Indicators of Good Nursing Practices for Vulnerable Groups in Primary Health Care: A Scoping Review

Objective: to map the indicators of Good Nursing Practices in Primary Health Care, from the perspective of Collective Health, reported to the vulnerable social groups. Method: this is a scoping review according to the PRISMA Extension for Scoping Reviews. The searches were carried out in2020 in six databases and in a virtual library. Independent reviewers performed the reading of the full texts, as well as treatment, analysis and synthesis of the content. Results: a total of 13 articles were found, the first from 2007 and the last from 2020. The data were classified according to the following empirical categories: assessment and control of health conditions(3 indicators); assessment of knowledge about health(3 indicators); use of sociodemographic characteristics to estimate risks or vulnerabilities(3 indicators); assessment and monitoring of health needs(5 indicators); promotion of safety and trust in health services(6 indicators); and assessment of the care process(4 indicators). Conclusion: the articles showed a variety of indicators that assess the interventions carried out in the context of Nursing in Primary Care with vulnerable social groups. These indicators are related to health conditions, especially those of the biopsychological body, reported to vulnerable populations, especially women, children, adolescents and older adults.


Introduction
The concept of Good Practices in the health area is broad and diversified. A study defines it as the best way to identify, evaluate and implement information through monitoring the health care results (1) . Another study considers it as a technique or methodology with proven reliability to guide a given result (2) . For other authors, it corresponds to the triad made up by the best results of scientific research studies, clinical knowledge and the users' needs (3) .
With regard to Nursing, the concept of Good Practices is understood as the critical process of reflection on the actions taken, in search for the effectiveness of a practice. Knowing the meaning of the practice is essential because, based on this knowledge, the nurse can apply the necessary amount of intellect in care organization.
In addition to that, the understanding of best practices is based on the assumption that, in a given context, some solutions are superior for solving problems when compared to others (4) .
From the perspective of Collective Health Nursing, it is considered that Good Nursing Practices (GNPs) in Primary Health Care (PHC) must contain principles such as: observing that this field of practice takes place in the geopolitical territory of social production and reproduction and that work in health aims at transforming the population's epidemiological profiles (5) . It is in the territory that the social phenomena expressed in the population's health profiles manifest themselves explicitly and demand knowledge and competences from nurses to recognize health needs and to face the vulnerabilities to which different population groups are exposed (6) .
Given the diversity of concepts of Good Practices, it is considered that, in addition to implementing them, it is necessary to establish criteria that may support the construction of indicators in order to parameterize care and the actions resulting from it. Indicators are quantitative or qualitative parameters that detail the objectives of a proposal according to its conduction (evaluation of the process) or scope (evaluation of results). In addition to that, they point to trends and act as instruments that do not operate by themselves (7) .
Although GNPs are found in the scope of PHC, studies on indicators that support these practices are not sufficiently known. Given this, the scientific question of this study was the following: What indicators are used to support the GNPs reported to vulnerable social groups in PHC? Based on this, the objective of this study was to map the indicators of GNPs in PHC, from the perspective of Collective Health, reported to vulnerable social groups.

Method
This is a scoping review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). This type of review is used to map evidence, explore the breadth or extension of the literature, and inform future research studies. It is also recommended to identify and analyze knowledge gaps about a particular research topic or field (8) .
The protocol for this scoping review is registered in Open Science. The review question was elaborated through the PCC strategy, which advocates the following mnemonic acronym as fundamental elements: P -Population, C -Concept and C -Context. For the search of evidence, the following elements were defined: P -Vulnerable social groups, C -Indicators of Good Nursing Practices and C -Primary Health Care. Therefore, the review question

Virtual Library Strategy
SciELO ("vulnerable populations" OR "disadvantaged" OR "social vulnerability") AND nursing a consequence of their insertion in the social production system (10) . Health Needs are linked to the potential to produce a health-genic paradigm, extrapolating needs.
Vulnerability, that is, the fragility to face the vicissitudes of life, is related to the process of social exclusion and its confrontation with subjects and social groups (11) . The Care Process is based on the dynamics of the practical realization of the epistemic care object, prioritizing the social groups' health needs (12) .
In data treatment, only peer-reviewed publications were considered. A critical evaluation of the texts was also carried out, mainly with regard to the methodology, according to the reviewers' expertise.
The instrument used to collect the information was incorporated into the webQDA qualitative analysis software (13) . The characterization of the studies was carried out using descriptive codes. Descriptive coding was performed using the automatic encoding tool, which allows importing files in XML format. Subsequently, the data were coded by the Tree Code System, allowing for the emergence of the empirical categories through the thematic content analysis technique (14) , which enabled the elaboration of the knowledge syntheses.
The exact considerations of the authors were considered as "indicators", regardless of the concept or purpose they served.

Results
The search in the databases mapped 1,095 potentially eligible studies, with 13 remaining in the final sample, as shown in Figure 2.
The study selection process was carried out by three independent reviewers and the differences were solved by a fourth reviewer.
The selection of studies was carried out in two stages. In the first stage, the titles and abstracts of the references identified through the search strategy were   10 studies having a quantitative approach and three with a qualitative approach.
In relation to the population studied, seven studies were conducted with adults, five of which included only women and three referred to older adults. There was an article about children and another about adolescents.

Title of the article Year Action performed Indicators
Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: Results of a demonstration project that combined continuous quality improvement and community health worker strategies (15) 2007 Care of school-age children with asthma: performed in community clinics for multiethnic and lowincome patients. The action involved improving care quality through a multidisciplinary team.
Monitoring of home visits, emergency, hospitalizations, day and night symptoms. Vaccine offer.

Miller Early Childhood Sustained
Home-visiting (MECSH) trial: design, method and sample description (16) 2008 Early childhood supported by home visits: carried out in a disadvantaged community. The action involved home visits by female nurses to at-risk mothers from prenatal and postnatal care until the child's second year of life.
Impact on parental knowledge, ability and satisfaction. Outcome measure for the child, the mother, the family and the environment.
MOSAIC (Mothers' Advocates In the Community) (17) 2009 Mothers' advocates in the community: performed in a primary care clinic. The action involved mentors responsible for supporting the reduction of intimate partner violence and depression among pregnant women and mothers with children under the age of five through home visits.
Reduction of partner violence and of depression among pregnant women and those with children under the age of five.
Strengthening overall health, well-being and the motherchild bond.
Quality of care provided in a special needs plan using a nurse care manager model (18) (19) 2014 Home visit by public or community health Nursing: carried out in the context of primary care. The action involved monitoring the Nursing care levels and the health behavior of vulnerable clients through home visits.
Behavioral, psychosocial and psychological needs. Promoter and managerial behavior in health.
Adolescent health promotion based on community-centered arts education (20) 2018 Art and education: carried out with adolescents in a situation of urban social vulnerability. The action involved participatory workshops to promote awareness and empowerment in health.
Collective representation of the concept of promoting adolescents' health. Development of a health goals program through art. Broadening the perspective on the educational activities. Reassessment of the activities developed.

Child protection outcomes of the Australian Nurse Family Partnership Program for Aboriginal infants and their mothers in
Central Australia (21) 2018 "Nurse partner of the family" program: carried out in an Aboriginal community. The action involved home visits by female nurses to reduce child abuse and neglect. Rev. Latino-Am. Enfermagem 2021;29:e3488.

Title of the article Year Action performed Indicators
Parent and facilitator experiences of an intensive parent and infant programme delivered in routine community settings (24) 2019 Program for parents and infants: conducted in two underprivileged areas. The action involved parents and the nurses' support for the infant's socio-emotional development through the parents' competence and well-being.
Development of positive parenting and child coping skills.

Provider Counseling and Weight
Loss Outcomes in a Primary Care-Based Digital Obesity Treatment (25) 2019 Behavior change related to obesity through digital components and human support: carried out in primary care. The action involved monitoring obese users for weight loss.
Weight control. Anthropometric and sociodemographic characteristics. Advice on weight. Empathy.

Hypertension Self-management in Socially Disadvantaged African Americans: the Achieving Blood Pressure Control Together (ACT) Randomized Comparative
Effectiveness Trial (26) 2019 Achieving blood pressure control together: performed in a primary care clinic with African-Americans. The action involved the patients' clinical follow-up.
Physiological control of blood pressure. Laboratory tests (albumin, creatinine). Anthropometric and sociodemographic characteristics. Comorbid and chronic conditions. Alcohol and substance use. Physical activities. Impacts and changes in medication use. Health literacy. Promoter and managerial behavior in health. (27) 2020

Qualitative evaluation of a community-based intervention to reduce social isolation among older people in disadvantaged urban areas of Barcelona
Health school for older adults: action carried out in two underprivileged neighborhoods. The action involved reducing social isolation among older adults by promoting individual and collective resources to enhance their ability to identify problems and activate solutions for health development.
Health literacy. Ambivalent conditions: group dynamics and family support.
Recognition of the facilitators: organization. Recognition of the barriers: health problems, excess of scheduled activities and absence of participants in the activities.
Promoter and managerial behavior in health.
Positive aspects: possibility of asking, being listened to and having an answer; the environment and the group; participatory session. Negative aspects: already known contents. Benefits: new learning; remembering things that they already knew and used to do for themselves and others; increasing the number of acquaintances; motivation to go out and a feeling of belonging.  Care from the individual context, group dynamics and family support. (15,(18)(19)(21)(22)(23)25,27) e) Promotion of safety and trust in health services Accessibility and reduction of barriers in service and monitoring. Welcoming in a comfortable environment. Service through a non-discriminatory and empathic posture. Strengthening emotional security, trust and bonding. Recognition of the facilitators and barriers to participation in the health services' activities.
Assessment of care quality. Outcome measures for individuals, family and environment. Survey of the positive and negative aspects of the activities from the users' perspective, as well as their benefits for health promotion.

Discussion
The knowledge of Collective Health Nursing has been developed from the deepening of the theoreticalmethodological frameworks and the construction and testing of instruments aimed at analyzing the work processes with the potential to intervene in the objective reality and, therefore, in the health-disease process of different social groups. In addition to that, it is possible to verify an expansion of these instruments' spectrum (11) .
This expansion was identified in the scoping review respective assessments (11) .
The "Assessment and control of health conditions" empirical category aggregates GNP indicators in PHC to vulnerable social groups, linking them to health care. In this category, the family appears as a care object and, in this sense, the study carried out in Brazil (29)  In the end, the participants built a collective product that represented the concept of promoting adolescents' health and encouraged self-determination for changes (20) .
In this same category, health literacy stood out, associated with the understanding of basic health information, so that users may support appropriate decision-making, with a view to promoting health care and preventing diseases. However, none of the articles that mention literacy used validated instruments for verification, as recommended (30) .
Users' empowerment regarding knowledge about health represents a step forward in overcoming the hegemony of clinical-focused care and is extremely important for the theoretical framework of Collective Health Nursing, as it refers to the singular, particular and structural dimensions of the phenomena that affect the individuals or social groups that demand Nursing care (10)(11) .
The third empirical category encompassed research studies using indicators related to sociodemographic characteristics to estimate social risks and vulnerabilities of the studied population (21)(22)(25)(26) . Recognizing the risks and social vulnerabilities to which the population is exposed is important to equitably guide the care actions reported to social groups.
A study on racial inequality and mortality due to COVID-19 considered that social vulnerability allows understanding the unequal effects of the pandemic on the African-American population based on the social conditions and on exposure to risk. Different levels of poverty, segregation and discrimination influence the ability to respond to the disease. Therefore, the increase in social vulnerability is proportional to health inequality (31) .
The fourth category involves the assessment and monitoring of the health needs of vulnerable populations.
The studies considered the protection, behavioral and psychosocial needs associated with sleep, weight and dementia. In addition to that, they took into account the individual context, life history, experience, and family support. The assessment of needs fulfillment was carried out through home visits and hospitalizations, mainly through Sensitive Conditions to Primary Health Care (SCPHC) (15,(18)(19)(21)(22)(23)25,27) .
A study carried out to verify the effects of the intervention and the results in home-care through home visits found positive aspects corresponding to three domains: health management, general health promotion behavior, and physical activity subscale score. However, the authors recognize that delineating the specific effect of home visits performed by Nursing professionals in changing health behavior is complex, especially due to the difficulty of associating a particular strategy with a specific clinical result (19) .
A study carried out in Canada including 68 women with significant social and health inequalities showed the importance of the health team establishing a trusting relationship with the service users, particularly with those who had stigmatizing experiences or negative judgments when seeking the health services (14) . Based on this, it is considered that the use of indicators in PHC involves knowledge and the development of care oriented towards equality in health.  (32) .
Finally, it is considered that valuing the Nursing work process involves measures of actions and quality of the care offered to the users -measures that will unveil problems associated with the scarcity of workforce and with the possibility of improving care (33) .
Nursing must also take ownership of common PHC tools, especially those that seek indicators for evaluating health policies, strategies and actions. A study analyzing instruments used in different countries found important domains in which the indicators must be adjusted or applied.
Among them, the following stand out: national governance of

Conclusion
The studies showed indicators that may qualify the interventions carried out in the context of Nursing with social groups which are considered vulnerable in PHC. With regard to these groups, residents in socially disadvantaged areas stood out, mainly involving the female population and the age groups corresponding to childhood, youth and older adults.
The indicators mapped also showed a relationship with the care of the biopsychological body beyond the multifactorial understanding of health-disease, entering the field of knowledge production for health promotion.
In addition to that, they highlighted the nurses' role in surveying the sociodemographic characteristics and health conditions, in monitoring health needs and in assessing the care process.