life and with access to informa-tion that can improve his/her health.With regard to the State, it is essential to develop public policies capable of improving social conditions and making it easier for individuals to choose what is best for themselves.
In the set of public policies, projects that positively affect the quality of life of the population, such as the Health-Promoting Schools [3], stand out.In this perspective, the HPS came up with a commitment to encourage PAHO member countries to promote programs and actions that favor the training of future generations of young people, aiming at providing them with the knowledge, skills and competencies necessary to promote and maintain their health, an attitude that extends for their family and community [6].
Health-Promoting Schools base on three main components: 1) health education, 2) the creation and maintenance of healthy spaces, and 3) access to health services, healthy eating and active life [20].Important systematizations and direction have occurred since the creation of the Latin American Network of Health-Promoting Schools during the Congress of School Health in Chile in 1995.Such strategy has represented the option for the institutionalization and conformation of public school health policies encouraged by PAHO in Latin America and the Caribbean [11,12].
In this logic, the School must "tear down" the walls and receive the subjects that inhabit its surroundings and, with them, dialogue and build expanded and participatory health and citizenship projects that incorporate the principles of Health Promotion and the criteria of healthy schools, by deepening the school and community relation, so that there is the expected participation, commitment and collaboration of the diverse subjects in the proposals to be developed, in order to extrapolate the geographical limit of the school space, occurring the immersion of the school in the community and vice versa.

Conclusion
Based on the assumptions of the Ottawa Charter, the results of this review revealed that the relationship between school and community in the perspective of Health Promotion has mostly been incipient, unrelated to the integral health proposal focusing on individual actions to the detriment of social rights.
Although the relationship between school and community in the perspective of Health Promotion is elementary and not deepened, the successful experiences show good prospects of overcoming.It is necessary, however, to move forward in strategies that bring school and community together, so that the Health Promotion movement becomes a reality in people's daily lives.

Table 1 .
Characterization of the articles regarding year of publication, country, authors, title, database and level of evidence.João Pessoa, Paraíba, Brazil, 2016.