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Katerina Fyodorova, an 85-year-old Russia immigrant, came to the United States in 1998 with the wave of immigrants coming from the former Soviet Union (FSU) with the collapse of the Soviet regime. Katerina is commonly referred to as a babushka or grandmother. She is widowed, her parents are deceased, and she has no living siblings and has no children.

Despite living in the United States for nearly 30 years, her primary language is still Russian. She speaks Russian in her home and associates mostly with other immigrants from the FSU. She lives alone in a high-rise, low-income housing in a poor-quality neighborhood in a large metropolitan area on the east coast of the United States. This area and surrounding environs have the largest people from the FSU, although Alaska and cities on the East and West coast also have large populations of such immigrants. Katerina enjoys accessing New York’s daily Novoye Russkoye Slovo newspaper and the cable television channels and radio stations available in Russian in the New York area.

Katerina is subsisting on a very limited income. At times she feels depressed and lonely and doesn’t know where to turn to. She sometimes feels a sense of hopelessness about her situation. She does not feel comfortable confiding in physicians because of the stigma associated with major depressive disorders in the USSR.

Speaking in a circular fashion, Katerina may describe her bittersweet memories of life under communism in her homeland and her current feelings of social needlessness, loneliness, and isolation. The unmet need for diagnosis and treatment of depression among immigrants from the former USSR now living in the United States has been reported in the literature (Landa et al. 2015). In study participants seen in a primary care clinic, 26.5% had a probable major depressive disorder. It is noted that such depression does not diminish in those who have lived in the United States for decades and is often underdiagnosed and untreated (Landa et al. 2015: 283).

1 Cultural Issues

Like many of her aging peers, Katerina’s healthcare can be characterized by a pattern of begat’ po racham or “running between doctors.” This includes a variety of both biomedical and traditional therapies. This pattern of healthcare has led to weaker patient-provider communication and lower levels of satisfaction with healthcare. She does not appear to have any serious medical problems, but has little to do, having much time on her hands, and is living in social isolation, in addition to not having a basic understanding of the normal aging processes. Such a non-systematic pattern of seeking healthcare among FSU immigrants to the United States has been described in the literature (Chudakova 2016).

In a recent visit at the clinic, she offered the clinic nurse an informal payment in the hopes of getting a “higher” level of care and bypassing the lines at the clinic as well as required paperwork, not understanding that such practices are not appropriate or expected in healthcare facilities in the United States (Gordeev et al. 2014). Such practice is an important health policy issue for those caring for immigrants from the FSU.

When Katerina sees a healthcare provider, she is likely to report only fair or poor health than her American counterparts which is also reported in the literature (Hofmann 2012). In Slavic cultures, “speaking positively about one’s own well-being is thought to bring misfortune” (Hofmann 2012: 319; Paxson 2005). However, her complaints are very vague and general.

When Katerina has a conversation with an American healthcare provider, she is often uncomfortable. She would prefer that providers should communicate with her in a paternalistic manner because this is what she was used to in the FSU (Younger 2016). This has also been reported in the literature in a study of immigrants from the FSU living in Germany (Bachmann et al. 2014).

When possible, Katerina prefers to use complementary therapies because they are less expensive, come from nature and thus come from God, and are available without prescription. She also perceives them as having fewer complications than biomedical therapies which are “too strong, chemical, and not natural” (Van Son and Stasyuk 2014: 546). Dietary proscriptions include onions, garlic, lemons, and beets. Herbs most commonly used include valerian, kava, Siberian ginseng, St. John’s Wort, pheasant’s eye, and yarrow (Tagintseva 2005). She makes decisions about these therapies by conferring with neighbors and friends who are also from the former FSU (Van Son and Stasyuk 2014). This kind of inappropriate self-care (samolechenie) is problematic as Katerina seeks to “become her own doctor,” characterized by dismissing potential health concerns by saying fatalistically, “it is as it is” (kakoye est).

2 Social Structural Issues

There are 15 Soviet republics, which include the Slavic states (Russian Federation, Ukraine, and Belarus; the Baltic States (Estonia, Latvia, and Lithuania); the Caucasus states (Armenia, Azerbaijan and George; the Central Asian republics (Kazakhstan, Uzbekistan, Turkmenistan, Kyrgyzstan, and Tajikistan) as well as Moldova. Many of these states have large populations of ethnic Russians. Katerina came from an ethnically and culturally diverse background, with a population of more than 150 minority nationalities and 100 different languages besides Russian living in Russia (Younger 2016).

Since 1991, many immigrants from the newly independent states of the FSU have come to the United States, including those from the Russian Federation. The 2015 estimate of the US population born in the former USSR is 1,066,944 (American FactFinder 2017a). New York State and surrounding areas have the largest percentage of people from the FSU, although Alaska and cities on the East and West Coasts of the United States also have large populations of such immigrants (American FactFinder 2017b).

Like many immigrants from the FSU, Katerina is an ethnic Jew who came because of an American program granting asylum to Soviet Jews because of anti-Semitism in the USSR (Landa et al. 2015). Katerina is secularized and religiously non-observant. The majority of former Soviet Jewish immigrants were over 55 years of age when they came to the United States, which is much older than other immigrant populations. Like many Jewish immigrants from the FSU, Katerina has close relatives living in Israel because of the divided destinations of Jews leaving the FSU after the fall of the Soviet Union.

3 Culturally Competent Strategies Recommended

The following are recommendations to enable the development culturally congruent and effective strategies to improve the quality of life in immigrants from the FSU living in the United States such as Katerina.

3.1 Individual/Family Level Interventions

  • In the primary care clinic, a physical and psychosocial-cultural assessment should be conducted with Katerina using a certified interpreter. This should include learning about language preference, how healthcare decisions are made, preferred communication style with healthcare providers, perceptions of the promotion of health and causes of illness, knowledge about community resources, and culturally preferred treatments for illness (Bachmann et al. 2014; Douglas et al. 2014). The more knowledge professional nurses have about specific cultural groups, the more accurate and complete the cultural assessment will be (Douglas et al. 2014).

  • Consult with social services to assist Katerina in accessing resources such as English classes, health education (including media presentations that have been translated into Russian), smoking cessation initiatives, and community services for seniors including meals and exercise programs.

  • Provide connection with any community organizations and other community resources for immigrants from the FSU.

  • Help Katerina understand the difference between normal aging and symptoms that may indicate underlying health conditions.

  • Help Katerina understand the potential health risks associated with combining biomedical and complementary therapies.

  • Help her to understand how to communicate effectively with healthcare providers.

  • Assess Katerina for a major depressive disorder using tools translated into Russian.

  • The Patient Health Questionnaire-I (PHQ) is a screening tool for depression which is available in Russia (Kroenke et al. 2001) (www.phqscreeners.com).

  • Help Katerina access resources to overcome feelings of despair and hopelessness, focusing on her strengths and resiliency as a survivor of challenging life circumstances.

3.2 Organizational Level Interventions

  • Provide a certified interpreter during healthcare encounters.

  • Provide staff with current literature on immigrants from the FSU living in the United States and meet to discuss the implications of that literature on their clinical practice.

  • Provide cultural competency education for providers serving populations of immigrants from the FSU such as the interprofessional education Russian cultural competence course at Washington State University described in the literature (Topping 2015).

  • Access, or develop, produce, and disseminate patient education material translated into English.

  • Collaborate with Russian focused media outlets to provide health messages on the radio and television stations and in print media.

3.3 Community Level Interventions

  • Collect quantitative and qualitative data in mixed methods studies on the challenges and needs of immigrants from the FSU to increase understanding and facilitate the development of appropriate interventions. This may be done in collaboration with resources such as the Davis Center for Russian and Eurasian Studies at Harvard or utilize local universities. This could include an oral history project with older immigrants such as Katerina which would increase our outstanding of the lives of immigrants from the FSU. These immigrants have stories to share that are richly descriptive and potentially helpful in facilitating quality healthcare delivery to them.

  • Collaborate with low-income housing facilities to work toward improving the environment in a way that helps Katerina and other FSU immigrants feel safe and connected.

Conclusion

Cultural issues specific to caring for immigrants from the FSU may include poor patient-provider relationships because of linguistic issues and differences in communication styles, help-seeking patterns of accessing multiple providers, the use of complementary rather than biomedical therapies, the potential use of informal payment, a lack of knowing the difference between natural aging processes and potential illness, and the significant potential for major depressive disorders. Strategies for culturally competent healthcare delivery at the individual, organizational, and societal levels should be designed and implemented to address Katerina and other immigrant’s vulnerability due to the social determinants of health related to the health and well-being of immigrants from the FSU (Douglas et al. 2014).