Russians in Minnesota

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Increasing the cultural competence of health care providers serving diverse populations

In order to provide equitable and effective health care, clinicians need to be able to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. According to the 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and ethnic minorities tend to receive lower quality health care than non-minorities even when access to insurance and income is accounted for. Failing to support and foster culturally competent health care for racial and ethnic minorities can increase costs for individuals and society through increased hospitalizations and complications.

Minnesota has one of the largest communities of Russian and Eastern European immigrants in the Midwest. According to data published by the State Demographic Center in June 2004, the estimated population of Russian immigrants in Minnesota was 12,500. Many Russians who immigrated to Minnesota in the late 1980s and 1990s were Jews who had endured repression under the Soviet Union. Since the fall of communism, people from Belarus, Ukraine, and other former Soviet Republics also have immigrated to Minnesota. Immigrants from the former Soviet Union as well as war refugees from Bosnia and Croatia settled throughout the Twin Cities, with Russian Jewish refugees initially settling in St.. Louis Park, downtown Minneapolis, and the
Highland Park area of St. Paul. Communities of Eastern European immigrants also exist in Burnsville, Eagan, Osseo, Robbinsdale, Rochester, Savage, and Shakopee, with more than 2,000 Bosnian refugees having settled in Fargo-Moorhead and Pelican Rapids.

The following cultural patterns may represent many immigrants from Russia and Eastern Europe, but do not represent all people in a community.

Social structure

The family is a source of stability for Russian Americans. Elders are expected to help raise their grandchildren if both parents are working and children are expected to care for their elders in old age. Children are expected to be respectful of
their elders, addressing them as Mr., Mrs., Uncle, or Aunt. The strongest personality in a Russian family (mother, father, eldest son, or eldest daughter) is usually the spokesperson and decision-maker for the family. Family members have strong kinship bonds,
provide support for each other during a crisis, and are often consulted during health care planning, especially when consents for release of information are required.

Compared with other major immigrant populations in Minnesota, Russian Americans are generally older (83 percent are age 50 or older), have fewer children, and are more educated (95 percent have at least a high school diploma).

In addition to speaking Russian, most Russian immigrants also speak the language of the republics where they formerly lived (e.g., Belorussian, Ukrainian, and Uzbek). Native languages of Yiddish and Ladino are also spoken at home, although typically only the oldest generation of Russian Jews can still understand and speak these older languages. Many Russian Americans hold professional positions as physicians, engineers, and teachers, although many encounter difficulties pursuing careers in the US due to certification or licensing requirements. The most recent arrivals tend to be less educated and are employed in manufacturing, trade, and service industries. Many small, Russian-owned businesses have been successfully launched in Minnesota.

Diet

Russian Americans often maintain a diet high in fat, carbohydrates, and sodium, contributing to health problems that include diabetes, hypertension, and coronary and gastrointestinal diseases.

During the early years of communism and food shortages in Russia, the main concern was eating enough calories to stay alive. Meals were heavy, fatty, and salty, though otherwise bland. The ideal meal for a working peasant included boiled buckwheat with lard and a fermented drink made from dense, sour, black bread—food that would “hold you to the earth” and last a full working day. Conventional wisdom dictated that the richer and more fatty the food, the harder one would work. Traditional meals eaten by some Russian Americans today include pickled and dried meats, fish, bread, potatoes, dumplings, porridge, cabbage and beet soup, and vegetables.

Religion

In the US, many Russian immigrants practice Judaism or Eastern Orthodox Christianity, Russia’s traditional and largest religion. The Eastern Orthodox church is widely respected by both believers and nonbelievers, who see it as a symbol of Russian heritage and culture. Many Russian immigrants in the US also belong to Christian Baptist and Pentecostal churches. Smaller numbers of Russians follow other Christian religions, such as Roman Catholicism, Armenian Gregorian, and various Protestant denominations. As a product of the anti-religion policy of the former Soviet Union established in the early 1900s, many Russian immigrants are atheists.

Medical care

Common diseases seen in immigrants from Eastern Europe include diabetes, hypertension, coronary disease, gastrointestinal problems, tuberculosis, mental illness, and alcohol and substance abuse.

Some Russians believe that disability or illness is caused by something the individual did not do right, such as not eating well or not dressing warmly enough. Good health is equated with absence of pain. Illnesses that do not cause pain often go undiagnosed and under-treated, such as diabetes, hypertension, and high cholesterol. Mental illness is regarded as disgraceful in many Eastern European countries. Immigrants often do not answer questions regarding a family history of mental illness or past treatment.

Expression of feelings in Russian culture is different from that in American culture. Many immigrants are unfamiliar with the cultural etiquette of American medicine and tend to expect more compassion and emotional closeness with their physician—seeking a professional yet close relationship with providers. In Russia, a patient can confess to a doctor as if speaking with a priest. Problems can arise in the health care setting directly from this cultural difference. Rather than appreciating the privacy and autonomy of American medical culture, patients may complain about the quality of medical treatment they receive and question the physician’s ability to understand their problems.

Practices associated with physical examinations in Eastern European culture are different from those in American medical culture. In Eastern Europe, hospital gowns are not provided during examinations. Most patients are examined in their undergarments; nudity is not considered shameful.

Some immigrants from Eastern Europe may be distrustful of physicians and reject health recommendations, such as refusing to take medications as prescribed or combining medications and therapies with home remedies and treatments. Home remedies are often used prior to seeking medical attention, such as oil rubs, mud or steam baths, and exposure to fresh air and sunlight. The “bonki” is a cold and flu remedy where glass cups are pressed on a sick person’s back and shoulders to ease symptoms. The bonki often leaves behind bruises and welts, which may be misinterpreted as a sign of physical abuse.

When a Russian person is ill, family members and friends are expected to visit in order to provide support to the individual and immediate family. Bad health news is not given to a person who is ill or disabled. The family does not want the person to become anxious. It is commonly believed that the individual needs to be at peace so physical and emotional conditions do not worsen. The family prefers to receive the news first, then decides whether or not to tell the patient of the condition and prognosis. Eastern European immigrants tend to appreciate the high quality medical care, equipment, and variety of medications available in America. They especially value the right to choose their own physician and receive follow-up care from that same physician. They appreciate having excellent medical services available in cities and remote areas, with preventive check-ups covered by insurance, home health aides, transportation services, and programs like meals on wheels.

Death and dying

To ensure a more peaceful death, family may believe that the patient should not know of imminent death. The moment of death and the patient’s last words are highly significant. In some cases families may prefer to care for the patient at home rather than a nursing home. Some family members may ask a rabbi, priest, or others to pray for the patient. Depending on the person’s religion, family members may want to wash and dress the body. Jewish families never leave the body alone until after burial as a sign of respect. Some Jews believe that the body should remain intact. Because both Christians and Jews believe the body is sacred, organ donation is uncommon. Most Russians will refuse autopsy. Jewish law forbids euthanasia and assisted suicide.

Culture in context

Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.

Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.