Editorial

The 'Good' Family Syndrome: Social and cultural issues in community and family health

Imelda Coyne
Children's Nursing, School of Nursing, Dublin City University, Dublin, Ireland

PP: 154 - 156

Article Text

Many nurses would openly admit to classifying families into two groups, the good families and the 'problem' family. Generally the good family is one that complies with all medical treatments, and behaves appropriately according to frequently unarticulated parameters set by health professionals. Conversely the problem family is one that fails to adhere to prescribed treatment plans, challenges health professionals, is over involved or too detached and oversteps the boundaries of their expected role. Unfortunately too many times families from different cultures end up being labelled as difficult or problematic because of perceived non-conformity to social norms and desired behaviours. They end up in the 'problem' family category due to biased attitudes towards their cultural backgrounds and/or socioeconomic status, despite only trying to cope with the situation from their own frame of reference and understanding. Families from different cultures may lack knowledge of what is appropriate behaviour in healthcare interactions which can result in misunderstandings and conflict. Learning to negotiate in a culture that has different norms and values is not easy when you are feeling vulnerable and ill. Labelling families is discriminatory. Many health professionals are prone to making generalisations about cultures which ignores heterogeneity and leads to erroneous assumptions and stereotypes. This leads to poor understanding which potentially leads to inadequate care.

The statistics on cultural groups' health status makes for sobering reading as these families usually have higher rates of illnesses but yet receive little if any preventive healthcare, inadequate health maintenance, and have limited access to health services. Research from the Netherlands suggests that cultural factors and poor living conditions seem to contribute to the poor health of immigrants, besides an adverse socio-economic position (Stronks et al 2001). Migrant families in particular generally suffer more illnesses, both acute and chronic, than do the general population because of unhealthy living environments, poverty and insufficient medical care. Lack of funds or inaccessibility to health services inhibits some families from seeking treatment for any but severe illness or injury. Alternatively cultural beliefs that value stoicism and self-reliance will prohibit many families from seeking advice or treatment for healthcare concerns. Consequently they only access healthcare services when symptoms have become acute or unbearable. Language barriers and the perception of services as being for the majority population prohibit cultural groups, in particular the elderly, from accessing many statutory and voluntary services.

The generally negative view of cultural groups ignores the fact that many such families show tremendous resilience when faced with illness, trauma and unexpected crises. Many families can usually rely on a wide informal network of support such as extended family members, friends and social networks that may not be so evident in other westernised cultures. Families bring patterns of functioning that is unique to each individual family and often families develop their own way of problem solving that facilitates their coping and adaptation. The social capital of extended families and community networks is now being recognised as a significant factor that contributes to families overall functioning and well being. Therefore a theoretical reframing of families from different cultures is required to acknowledge healthy family functioning and provide culturally competent care. Viewing families from a positive perspective rather than a deficit approach would encourage recognition of families' resilience, hardiness and adaptation. Although research is proliferating in this area, there remains a deficit of knowledge about cultural minority families' successful coping strategies and patterns of functioning. Intergenerational communication and support contributes to families' social capital and hence should be respected and valued by health professionals.

Valuing families cultural and ethnic identity is central to the provision of culturally competent care and culturally specific information and advice. Taking time to communicate effectively with families will result in increased understanding of their worldviews, which will shape healthcare interactions and intervention to families individual needs. People from diverse ethnic groups have unique social, cultural and linguistic backgrounds that profoundly influence their perceptions of health and illness. Families also carry, from generation to generation, cultural beliefs and traditions associated with health and illness (McCubbin et al 1993). Nurses need to understand the beliefs systems of families, learn about their help-seeking behaviours and actions to manage treatments to optimise nursing care. Likewise effective health promotion strategies will only work if social and cultural issues are factored into the interventions.

International migration has led to a growing multicultural world and demographic changes within most western countries. Hence the trend is set to continue of diverse cultures which expect to receive quality healthcare that is culturally sensitive. Since May 2004, there has been a steady flow of migrants into Ireland, particularly from the new EU accession countries. Ireland is not the first country to attract inward migration but it is a relative novelty in a country that until a decade ago, was a long-standing exporter of its own population. We must learn from other countries who have integrated with other cultures to learn successful strategies which can be used to ensure that cultural groups are not socially isolated and deprived of adequate healthcare. We need to focus research on the interactive effects of social and cultural issues on healthcare provision and health promotion interventions.

With the population growing increasingly diverse, there is a developing need for cultural competence among nurses and throughout healthcare organisations. The evidence from different countries suggests that nurses understand and support the principle of culturally competent care (Berlin et al 2006; Narayanasamy 2003). However knowledge does not necessarily equate with cultural awareness or cultural competence. In reality most nurses struggle to provide cultural care that is sensitive, responsive and relevant for different cultural groups. Nurses have their own cultural frame of reference and a culture associated with their occupation. Frequently nurses are not aware of their own cultural values and how those values influence their thoughts, actions and interactions (Cooper-Brathwaite 2005). Those who are aware of their own cultural founded behaviour are more sensitive to cultural differences and less likely to label behaviour as 'abnormal'. Many community nurses have had no formal education or training in cultural competence (Cooper-Brathwaite 2005; Berlin et al 2006). It may be unrealistic to expect nurses to remember lists of all the cultural beliefs and customs of all cultural groups they encounter. But what we can expect is that healthcare professionals will approach each family as unique, and seek to understand their frame of reference, respect cultural differences, obtain relevant cultural data and provide culturally sensitive care throughout the illness trajectory. Models of cultural competence can be useful aides in structuring nursing interventions (Campinha-Bacote 1999) and linguistic services plus bilingual healthcare workers can help reduce language barriers thereby enhancing the communication process (Cioffi 2003). Cultural courses should be integrated with content in nursing programmes to equip nurses with knowledge and skills to provide culturally competent care to families. The mounting evidence of links between disease and health behaviour and the influence of family, other social groups, and the environment on the development and maintenance of health practices compels nurses to take a multisystem and cultural perspective for positive outcomes. As the papers in this section clearly illustrate, providing culturally competent care is fundamental to families' recovery and overall welfare.

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