Section 4.3: Community Organizing Participatory Action Research (COPAR) & Family Nursing Care

Community Organizing Participatory Action Research (COPAR) & Family Nursing Care

Public health nurses operate on multiple ecological levels, utilizing Community Organizing Participatory Action Research (COPAR) to address macro-level community concerns, and the Family Nursing Process to deliver micro-level care to families in their natural environments. Both frameworks emphasize client empowerment and self-reliance.

1. COPAR: Philosophy, Principles, and Phase-by-Phase Process

Community Organizing Participatory Action Research (COPAR) is a continuous, community-driven process of educating, organizing, and mobilizing people to critically analyze their socioeconomic and health conditions, take collective action to address their problems, and establish self-reliant structures.

Philosophy and Principles

The philosophy of COPAR is rooted in the belief that health is a fundamental right and that the marginalized, poor, and powerless possess the capacity to transform their lives. Rather than a "top-down" approach (where external experts dictate solutions), COPAR uses a "bottom-up" model. The nurse acts not as a benefactor, but as a facilitator, partner, and catalyst. The core principles of COPAR are:

1. People-centered: The poor and marginalized are the primary authors and beneficiaries of development.
2. Participatory: The community must actively participate in research, decision-making, implementation, and evaluation.
3. Critical Consciousness (Conscientization): Community members are guided to identify the root causes of their health problems (e.g., poverty, landlessness, political oppression) rather than merely treating the symptoms.
4. Collective Action: Community organizing must lead to cooperative, organized efforts to achieve systemic changes.

Phase-by-Phase Breakdown of COPAR

COPAR is executed through four distinct, overlapping phases:

  +------------------+     +---------------+     +-----------------------+     +-------------------------------+
  | Pre-Entry Phase  | --> |  Entry Phase  | --> | Organization-Building | --> | Sustenance & Strengthening    |
  | (Site Selection) |     |  (Immersion)  |     |   (CHO & PCD Setup)   |     |    (Phase-out & Linkages)     |
  +------------------+     +---------------+     +-----------------------+     +-------------------------------+

Phase 1: Pre-Entry Phase

This is the preparatory phase before the organizing agency enters the community. The focus is on selecting the community site and preparing the organizers.

• Concrete Steps:
  1. Formulate institutional goals and criteria for site selection.
  2. Identify potential communities through secondary data analysis (census records, municipal health profiles). Criteria for selection include: high disease burden, depressed socioeconomic status (low average income), stable peace and order, accessibility, and absence of other non-governmental organizations doing overlapping work.
  3. Conduct a Preliminary Social Investigation (PSI) by reviewing existing records and maps.
  4. Establish courtesy calls and coordinate with local government officials (municipal level).
  5. Make the final selection of the barangay.
• Nurse's Role: Planner (designing the program and criteria), Researcher (gathering and analyzing secondary health and demographic data), and Coordinator (negotiating with municipal authorities).

Phase 2: Entry Phase

Also known as the integration phase. The organizer integrates with the community to establish rapport, build trust, and gain a deep understanding of community culture and dynamics.

• Concrete Steps:
  1. Immersion: The nurse lives in the community, adopting the lifestyle, language, and culture of the locals.
  2. Courtesy calls: Formal courtesy visits to barangay officials (Barangay Captain, councilors) and informal leaders (elders, traditional healers, teachers).
  3. Deep Social Investigation: Continuous, informal gathering of data through observation and conversation (walking around the barangay, attending local events).
  4. Identify Potential Leaders: Locate key community members who are natural leaders (respected, active, willing, and representative of the poor).
  5. Form a Core Group: Bring together 5 to 10 potential leaders to form a temporary advisory body that will guide the initial organizing activities.
• Nurse's Role: Immersionist (living with the people), Facilitator (building trust, guiding initial discussions), and Observer (mapping community power structures and cultural practices).

Phase 3: Organization-Building Phase

This phase focuses on establishing formal community structures and building capacity for collective health action.

• Concrete Steps:
  1. Train the Core Group in leadership skills, group dynamics, and basic health issues.
  2. Conduct a Community Assembly to present the findings of the social investigation and gain broad support.
  3. Formally establish the Community Health Organization (CHO) through democratic community elections.
  4. Form committees (e.g., Health, Sanitation, Education, Finance) within the CHO to delegate tasks.
  5. Train Community Health Workers (CHWs) or Barangay Health Workers (BHWs) in primary care, first aid, and disease prevention.
  6. Conduct a Participatory Community Diagnosis (PCD): The community members themselves design, conduct, analyze, and present a survey of their barangay's health problems.
• Nurse's Role: Educator (conducting leadership and health training), Organizer (facilitating the formation of the CHO and its committees), and Technical Advisor (guiding the community in executing the PCD).

Phase 4: Sustenance and Strengthening Phase

The final phase focuses on self-reliance, evaluation, and preparing the organizing agency for exit (phasing out).

• Concrete Steps:
  1. Implement community-identified health plans (e.g., building water systems, starting communal herbal gardens, conducting sanitation campaigns).
  2. Establish a formal referral system between the CHO and the RHU.
  3. Link the CHO with external resources, government departments (DOH, DA, DSWD), and non-governmental organizations (NGOs) to secure funding or technical assistance.
  4. Set up income-generating health initiatives (e.g., community pharmacy or botika).
  5. Conduct periodic monitoring and evaluation of health programs.
  6. Phase-out: The nurse gradually withdraws from the community, handing over all administrative and financial control to the CHO.
• Nurse's Role: Consultant (providing advice only when requested by the CHO), Connector / Linkage Builder (networking the CHO with external resources), and Evaluator (guiding the CHO in assessing program sustainability).

2. The Family Nursing Process: Assessment, Prioritization, and Health Tasks

The Family Nursing Process is a systematic framework that views the family as the unit of care. It recognizes that health is a family affair; an illness in one member affects the entire family structure, and the family's practices dictate individual health outcomes.

First-Level Assessment

This step involves identifying existing and potential health conditions or problems of the family. The nurse categorizes findings into four categories:

1. Wellness States / Potentials: The family's readiness to achieve a higher level of health and functioning.
   • Examples: Readiness for enhanced immunization status; potential for enhanced breastfeeding; healthy lifestyle maintenance.
2. Health Threats: Conditions that are conducive to disease, accidents, or failure to realize health potential.
   • Examples: Poor environmental sanitation (open garbage disposal, standing water, lack of a sanitary toilet); family history of non-communicable diseases (hypertension, diabetes); risky behaviors (active smoking, alcohol abuse); fire hazards (exposed wiring, stored gasoline); and overcrowding.
3. Health Deficits: Instances of failure in health maintenance, active disease, or developmental disability.
   • Examples: A child with active bronchopneumonia; a father with untreated pulmonary tuberculosis; an aunt with uncontrolled hypertension; or severe malnutrition in a toddler.
4. Foreseeable Crises: Anticipated periods of stress or life-cycle transitions that demand family adjustment.
   • Examples: Pregnancy; birth of a new baby; a child entering school; marriage; retirement; or the death of a family member.

Second-Level Assessment: Family Health Tasks

Once a problem is identified in the first-level assessment, the nurse performs a second-level assessment to determine the family's capacity to resolve the problem. This is structured around the five Family Health Tasks:

1. Recognizing the presence of the health problem: Can the family identify symptoms and understand their implications? Inability reasons: Lack of knowledge, denial, fear.
2. Making decisions about taking appropriate health action: Will the family seek care or change behavior? Inability reasons: Financial barriers, lack of trust in doctors, fear of treatment, cultural beliefs.
3. Providing nursing care to the affected family member: Can the family administer medications, prepare therapeutic diets, or assist with activities of daily living? Inability reasons: Lack of physical skills, lack of resources, caregiver fatigue.
4. Providing a home environment conducive to health maintenance and personal development: Can the family modify their physical and social environment (e.g., isolating a TB patient, cleaning stagnant water)? Inability reasons: Inadequate housing, lack of space, financial limitations.
5. Utilizing community resources for health care: Does the family know about and access the local BHS, RHU, or PhilHealth benefits? Inability reasons: Lack of information, physical distance, bad experience with clinic staff.

Family Nursing Diagnosis: Formulated by linking the first-level problem with the second-level task failure. E.g., "Health Threat of poor environmental sanitation due to the family's inability to provide a home environment conducive to health maintenance, secondary to lack of financial resources."

Prioritization Criteria (Bailon-Maglaya Scale)

When multiple family health problems are identified, the nurse collaborates with the family to prioritize them using the Bailon-Maglaya Scale:

Scoring Formula: ext{Score} = rac{ ext{Actual Score of Criterion}}{ ext{Highest Possible Score of Criterion}} imes ext{Weight} The scores for all four criteria are summed. The maximum possible total score is 5. Interventions are prioritized for problems with the highest total score.

3. Home Visits and the Public Health Bag Technique

A Home Visit is a purposeful, face-to-face interaction between the public health nurse and the family in their home.

Purpose and Scheduling

The primary purposes of home visits are to assess the home environment, deliver direct nursing care, conduct tailored health education, and evaluate family progress. Visits are scheduled based on priority:

• High priority: Postpartum mothers, newborns, individuals with active communicable diseases (e.g., active TB, measles, dengue), and clients with unstable, acute health deficits.
• Moderate priority: Pregnant women in their second trimester, clients with well-controlled chronic diseases, and families with general health threats (e.g., poor sanitation).

The Public Health Bag (PHN Bag)

The PHN Bag is a tool used by community health nurses to perform nursing procedures with ease, efficiency, and safety. It contains basic equipment and solutions. The key concept of the bag technique is the strict preservation of asepsis to prevent cross-contamination between the nurse, the bag contents, the patient, and the home environment.

Core contents:

• Top/Inner pocket: Soap in a soap dish, hand towel, and apron. (These are taken out first).
• Main compartment: Thermometers (oral/axillary and rectal), BP cuff and stethoscope, scissors, forceps, cotton balls, gauze, adhesive tape, band-aids, alcohol lamp, test tubes, Benedict's solution, acetic acid, and paper waste bags.
• Outside or flat compartments: Paper lining (or plastic lining) used as the work barrier.

Step-by-Step Public Health Bag Technique

1. Arrival and Site Preparation: Upon entering the home, greet the family, establish rapport, and state the purpose of the visit. Locate a clean, flat surface (a sturdy table or wooden chair) away from drafts, pets, and children.
2. Lining Placement: Retrieve the clean paper or plastic lining from the bag. Spread it flat on the surface with the clean side facing up. This serves as a barrier. Place the closed PHN bag on this lining.
3. Initial Bag Opening and Hand Hygiene: Open the bag. Take out the soap in its dish, the paper towel, and the apron. Close the bag immediately to protect the remaining contents from air particles.
4. Perform Handwashing / Hand Hygiene: Thoroughly wash hands using the soap and towel, or rub hands with isopropyl alcohol. This ensures hands are clean before touching the clean inside of the bag again.
5. Apron Application: Put on the apron. The clean side of the apron must face the nurse's uniform, while the outer side faces the client. This protects the nurse's uniform from contamination during care.
6. Equipment Retrieval: Open the bag, retrieve the specific instruments and solutions needed for the planned procedure (e.g., thermometer, cotton balls, alcohol, dressing kit), and close the bag immediately.
7. Perform Procedure: Carry out the nursing intervention (e.g., taking temperature, performing wound care, checking blood pressure). If hands become contaminated (e.g., touching wound discharge), perform hand hygiene immediately.
8. Disinfection of Equipment: After completing the procedure, clean and disinfect all used instruments (e.g., wipe the thermometer bulb-to-stem with an alcohol swab, clean the stethoscope chest piece). Allow them to dry.
9. Pre-packing Hand Hygiene: Wash or sanitize hands once again before returning the clean items to the bag.
10. Bag Packing: Open the bag. Return all disinfected instruments to their designated compartments. Remove the apron, folding it with the contaminated side (outer side) facing in, and place it in the bag. Close the bag.
11. Lining Disposal/Storage: Lift the paper lining. Fold it with the contaminated side (the side that touched the home's table) facing in. If it is disposable, throw it in the waste paper bag; if reusable, place it in the designated outer compartment of the bag.
12. Record Keeping and Next Steps: Document all clinical findings, nursing diagnoses, and interventions in the family health record. Discuss the plan and schedule the next home visit with the family before departing.