Culture-Sensitive Health Care: Immigrants of Former Soviet and Soviet Bloc Countries
The population groups discussed in this section include those from the former Soviet Union, former Yugoslavia (Bosnia and Kosovo), and Poland. These groups represent diverse cultures and religions. They may be of Jewish, Catholic, Protestant, Pentecostal Christian, Orthodox Christian, or Muslim. While older members may follow these religious traditions, many of those who grew up during the period when Communist governments actively discouraged religion have no formal religious beliefs of any kind. Still, because of long histories of religious strife, members of these populations tend to group themselves on the basis of these religious backgrounds.
In spite of the diversity of culture and religion, the former communist economy has created certain common attitudes about the balance between personal and public roles and responsibilities regarding health care. Under the Communist system, health care, regardless of the quality, was considered the right of every citizen. Furthermore, enough similarity existed in the health systems in Russia, Yugoslavia, and Poland to have generated common expectations and "techniques" in defining the need for and the delivery of medical treatment.
General Keys to a Good Professional Relationship
Potential Culture and Climate-Related Health Concerns Common to All Groups
1. Obesity, gallbladder disease, diabetes, elevated cholesterol levels, cardiovascular disease
Food plays a major part in the rules of hospitality as well as in many of the religious and cultural traditions among these groups. All have a tradition of eating foods that are high in saturated fat. The cold hard winters that all regions share have produced similarities in the traditional diets of the Russian, Ukrainian, Bosnian and Polish immigrants to the United States. Despite the fact that Russian Jews and Muslim Bosnians are forbidden to eat pork -- a staple meat in the Polish diet, the need to preserve food without refrigeration has made dried sausage and the pickling (high salt content) of meats, fish, and vegetables popular. Russian Jews substitute chicken fat for both the cooking lard used in Polish cooking as well as for the butter used on the large quantities of bread consumed by each group. Long, cold winters make root vegetables more available than leafy-green vegetables. These vegetables are used in stews and heavy soups resulting in most of the nutrients being cooked out. While it is customary for Russian Jews to eat chicken (which is often boiled with the skin on) and Poles to eat carp (often boiled or fried in lard) on Friday nights, the fat content and the over-cooking of vegetables is probably similar.
2. Smoking, pollution, and related lung disease and cancer
Many older Russian Jews, Ukrainians, and Poles are heavy smokers. Those who come from large urban areas often display many of the respiratory problems caused by air pollution produced by large factories. The immigrants from Poland and the Russian areas around Chernobyl also need to be checked regularly for the many cancer producing products of nuclear fall-out.
3. Alcoholism
Although alcoholism is not a frequent problem with Russian Jews or Pentecostal Christians (who are forbidden to use alcohol or tobacco), it is a long-standing problem for Ukrainians and Poles. Although most Muslims are forbidden to drink, most Bosnian Muslims consider themselves Europeans first and Muslims second. While alcoholism has been mentioned as a frequent problem in former Yugoslavia and drinking alcohol is permitted by the Bosnian Muslim church, there is nothing in the literature to indicate that alcoholism is a major health problem with any of the three Bosnian religious groups.
4. Somatization of Mental Illness
Because mental illness is considered a stigma in most Eastern European cultures, the depression and stress which is often caused by the inherent problems of immigration such as having to deal with a strange culture, physical environment, and language are often channeled into physical complaints.
General Perceptions of US Health Care and the Role of the Health Care Institution in the Patient's Life
The health system in Soviet Russia was organized around regional clinics. When someone became sick they would stay in bed and wait for a medical aid to come to examine the patient and provide treatment. (In Russia, such an aid is called a feldsher The Polish name for the aid is the same but takes on the Polish spelling: felczer). Clinics were open a set number of hours and physicians worked a fixed shift. If the physician didn't have time to see all the patients by the end of the shift, he or she simply left and the patients had to come back the next day. Since appointments weren't kept, patients tended to arrive early (or very late with an "emergency"), complain loudly, and repeatedly remind the nurses that they were present.
Many Russian immigrant patients are frequently viewed as loud and complaining by United States caregivers who soon come to suspect that they are exaggerating their pain or symptoms. It is important understand that the patients come from a system in which it was definitely a case of "the person who makes the loudest noise" got the best (or often the only) treatment. A complaint of severe chest pain was often the only way to get seen by a physician.
In spite of lack of finances and facilities in the former Soviet Union, the American practice of short hospital stays is very different from that in most former Soviet bloc nations. One report published by the Western Journal of Medicine in 1982 stated that one in every four Russians was admitted for a hospital stay every year and that the average length of each hospital stay was 15 days.
Bosnian Health Beliefs and Practices
Children are highly valued and welcomed in most Bosnian families. Birth control devices were severely limited in Bosnia despite the fact that there were a number of pharmaceutical companies in the former Yugoslavia. The two most widely used methods of birth control were oral contraceptives and abortion to limit the number of children born and control the length of time between births. It is not unusual for Bosnian refugees in the United States to request assisted abortion as a means of ending unwanted pregnancies. Caregivers are advised to discuss with all women of childbearing age the many options open to women in the United States as a means of controlling and spacing pregnancies.
Disclosure of Life Threatening or Terminal Illness
In many places throughout the world, a patient would never be told that he or she had a life threatening or terminal illness. This would be considered a death sentence--especially if that disease were cancer. Consult the family about how much information should be revealed to the patient.
Family members will generally want to be present during the final moments of a patient's life.
Availability and Quality of Health Care
Like most former Soviet Bloc countries, health care was free of charge. The quality and standard of care was also considered comparable with that provided in Western Europe. The presence of several international pharmaceutical companies made it fairly easy to obtain medications. In spite of the above, physicians were poorly paid and it was expected that patients and their families would offer monetary and material compensations to caregivers as a means of assuring quality care or to obtain longer periods of "work leave authorization" from district physicians. If patients were not satisfied with the care provided at the district level, they could request permission to see a specialist at a larger facility. Training for nurses is at a "trade school" rather then a university level in Bosnia so Bosnian patients may not be familiar with the level of training which nurses receive in the United States. They may not understand why nurses commonly take a patient's pulse or blood pressure or give even routine medical advice.
Traditional Health Beliefs and Practices
The common practice of attempting to cure minor health problems and illnesses with herbs and special foods prior to seeking care at a health facility has been carried to the United States by many Bosnian refugees. The home garden in which herbs are grown is extremely important. Common remedies include a cabbage leaf pressed to a wound to reduce swelling, a potato slice pressed to the forehead or the oil of a plant to cure a headache, or a drink made out of boiled parsley for stomach ache. These remedies may be continued when care by a biomedical physician is sought.
Many Bosnians, especially men, are heavy smokers and suffer the types of lung and throat problems caused or irritated by cigarette smoke. Now that we know the harm done by second hand smoke, it is also suggested that caregivers carefully consider not only the harm done to the smoker but also to other members of the family.
Diabetes, high blood pressure, heart disease, and obesity are also health problems. Although Bosnians do consume a fairly good quantity of vegetables, they also eat a lot of fatty foods. Their diet, coupled with a lack of a tradition of regular exercise, can contribute to illness. In treating Bosnians, it is also important to be aware that it is common to discontinue medication as soon as it brings some relief or because the patient has been told that he cannot drink while on a course of antibiotics.
There is a strong stigma against mental health problems of any kind in Bosnian culture. This may deter refugees who have a past history of mental illness from including this information during a health history. They may also be reluctant to reveal any previous history of mental illness due to fear that it will negatively affect their status as refugees.
When a caregiver suspects that a patient may be suffering from Post-traumatic Stress Syndrome or depression, the patient and the patient's family should be helped to understand that the American health care system is accepting of mental problems and the need for mental health treatment. It is important that a culturally appropriate approach be used when referring a Bosnian patient to the Center for Victims of Torture or to a mental health provider. This provider should have special knowledge and experience in the identification and treatment of war related trauma.
Suggestions for Caregivers of Bosnian Refugees
Similar to the other populations included in this chapter, some of the most common health problems of new immigrants are heart disease, respiratory diseases, smoking and obesity (particularly in women). A life style in Poland which does not include physical exercise as a common leisure-time activity, a high incidence of smoking, and a high fat, high cholesterol diet contribute to these diseases. Many Polish immigrants living in Polonia communities worked or lived in close proximity to Polish factories and steel plants built after World War II. These were constructed without filtering systems and were located close to major cities. Hence, a large percentage of this population has been exposed to excessive pollution contributing to a high incidence of respiratory disease and cancer. Immigrants from Eastern Poland arriving after the Chernobyl incident in Russia may also have been exposed to radiation that seeped into the ground and water systems. The major Polish health problems of the 1970's were tuberculosis, infant mortality, psychoneurosis, cardiovascular disease, musculoskeletal disorders, and alcoholism. Tooth decay may also be a problem because of a shortage of dentists in Poland.
Polish immigrants should be screened for cardiac diseases, alcoholism, respiratory conditions, thyroid disorders (Poland stopped using iodized salt throughout the 1980's), and cancer--particularly leukemia.
Attitudes and Behavior Toward Physicians
Physicians hold an extremely high position in Polish society although their pay is extremely low. Physicians are considered authority figures and, in general, patients will follow medical orders carefully. It is very uncommon for the patient to ask for a second opinion. This would be considered highly disrespectful to the physician. When patents do not fully trust the physician or feel that they are not getting better, they often change physicians. Age and seniority are equated with knowledge, and patients in Poland often try to get their physician to send them to see "a professor." Because of the cultural attitude regarding age and wisdom, Polish American patients may be very distrustful of young residents and physicians.
Patient Information Regarding Illness and Patient Involvement in Medical Decisions
In Poland, it is common for lay people to talk of having a "weak heart," a "bad liver," etc. Friends and relatives will not question them about what kind of heart disease they suffer from or what kind of treatment they have received because it is not assumed the person will know. Polish immigrant patients are, therefore, extremely uneasy with the American medical practice of educating the patient in great detail about the exact nature and prognosis of his or her disease. This knowledge is considered the domain of the physician. His responsibility is simply to do what is necessary to make the patient well.
A negative prognosis is almost never shared with the patient. A diagnosis of cancer of any kind will be kept from the patient because it would be considered a death sentence. In Poland, the physician would be expected to modify any form of bad news to give the patient hope for full or partial recovery.
Pregnancy and Childbearing Beliefs and Practices
The high value placed upon family makes the bearing of children a very important element of family life. Although the Catholic Church forbids birth control and abortion, the primary method of birth control in Poland during the 70's and 80's was abortion. When other forms of birth control were used, the IUD was selected over oral methods because of a fear and distrust of the pill. This distrust is often felt by immigrants of childbearing age as well as by children of immigrants.
The pregnant Polish woman will pay a great deal of attention to prenatal care and will make every effort to eat well and get adequate rest to insure a healthy baby. She will seek care in a prenatal clinic if she cannot afford private care and will be careful to comply with medical advice. However, because of the traditional belief that the pregnant woman is "eating for two", it is important for the caregiver to monitor carefully the woman's weight gain and provide patient education about the dangers of putting on excess weight.
Women are expected to rest for several weeks after delivery. It is common for her to take only minimal responsibility for the care of the newborn child. During these weeks of recovery, it is common for her mother or mother-in-law to step in and devote herself full time to these duties. The working mother and/or her parents may be shocked at the short amount of maternity leave given to women in the U.S. In Poland, women are legally entitled to 90 days leave with partial pay.
Second and third generation Polish immigrant women will wish to breast feed their children. The caregiver or care giving institution should provide counseling and education about breast-feeding techniques.
Most Polish immigrants will find it very embarrassing and difficult to discuss details of the marital relationship with a third party. In spite of the high anxiety level regarding the woman's ability to conceive, Polish couples tend to take a more passive approach and wait longer before seeking medical assistance than couples of other cultural groups
Childbirth is considered the "woman's" affair and the woman traditionally remained isolated from both her husband and immediate family while in the labor and delivery room. The woman was admitted with labor pains and came out of labor and delivery with a child in her arms. Because of this tradition, Polish American husbands may feel very uncomfortable with the American procedure of encouraging the husband's involvement in labor and delivery.
Attitudes Toward Mental Health
Physical (or even supernatural) basis for illness will always be considered before a mental one. Even immigrants who suffered the trauma of World War II and openly attribute their illness to these experiences rarely seek help from a psychiatrist or mental health professional. They are more likely to seek the advice of family, friends, or their priest. Studies of first time admissions to psychiatric institutions have shown that amongst Eastern Europeans, there is a higher rate of admission from immigrants than from those born in the United States. There is also a higher rate of admission for women then for men. One reason given for mental difficulties faced by Polish patients is that those who live in primarily Polish-speaking neighborhoods and shop in Polish stores, use their children as intermediaries when forced to interact with the American environment. Consequently, they develop fewer coping skills.
Poles have a strong sense of family and hold the belief that they should take care of an immediate family member who is dying. Although they are usually willing to accept hospice care which is provided in the home, they may reject care outside the home. It is common for friends and family to wish to stay by the bedside of the dying person. Other friends and family may show their concern by bringing food, caring for children, and assisting in other ways.
It is customary to hold a wake for one to three days. This is followed by a Mass and a religious burial. The dead continue to be honored on All Souls Day (November 1) when the family attends a Mass and make special offerings to the church. Family members also continue to tend their loved one's gravesite by planting or bringing flowers and keeping it free from weeds.
Traditional Health Beliefs and Practices
Although there is a long tradition of biomedicine in Poland, it coexists with religious and herbal healers and a strong belief in holistic medicine. Large meeting halls are easily filled when someone claims a gift of healing by the "laying on of hands". Even educated and sophisticated Poles may believe that factors such as the weather, underground water currents, and stress influence their health. Before laying the foundations for a house, a diviner may be hired to locate underground water currents. This is because some believe that illness may be caused if a person's bed is positioned so that it crosses, rather than is placed in the same direction as an underground current. When asked what they think has caused their illness some Poles may reply that their problems are simply due to having had "a hard and difficult life."
Strong religious faith supports a belief in the supernatural healing powers of persons and sanctuaries. An important indication that a Pole, especially an older person, may hold such strong beliefs is religious medals that might be pinned to the patient's undergarments. These should not be removed or ridiculed, but should suggest careful questioning regarding the patient's view of the cause of the illness and what he or she has been doing or taking to treat the problem.
In Poland, holistic medicine is more widely accepted than it is in the United States. Physicians often prescribe herbal medications that are filled at pharmacies. Tincture of valerian is often prescribed as a sedative, tincture of belladonna for peptic ulcer, as well as a large number of herbal teas, such as hyterci for indigestion, and dill tea for colic and gas pains in newborns and infants. Chamomile tea is prescribed for upset stomach and externally as a disinfectant and for vaginitus. Many Polish immigrants have continued to grow herbs for medicinal purposes after coming to the United States. Information about such herbs can be found in, Polish Herbs, Flowers, & Folk Medicine (Knab, Sophie Hodorowicz, New York, Hippocrene Books, 1995).
Polish immigrants often have a great trust in "natural" medications and may use them in addition to what the American caregiver prescribes. In order to avoid "double-dosing", it is essential that caregivers carefully question patients regarding use of herbal or other forms of medications.
Poles often have a strong sense of stoicism as well as a sense that "this illness or trouble was meant for me". This often leads to an acceptance of the problem that causes the person to postpone seeking treatment until daily function is impaired--sometimes too late for cure.
Suggestions for Caregivers of Polish Americans