The People and Culture of French Québec

While New France was claimed by Jacques Cartier in 1534, the actual settlement began in 1604. Québec traces its cultural origins to the Catholic colonists who came from Normandy and west central France and to the French explorers and traders who soon penetrated beyond the Great Lakes to the prairies ( ). Conflict between England and France, climaxing in the Seven Years’ War (1756–1763), ended with a conquest by England. The colonists of New France formed bonds with the indigenous Huron and developed ties with the arriving Scottish traders, farmers, and merchants. In the years that followed, an agricultural-, family-, and church-oriented culture evolved that had a high degree of homogeneity and rapidly became differentiated from the French culture ( ; ).

With power in the hands of England and extensive British immigration, the urban centers of Montréal and Québec City became predominantly English speaking. While the language of commerce was English and the British controlled business and trade until the mid-nineteenth century, agriculture, law, and medicine proved to be the primary professions of the French in the province. Large-scale Scottish migration in the eighteenth and nineteenth centuries contributed literate and skilled immigrants to the growing population ( ). Further, a poor potato crop in Ireland, causing a widespread famine, prompted another wave of immigrants. A cholera epidemic at the peak of the immigration took numerous lives, resulting in many Irish children arriving as orphans. Although they were assimilated through adoption by French-speaking families, they often kept their own names, which explains names such as McNeill and Ryan among today’s French-speaking population. More recent waves of immigration have added a further dimension of sociocultural complexity ( ; ).

In 2011, Québec welcomed 49,490 immigrants, more than half between the ages of 25 and 44 and with university education ( ). These included professionals, entrepreneurs, or workers; some were rejoining family members, and others (about 20%) were refugees. While most came from French-speaking countries like France, Morocco, Algeria, Congo, and Haiti, others were from China, the former Soviet republics, Romania, Sri Lanka, India, Pakistan, the former Yugoslavia, and Libya. Only about 15% of these immigrants chose to reside outside the Montréal area. Although overt and organized racism or extreme marginalization of Québec’s ethnic minorities is rare, certain social, cultural, and racial barriers on one side, and resistance to total integration on the other, slow complete integration ( ). While Québec feels the duty to accommodate new immigrants, the “niqab” has become a flash point in the debate about the price such accommodation will cost society, as well as the focal point of a policy of the Québec Human Rights Commission restricting its use where identification is required ( ).

Quiet Revolution

In the years after World War II, Québec underwent a rapid transition from a rural to an urban technological society. Starting in the 1950s, the control of political institutions and business enterprises shifted into the hands of French-speaking Québecers ( ). However, well into the 1960s, Québecers were oriented to family and to the church. The latter, in Catholic Québec, not only dictated mores and behavior and served as the major social and health resource but also participated actively in political affairs. The so-called Quiet Revolution resulted in social, political, and behavioral transformations as extensive as any produced by violent revolution. Secularization resulted in changes in structure and power rather than in function or values. The state assumed control of schools, health care, and welfare programs.

Moreover, the Quiet Revolution stimulated feelings of nationalism and led to legislation to protect language and culture. The movement in favor of the political independence of Québec from Canada was also fueled, contributing to a charged emotional climate between those “for” and those “against” separatism and augmenting tensions between provincial and federal governments. Separatist sentiments peaked in the referendum on secession in October 1995, which rejected separatism by a narrow margin. Although the issue has remained on the political agenda, many Québecers feel that it is time to make the best of the current constitutional status and to redirect concerns to economic, health, and education priorities ( ). However, 50 years after the Quiet Revolution, young English-speaking Québecers want to learn French and to live and work in Québec ( ).

Economy

The profound change in the politico-economy was associated with more families needing two sources of income to maintain living standards, women with higher education pursuing careers, a decline in the birthrate, and an increase in the number of the elderly ( ). By 2010 in Québec, while there was no significant change in the number of women in traditionally female jobs (e.g., nursing), women were beginning to make inroads into male-dominated professions (e.g., medicine). In the greater Montréal area, more than half the jobs in the financial and business sector were filled by women, with a decline in women in senior management over a 10-year period ( ).

The Québec Employers Council on Prosperity reports that Québec currently faces an economic challenge (in terms of gross domestic product as compared with 34 other provinces and countries, Québec ranked twentieth). It is well positioned concerning university graduation, taxation on investments, spending on research, and the development of sustainable natural resources such as hydroelectric power, but it was rated less strongly in relation to certain areas such as economic integration of immigrants and public debt (Centre for Sustainable Living Standards, 2015; ). However, since 2004, inflation has ranged annually between 0.6% and 2.3%. With a mean annual increase in the consumer price index of 1.6%, Québec knows greater price stability than 155 of the 160 countries for which the statistic was available (Centre for Sustainable Living Standards, 2015; ).

Health Care

Catholic religious orders brought health care and hospitals to New France and were responsible for training many generations of nurses. Protestant religious groups and Scottish-trained physicians provided for the health of the English-speaking populace. The latter were influ­ential in the development of scientific medicine and hospital organization in Québec and throughout the rest of Canada. In 1969, the province put into place a medical insurance program, followed in 1970 by the development of a network of social services ( ). By law, health care is offered by public access to hospitals, local community health centers, and affiliated community agencies, as well as to centers for residential and extended care, child and youth protection, and rehabilitation. In addition, a public insurance program for prescribed medications is in place for Québecers without private coverage ( ). Moreover, private care providers (e.g., medical imaging clinics) thrive in various urban centers ( ). Currently practicing in the province, there are 2.13 doctors per 1000 inhabitants, of whom approximately half are general practitioners ( ). However, the 10th Annual Canadian Medical Association Poll reports that, although the system delivers values for the financial investment, Québecers feel a certain dissatisfaction with overall quality of care that could be ameliorated by greater availability of family doctors, and that many fear that the demographic bulge of the ageing baby boomers requires reorganization of the system if it is to provide the health care wanted and needed ( ).

Ordre des infirmières et infirmiers du Québec (OIIQ) supervises schools of nursing and professional practice, registers nurses, and carries out inspections of nursing practice in hospitals and community health centers. According to this association, 68,754 nurses (mean age: 42.3 years) are registered in Québec, 84% of whom report permanent employment and approximately two thirds of these working full time ( ). Intense movement is under way to ensure the baccalaureate degree as entry into practice, and currently 44.7% have university preparation; the others for the most part come from a collegial system, with hospital schools of nursing having been closed for many years ( ).

During the past years, the province has been involved in health care reform and a shift to ambulatory care, with the concurrent problems of high costs and shortages of staff and hospital beds. However, such reforms have increased professionalization in nursing practice and more autonomous roles in patient/family education ( ). Given current health care requirements, additional spaces have been opened in basic nursing programs, and the Ministry of Health has offered both substantial bursaries to augment advance nursing practice preparation in the universities and has announced the opening of 500 positions for advanced nurse practitioners within the health system ( ; ).

The OIIQ is also a leader in the promotion of a contemporary vision of nursing care that is professional, clinical, and evolving (e.g., in the development of new roles for an increased number of nurse practitioners and clinical specialists, in redefining the nurse role augmented by shared medical acts, or participating in team care) ( ; ; ). A number of recent studies have also contributed to the development and validation of advanced nursing practice. These include a study by , which examined the process of conceptualization by future stakeholders of a new nurse practitioner’s role in a pediatric emergency setting; they saw it having an essential clinical focus and themselves as active participants in both its development and implementation. Another such study performed by focused on how the consultation role of the clinical specialist emerged in an active care setting; it also included managing crises situations, ensuring continuity of care, and supporting other professionals, but it required constant clarification in the context of the clinical situation and the evolution of the system.

Education

During the nineteenth and most of the twentieth centuries, free schooling was provided to the eighth grade, and high schools and colleges were private, maintained for the most part by Catholic or Protestant religious groups. In 1943, attendance became compulsory in the Canadian school system. In 1960 and 1961, a series of laws was enacted that provided free universal education through the eleventh grade and compulsory education to 15 years of age ( ). System restructuring led to a network of free postsecondary junior colleges; universities provided 3-year undergraduate programs, as well as graduate and professional education. School boards were originally organized according to religion, with Catholic and Protestant boards operating schools in both French and English. In 1993, the Supreme Court of Canada upheld the constitutionality of a 1988 law that reformed governance of school boards along linguistic rather than religious lines. By 2004 such reorganization had been completed throughout the province. Today, private schools, which may be religious or secular, coexist with the public system. Organizational school reform has centered on devolution of powers based on a philosophy of school-based autonomy, accountability, and parental involvement. Although concomitant curriculum reform focuses on competencies to enable students to acquire skills and adjust to a fast-changing world, the effects of the such efforts, as well as those directed to the integration of “at-risk” groups (such as non–French-speaking immigrants or children with learning needs) are still being determined ( ). However, level of schooling continues to improve; the number of Québecers with a university diploma rose from 12% in 1990 to 23% in 2009, and the proportion of those without a high school diploma dropped from 38% to 16% ( ). More specifically, by proportion of the population, 7.8% held an advanced university degree; 18.1% held a bachelor’s degree; 3.5% held a university certificate below the bachelor’s level; 20.2% held a certificate or diploma college or CEGEP; 17.4% held a certificate or diploma of a trade school; 19.5% held a high school diploma; and 13.5% had no diploma ( ).

Language and Culture

The French-Canadian people of Québec are a linguistic minority in North America and, as such, fear the eventual loss of their cultural identity. Despite their ongoing efforts to preserve the distinct nature of the French-speaking culture, they are bombarded by pervasive American political and cultural influences exerted through various media, including film, radio, television, magazines, and recordings ( ; ). The use of the Internet poses a particular dilemma in the reconciliation of international science and business with the protection of linguistic identity ( ).

A charter ( Charte des Droits et des Lois ), which established French as Québec’s official language, was established to protect Québec’s language, culture, and identity ( ). These laws have enabled the French language to prosper and promoted the use of French among newly arrived immigrants and within commercial enterprises and public institutions. Several organizations have been created to monitor and encourage the use of French—for example, the Commission for the Protection of the French Language, which handles complaints concerning the unavailability of health or social services by French-speaking clients, and the Office of the French Language, which is charged with maintaining the quality of the French language and administering French competency tests to individuals entering the health (and other) professions ( ).

French

French is the everyday language of most of the people of Québec and the foundation of their cultural identity. The language brought from the old country was shaped and refined for two centuries from an amalgam of accents and expressions of various regions of France, with the assimilation of American Indian words designating places, lakes, flora, and fauna. In speaking this language, the r s can be rolled, and long vowels, t s and d s can slide into certain front vowels with a postconsonantal s sound ( ).

With the migration of rural populations to the cities and the common use of English in the workplace, a popular level of language often referred to as joual (literally, “stock of an anchor”) was created. This type of speech, reserved for oral communication, incorporates English words into a syntax and grammatical system that is essentially French ( ). The resulting speech patterns are, at times, quite remote from the standard French used by intellectuals, writers, and those in the media. In 2013, French was the native language of 99.3% of the population of Québec as compared with 21.1% in the rest of Canada ( ). Some 30% of the urban population is bilingual, speaking both French and English. Another 35 languages are spoken in the province, including Italian, Greek, Chinese, Native Indian dialects, Inuit, Slavic, Spanish, Chinese, Vietnamese, Persian, and Tamil ( ). Immigrants usually learn French as a second language and frequently learn English as a third language. However, the more than 50% non–French-speaking immigrants arriving yearly tax the process of integration into the French-speaking society ( ).

Communication Behavior

As the French language evolved, so did the behavioral patterns of its speakers. For example, there is a tendency to use the familiar pronoun tu (you) soon after a first meeting or being introduced to someone—a habit frowned on in France ( ). Québecers are warmhearted people who express their thoughts and opinions openly, are expressive, and use their hands for emphasis when speaking. However, they do not use as many nonverbal movements as the Italians, Spaniards, or the continental French. They enjoy the interaction of social gatherings, celebrate important dates, have a quick sense of humor, and enjoy conversation and discourse. When these individuals are married with young children, they tend to associate with others in similar life situations. They express themselves in the performance, visual, and written arts; cinematography and television production flourish, along with theater, dance, and music; and events such as the yearly jazz festival have become international. Local artists not only are influenced by cultures from all over the world but also are becoming appreciated internationally.

Conversation on subjects having to do with community, day-to-day life, and children, composed of modern multimedia sources exist where people of both sexes discuss celebrities, politics, art, or world events. Modern media allows such virtual communication as, for example, real-time viewing of Montréal’s city council meetings ( ) or use of an interactive Web site devoted to parenting ( ). Women are not only aware of feminist concerns but are increasingly vocal concerning issues of status, needed services, and treatment by various government agencies (e.g., Montréal women have marched on the capital to sensitize law makers about women’s rights [ ]).

Implications for Nursing Care

In Québec, as elsewhere, the nurse must respect the client’s choice of language, not only to ensure clear communication but also to meet the requirements of Québec law. The Québec nurse realizes the centrality of good communication to patient/family care and education ( ). Most nurses and doctors are bilingual, and whether they work in traditionally anglophone (English-speaking) or francophone (French-speaking) health settings, they care for patients and families whose mother tongue may be French, English, or a host of other languages ( ). The ethnic mosaic that exists requires that the nurse be sensitive to the style, mode, and context of the communication patterns, not only of Québécois of different backgrounds and education but also of diverse ethnic groups in different stages of social and linguistic integration into the province ( ).

The nurse must be familiar with the popular Québec expressions used to designate parts of the body (such as passage for “vagina”) or certain infections (such as chaude pisse for “gonorrhea”) or health and illness. Those who are older or with a rural background might say that a person able to resist illness is as “strong as an ox” or “able as a bear,” or when ill that the sufferer has a “weak constitution” ( ). When interacting with the older generation, the nurse should avoid using the familiar tu form because such usage is considered to show lack of respect.

Conceptualization of Space

The representation of space in Québec’s consciousness is process-oriented, related to urban-rural tensions and historical and social-political evolution, as well as to place-based identity ( ). This representation may be seen in three (interrelated rather than sequential) attitudinal themes: (1) spatial possession, depending on the underlying premise that specific groups can own, name, and control space; (2) spatial oppression, or domination or oppression by military force, patriarchy, class system, economy, or capitalism; and (3) spatial mobility, the tension between mobility and stasis, whether physical movement or identified with gender and ethnicity. The frame of reference consists of reterritorializing maps of power, domination, and marginalization.

Interpersonal Space

In public, Québecers tend to avoid physical contact and maintain a certain physical space. At work they may be in closer contact than in public, but individuals generally attempt to maintain a distance of 18 to 30 inches between themselves and others ( ). Among friends and close relations, greater intimacy is permitted. Men may pat each other on the back or shake hands when they meet but seldom embrace or kiss. Women embrace or kiss cheeks but seldom walk arm in arm. Normally, physical contact in public is limited to young lovers, between adults and young children, or between adults at emotional or difficult moments when they require support.

Physical Space

Families generally live in apartments, condominiums, or single-family dwellings in the cities and suburbs, or in single-family dwellings in rural areas. Housing, particularly low-cost and public housing, is available chiefly in the larger cities, but there are homeless among the young, the addicted, and the chronically mentally ill ( ). Despite immense territory, some 80% of the population is concentrated in the southern part of the province. Most people reside in the larger cities, such as Québec City (the capital), Montréal, Sherbrooke, Trois Rivières, or Laval. Montreal has been deemed the second happiest place in the world by a well-known travel guide ( ); the first place went to a South Pacific island nation. Montréal is home to innumerable festivals (e.g., jazz, film, Haitian, fringe, fantasia, circus) during the summer, and for the past 180 years, without exception, it has hosted one of the world’s largest St. Patrick’s Day parades, turning the city completely green for the day (no matter one’s ethnic background).

Implications for Nursing Care

An understanding of cultural geography can help nurses realize that space meanings are subtly constructed through a reworking of the past. Québecers are jealous and protective of their usually ample physical and personal space. In caring, the nurse avoids overly familiar attitudes, maintains distance when conversing, respects the privacy needs of patients and families, and recognizes the patient’s sense of modesty when receiving intimate care.

Family and Church

In early colonial days, families were large and stable, and family members felt a sense of belonging, not only to their land but also to the “Holy Mother the Church,” accepting its dominance in health care, education, and population management ( ). During the period preceding the world wars, rural families often had 8 to 14 children, in order to provide additional help with farm work and out of respect for the teachings of the church. With the advent of the Quiet Revolution of the 1960s, the state assumed responsibility for the family through health and social services. By the late 1970s, changes in social attitudes and legislation permitted divorce, contraception, and abortion ( ).

Evolution of the Family

In the past, family roles were well defined: the father was head of the family and responsible for its material well-being, and the mother had specific household and possibly farm duties and was caregiver and religious educator. The family was seen in Québec as a group of parents and children united by multiple and varied ties, favoring the development of person and society, for mutual support during life ( ). Family roles remained relatively unchanged until women, under socioeconomic pressures, began to join the workforce in greater numbers and became the heads of single-parent families. With the transition to the new generation of families, men and women began to reevaluate their familial roles; however, family functioning has not evolved without some difficulties ( ). Often the mother has maintained a double burden, still encumbered with her former tasks while assuming the obligations of outside employment. However, amid social change, the mother has remained the principal health care giver in the Québec family, instilling and supervising the practice of healthy habits within the family ( ; ).

Québec suffered a major decrease in the birth rate in the 1960s and although the number of births had dropped to 76,100 by the year 2005, it had risen to 87,600 in 2008; however, abortions had risen from 1.4 in 1971 per 100 live births to 38.1 in 1999 ( ). By 2011, the birth rate was 9.9. Whereas the fertility rate was 1.69 children per woman in 2011, Britain’s fertility rate was 1.7 and that of the United States was 2.1 ( ). In 2006, the mean number of children per family was 1.02; 83.4% of families were biparental, and, of these, 14.2% were reconstituted; 77.9% of single-parent families were headed by women ( ). In 2006, 13% of Québec’s children were growing up in low-income families ( ). Currently, about 32% of the adult population is not married (single, divorced, etc.); 38% are legally married and 20% live in common-law marriages ( ). In Canada, more than 340,000 children are growing up in mixed-race families, through inter-racial adoptions or in a growing number of ethno-cultural conjugal unions, composing 5.1% of Canadian couples who are mostly found in urban centers such as Vancouver, Toronto, or Montréal ( ).

The two-parent family remains the ideal, the fathers of young children play a larger role in the care of children and their home environment, and the reconstituted family unit has become an accepted social phenomenon ( ). However, a province-wide study of the health of families with children concluded that single-parent and reconstituted families seem more at risk than two-parent families. Whereas the regular use of alcohol varied little with type of family, smoking ranges from 28% in two-parent families, to 49% in single-parent families, to 54% in reconstituted families. Elevated psychological distress was reported in 18% of two-parent families but in 32% of the single-parent families and in 29% of the reconstituted families ( ).

New Models of Interdependence

Québec society has evolved in such a way that diluted traditional networks of support built around family and relatives, the neighborhood, and various religious institutions ( ). However, changing cultural mores and options, emerging lifestyles, or shared problems over the past few years have stimulated the creation of new models of interdependence, individualization, and actualization for women, as well as legalization of gay and lesbian unions and adoptions ( ; ). Regrouping of individuals into new networks of mutual aid or self-help is particularly significant. Community and volunteer organizations that have assumed many social and health functions for a variety of individuals are often inspired by needs no longer met by traditional means or by emerging social and health needs, such as persons living with acquired immunodeficiency syndrome (AIDS) ( ).

Aging of the Population

Demographic changes in the past 30 years have left Québec with a growing percentage of older citizens. The number of persons over 65 years is projected to grow from 1.2 million in 2011 to 2.3 million in the following 20 years; this group will then represent 25% of the population as compared with 9% in 1981 and 16% in 2011. There was also an increase in disabilities such as pain and decreased mobility with age: the rates were 8% in the 15–64 age group, 22.5% in those 64–74 years, and 46% in those over 75 years ( ). This general aging of the population includes an increase in the number of elderly women in relation to men, a proportion of about 3 : 2, and an increase in the number of the very old (i.e., over 80 years).

Youth

In 2010 in Québec, children, youths, and young adults composed 28.4% of the population (0–4 years, 5.3%; 5–9 years, 4.9%; 10–14 years, 5.5%; 15–19 years, 6.5%; 20–24 years, 6.2%) ( ). Socioeducational problems are present (e.g., children with learning needs, homelessness, teenage pregnancy, drug addiction, street gangs), and whereas the general unemployment rate in Québec is about 9%, it is over 14% for youths 15 to 24 years of age ( ). However, child and youth welfare is a priority for the province: there are provincial programs in pre- and postpartum care, scholastic adaptation for children with learning disabilities, recreation, and job training for youth and young adults.

Religion

Even with the British military conquest, the Catholic Church remained a social and political force in French Canada, defending faith, language, and culture ( ). The church was actively involved in financial, educational, and health affairs. In the 1960s, however, the Quiet Revolution brought about greater separation of church and state. At that time, attendance at church declined greatly, and religious affiliations became more diversified ( ). However, despite the decline in Catholicism’s influence and practice, more than 6 million Québecers consider themselves to be Catholic. Many individuals conform to a model whereby one calls oneself “Catholic” and marks certain important life events in life by a church ceremony (baptism, marriage, funeral, and so forth) and continues to support a school system organized on religious groups ( ). Today, Québec is noted for a growing interest in spirituality, a search for values, and diversification of beliefs and religious affiliations, including Protestantism, Judaism, Buddhism, Islam, Sikhism, Hinduism, and Seventh-Day Adventism ( ).

Implications for Nursing Care

The integration of extreme diversification of ethnic, cultural, and age groups in Québec presents a challenge for the nurse. By assessing the cultural attitudes of the client and family caregivers toward health, human reproduction, illness, and health care, the nurse takes the first step in assuring clients’ enabling and empowerment. An investigation of community nurses in Montréal found that family participation was one of the most important facilitators to care, and that patient/family participation in care objectives was one of the most important nursing strategies ( ). Nevertheless, despite Québec’s evolving social complexity, the social canvas of the province is still, in many ways, held together by the influence by the older generation, a sense of family, and sharing and mutual aid between generations. In working with single-parent families or those with limited financial means, the nurse may work with families whose members suffer from a variety of health and social problems. With feelings of powerlessness, whatever the family’s status, self-confidence is undermined. The nurse can help family members understand their situation, participate in the care process, and deal with the health system. Within any family, efforts can be made to improve functioning in health matters, whether by improving competencies, direct support, information, and advice or by arranging access to resources. The nurse can also become an advocate for families so that they may obtain the social and health services to which they are entitled ( ; ).

An aging population and a diminishing national health budget require that more community services be available to enable elderly people, with functional limits, to remain in their own homes. Day hospitals and centers staffed by multidisciplinary teams that offer various social services are increasing in number. note that both gender and kinship should be considered with respect to support when assisting French-speaking primary caregivers in providing care for aging and disabled relatives in the home.

Past and Present

The development and diffusion of time sense (the way we see and live time) is a phenomenon for the people of Québec that is related to the consciousness of time in the context of the value and rhythm of human life of a Catholic and rural society; the preciousness of time and calculation of time within the modernity of the educational system, urban industrialization, and the evolution of a city-based mechanized society; and the importance accorded to time in an era of developing communications ( ). French Québecers tend to attach primary importance to day-to-day affairs and to living in the present. Pleasure and sorrow are generally accepted as they occur, with an attitude that life goes on from one day to the next ( ). However, climatic and historic conditions have prompted planning to survive long and cold winters and a context of stability that provides structure for these values and attitudes. For older Québecers, time is intimately associated with religion. They envision the future with the hope of life after death. Anniversaries of the death of family members are often commemorated by a Mass. However, many of the young and urban, being less influenced by religion, tend not to follow such traditions. For women in modern Québec society, time has taken on a new meaning as working women assume a variety of roles (wife, mother, professional person).

Although time is determined by the flow of the successive seasons for rural populations, urban life is characterized by variations in the distribution of time as reported by study participants in a study by ; more than half expressed preference for engaging in free or leisure time activities, about 17% preferred time devoted to family and domestic responsibilities, and about 7% favored work time. In 1998, productive time for Québecers (work and domestic responsibilities) averaged 7.8 hours per day in households without children and 9 hours in those with at least one child ( ); however, living with children is associated with a negative impact on physical activities ( ). Time accorded to leisure activities (media, social, cultural, physical activities, and sports) totaled about 6 hours a week ( ). The most popular cultural activities were recreational games, dancing, audiovisual entertainment, plastic arts, and literary activities. Outdoor activities and sports accounted for time spent by people of all ages: more than 40% cycled; about one third camped, fished, or skied; and about 15% golfed, canoed, or rode snowmobiles.

Implications for Nursing Care

The nurse must consider the present-time orientation, often demonstrated by the importance attributed to practical goals, when interacting with families and individuals, as well as in the approach and content of health education. A verbal “contract” between the nurse and patient and family, of prioritized collaborative objectives including a time frame, often proves advantageous in enabling and in supporting self-care within the context of health promotion and therapeutic regimens.

Attitudes toward Health

In intellectual circles in Québec, health is perceived as being in complete possession of one’s physical and mental capacities and as a way of improving one’s status, professional or otherwise ( ). For financially secure families, health is seen as an ideal state in which illness is absent, whereas illness is seen as a slow and insidious degradation of health that occurs over time. In lower socioeconomic groups, health is defined as the ability to work, to be self-sufficient, and to satisfy primary needs. The disadvantaged often attach less value to a general state of good health, often seeking resolution of immediate problems without follow-up of long-term goals. Illness is seen as a stroke of bad luck, causing a momentary rupture in one’s normal state of health.

More than 90% of Québecers over the age of 12 considered themselves to be healthy but reported visiting a health professional within the previous 12 months ( ). However, previously found that those from 45 to 64 evaluated their health more negatively than did the youth; the poorer and less educated rated their health less favorably, and persons employed saw themselves to be in better health than those who were unemployed. Factors associated with an unfa­vorable self-evaluation of health included problems with weight, limits on activities, consultations with health professionals, and psychological distress. The practice of medicine has always held a place of prestige and political power in Québec.

Published yearly by a local newspaper, a “barometer of the professions” including 30 professions/occupations indicates that Québecers sustain a level confidence of 97% in firefighters, 96% in nurses, and 91% in doctors, as compared with 40% in priests, 29% in lawyers, and 6% in the proverbial used car salesmen ( ). However, with the advent of consumerism, the people of Québec began to participate more directly in health care decision making, and the ideology of the powerful medical establishment is now being questioned by both ordinary people and other health professionals. Various “alternative medicine” and spiritual approaches to health have become more popular, apparently in answer to a need for therapies that are global and allow greater personal control ( ). Furthermore, in a recent poll, three fourths of Québecers were found to be in favor of a special tax on energizing and sweetened drinks with the revenues being invested in health prevention ( ).

Social Environment of Health

Because of the strong interrelationship between an individual’s social environment and health and the value placed on families, Québec’s health and welfare policy is directed to reinforcing family and social networks. A survey of 1014 people across the province asked, “What is the most important thing in life for you?” The answer was emotional life and support (43%) before more time, work, or money ( ). Further, a surrounding family was seen as essential, and the emotional and psychological affinity was viewed (61%) as most important to a successful life as a couple. In their study of the health and social support of Québecers, concluded that men; persons widowed, separated, or divorced; and persons between the ages of 25 and 64 were comparatively more dissatisfied with their level of social interaction and social support. Men were more dissatisfied with living alone, and women in general had better social support. One person in four with a spouse, whether cohabiting or not, reported difficulties in the relationship. Further, in 2008, 12% of youths (3–14 years) experienced moderate or severe socioemotive difficulties, relational troubles being the most frequent and boys being more susceptible than girls ( ).

However, even though 65% of the population considered spiritual life to be very important, 64% seldom or never frequented a place of worship ( ). Generally, it was those persons who considered themselves to be in a poor state of health or who were limited in their activities who most valued spiritual life and attendance at religious worship. Those persons who most frequently attended religious services were less likely to report a high level of psychological distress or suicidal ideas.

The work environment in Québec has been found to affect health; 3% of workers reported violence and 18% intimidation, and 8% of women and 2% of men were subjected to unwanted words or gestures of a sexual nature constraints at work (such as combined low level of work autonomy with a high level of psychological demand) were found to be associated not only with psychological distress but also with perceptions of poorer mental and general health. Certain work conditions (e.g., working nights, exposure to solvents or vibrations), as well as certain characteristics of the work environments (such as size of the company, work organization, age of workers), were found to be associated with a high risk of accidents ( ).

Physical Environment

Problems of pollution and waste management constitute a serious challenge to the environment in terms of costs, contamination, and health. A water-purification program, in Québec since 1981, involves water-processing plants and greater control of industrial waste ( ). Public awareness has intensified and public programs have been created concerning reducing atmospheric pollutants, recycling, composting, using natural products, disposing of dangerous household wastes, and cleaning up lakes and rivers. With collaboration between the province and its inhabitants, there has been a reduction from 28 to 7 (from 2007 to 2009) restrictions in the use of lakes because of blue-green algae ( ). Further, pesticides, which are linked to cancer and diseases affecting children, have been banned from use on private lawns and gardens, as well as on the grounds of schools and other provincially owned green spaces ( ).

Determinants of health and well-being include physical activity and exercise, vaccinations, control of body weight, the practice of behavior proper to women’s health, and the practice of safe sex. There has been an increase from 45% in 2003 to 54% in 2009 in the rate of Québecers who report being active, rather than sedentary, during their leisure time; however, in adolescence (12–17 years), girls are less physically active than boys (53%) (Santé et Services sociaux de Québec, 2010b). Although the rate of obesity is lower in Québec than in the rest of Canada, the number of obese children has almost tripled since 1981. Further, obesity related to health risk has also increased, with 32.7% of the province’s adults now overweight and 15.5% obese ( ); and obesity-related illnesses cost the Québec health care system more than half a billion dollars annually, or 5% of total direct health care costs in the province ( ).

In the mass inoculation of 2009, 57% of the population were vaccinated against the flu (H1N1); by the 2008–2009 school year, 90% of students in grade 4 were vaccinated against hepatitis B and 80% of girls in the third year of high school were vaccinated against human papillomavirus ( ). Moreover, in a study by , about 27% of women over age 15 practiced self-examination of their breasts, and 50% indicated that they had a medical examination of their breasts, 49% had a mammogram, and 44% had a Pap test within the past year. Oral contraceptives were used by more than 50% of women ages 18 to 24, and by about 7% of those over age 35, for a total of 57% of the female population.

noted that health professionals, other than physicians, are assuming increasing importance in the health care system. While health problems, incapacity, and psychological distress prompt consultation with a health professional, the most important factor in seeking health care is perception of one’s state of health. Persons without a health problem were more likely to consult another professional rather than a physician. Info-santé (Info-Health), a telephone service in which nurses give information and advice on health and social matters, is available 24 hours a day, 7 days a week ( ). Seventy-five percent of the population knew of the availability of telephone service, and 32% of those used it.

reported that in the 2 days prior to their study, half of their respondents had consumed at least one prescription or nonprescription medication. The proportion of women who consume medication is greater than that of men, although it should be noted that this use includes contraceptives and hormone replacements. Use increased with age, and nonprescription use increased with revenue and education. indicated that 6% of Québecers had been hospitalized and 4.2% had been treated in day surgery during the previous year. Persons living alone, the chronically ill, aged, and new single-parent mothers were the most likely to receive home care. Families, in partnership with home-care nurses from local community centers, were the principal source of help and care at home, following hospitalization or during long-term illnesses ( ). Further, 20% of Québecers 15 years or older cared for an aged person without remuneration (Santé et Services sociaux de Québec, 2010a).

Rituals Related to Death and Dying

Functionality, aging, spousal death, and dying are interrelated as the older Québecer “downsizes” from the family home to a smaller apartment or care environment and to a smaller set of “things.” In Québec, such a move, often accompanied by a compulsion to divest themselves of many of their belongings, is called casser la maison (literally, “breaking the house”). An ethnographic study, realized in Montréal by and seen as descriptive of the social organization of death across Québec, reveals that to casser la maison is not a means of merely separating from one’s belongings; more essentially it is a ritualized form of ancestralizing oneself by placing those possessions with kin or other recipients, guaranteeing one’s survival in memory. Marcoux argues that casser la maison begins with a compulsion toward detachment but evolves into the appropriation of the event in the reconstruction of self: the acceptance of the loss of status through the acceding to the higher status of ancestor.

For earlier generations in Québec, death was formalized and dealt with by adherence to the symbols and ceremonies of the Catholic Church, usually in the context of the family, and by a strong belief in an afterlife. Death and anniversaries of the death of family members are often commemorated by a Mass. Although in the 1950s cremation was unacceptable to Québec’s Roman Catholics, with increased secularization and urbanization, it is now requested twice as often as body burials ( ).

Today, the final agony of death and all the emotions it provokes are frequently concealed from public view, since death usually occurs in an institution. Death is often perceived as the ultimate failure, by both family and health professionals, since it cannot be mastered or controlled by technology. However, the attitudes, values, and outlooks concerning the ethical problems of death, assisted suicide and euthanasia, treatment and cessation of treatment, and the accompaniment of the terminally ill are considered worthy of continued scientific study and philosophical discourse ( ). A recent poll in Québec that indicated strong support for assisted death in end-of-life situations also reflected confusion between ceasing unusual measures to prolong life and euthanasia ( ).

Implications for Nursing Care

In a multicultural society like Québec, health and illness are, in part, determined by the degree of an individual’s integration into a society and the social support supplied by the community. Social support has a preventive value if it is associated with networks that are stable, homogeneous, and dense and that provide a variety of links between individuals ( ). Health care planning must be sensitive to such diversity to be effective. A public-centered approach is at the heart of health and social service reform in Québec ( ). It is essential that the nurse be integrated into the interdisciplinary team in effective decision making about health and social services ( ).

Three differentiating factors contribute to health care assessment in a multicultural setting. First, nurses should note the meaning of health and illness in terms of the underlying significance of these concepts in the cultural group. Second, descriptions of symptoms, compliance with treatment, and reaction to pain will differ according to social level and ethnic origin. Third, the client’s gender influences how individuals view their bodies and the adoption of dependent or independent behavior patterns with regard to health ( ). These factors influence one’s representation of illness, the way the client’s illness is explained, the assumption of responsibility for personal health through self-care, and participation in the treatment regimen. Because women are ordinarily the principal health agents in the family, nursing interventions can be directed toward encouraging their collaboration in fostering healthful living habits.

In the larger cities, polluted air is associated with such problems as asthma, bronchitis, and allergies affecting the skin, eyes, and respiratory tract. Families could be advised to minimize use of possible allergy-producing substances found in rugs, bedding, and humidifiers in homes with young children, older people, persons suffering from asthma, or individuals with symptoms of acquired immunodeficiency. Prevention of symptoms caused by stagnant air in large buildings or factories also falls within the domain of the nurse concerned with the work environment and the reduction of worker absenteeism.

Since hunting and fishing are popular activities in Québec, it is of concern that certain pollutants may be present in fresh water and soil. Therefore, pregnant women should be advised against consuming freshwater fish or game during pregnancy. Even when women are not pregnant, the federal government recommends that fish from contaminated lakes be consumed no more than once a week to prevent accumulation of polychlorinated biphenyls in body tissues. The nurse’s role includes participation in awareness campaigns, in short- and long-term preventive measures, and in research to determine possible interrelations between such factors as pollution, health, lifestyle, and heredity.

With the aging of the population and the subsequent increase in the incidence of chronic illnesses has come intensification in the use of various drugs and medicines in the community. It is the nurse’s responsibility to help clients maintain their medical regimen and to inform them about the dangers of uncontrolled and irrational use of prescription or nonprescription drugs, of accidental or intentional intoxication, of teratogenic and iatrogenic effects, and of physical and psychological dependency.