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Increasing the cultural competence of health care providers serving Minnesota's diverse populations
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Common health equity issues for Russian populations
Cultural competence is the ability to recognize and understand the role culture plays in health care and to adapt care strategies to meet patient needs.
Get to know patients on an individual level. Each person’s preferences, practices, and health outcomes are shaped by many factors. Generalizations in this material may not apply to your patients.
Russians in Minnesota
Approximately 48,000 to 60,000 Minnesotans claim Russian ancestry, according to the Minnesota State Demographic Center’s estimate , with the higher estimate from community leaders. Census data indicates 8,500 people in Minnesota were born in Russia. The Russian population in the U.S. is estimated to be 3.13 million, with the largest populations scattered across New York, North Dakota, and Virginia.
The first wave of Russians coming to the U.S. took place between 1880 and 1917, when millions left Russia for political or economic reasons, including Russian Jews who were escaping religious persecution. Russians continued to immigrate to the U.S. throughout the 20th century. Since the fall of communism, people from Belarus, Ukraine, and other former Soviet Republics also immigrated to Minnesota. Jewish Russian refugees initially settled in St. Louis Park, Minneapolis, and the Highland Park area of St. Paul.
A Wilder Research survey indicates that Russian immigrants are much less likely to miss or want to return to their country of birth than other immigrant populations.
Most Russian-Minnesotans speak Russian in addition to the languages of their native republics (e.g., Belorussian, Ukrainian, and Uzbek). Yiddish and Ladino also are spoken at home, although typically only the oldest generation of Russian Jews can still understand and speak these older languages. Of people who identified culturally as Russian, census data indicates only 5 percent do not speak English well. In a 2000 Twin Cities survey, only 13 percent of Russian immigrants indicated that they can “speak and understand English very well.”
Data on Russian-Americans is limited and may not apply to populations in Minnesota. Some health issues could be biologically tied to race; many are tied to social inequities, including poverty.
Social determinant disparities
Social determinants of health are economic and social conditions that influence the health of people and communities.
The Russian community in Minnesota is diverse. Many aspects of Russian-Minnesotan culture reflect the culture of the general U.S. population and generational differences impact social practices. 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 (often the 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, Russians are generally older (83 percent are age 50 or older), have fewer children, and are more educated. Many Russians hold professional positions as physicians, engineers, and teachers, although many encounter difficulties pursuing careers in the U.S. due to certification or licensing requirements. Russians arriving more recently to the U.S. tend to be less educated than earlier immigrants. They are often employed in manufacturing, trade, and service industries, and many have launched successful businesses.
Most Russians practice Judaism or Eastern Orthodox Christianity, Russia’s traditional and largest religion. The Eastern Orthodox Church is widely respected among Russians by both believers and nonbelievers, who see it as a symbol of Russian heritage and culture. Smaller numbers of Russians are Roman Catholics, attend the Armenian Gregorian church, or follow other Christian religions. As products of the anti-religion policy of the former Soviet Union established in the early 1900s, many Russian Americans are atheists.
As immigrants acculturate, they replace traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension. Russians often maintain a diet high in fat, carbohydrates, and sodium, contributing to health problems that include Type 2 diabetes, hypertension, and coronary and gastrointestinal diseases. Traditional meals eaten by Russians today include pickled and dried meats, fish, bread, potatoes, dumplings, porridge, cabbage and beet soup, and vegetables.
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.
Common diseases seen in immigrants from Russian and Eastern Europe include diabetes, hypertension, coronary disease, gastrointestinal problems, tuberculosis, mental illness, and alcohol and substance abuse. Some Russian immigrants believe that disability or illness is caused by something the individual did, 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 Type 2 diabetes, hypertension, and high cholesterol.
Many Russian immigrants are unfamiliar with the cultural etiquette of American medicine and may 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 may arise in the health care setting directly from this cultural difference. Rather than appreciating the privacy and autonomy of the 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 countries are different from those in the American medical culture. In Russia, hospital gowns are not provided during examinations. Most patients are examined in their undergarments; nudity is not considered shameful.
For some of the reasons above, Russian immigrants 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 bruises and welts, which may be misinterpreted as signs 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 often not given to a person who is ill or disabled as the family does not want the person to become anxious and it is commonly believed that the individual needs to be at peace so physical and emotional conditions do not worsen. The family may prefer 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, such as home health services, transportation services, programs like meals on wheels, and preventive check-ups covered by insurance.
Approximately one in five of all adults in the U.S. experiences mental illness in a given year. Empathy is not readily understood by many Russians. Russians frequently mistake empathy in therapy for sympathy or pity, which is less acceptable to them. Mental illness is regarded as disgraceful in many Eastern European countries. Russian immigrants often do not disclose a family history of mental illness or past treatment.
Older immigrants are less likely to have English skills which may increase the loneliness, isolation, and depression.
End of life
When discussing end of life issues with any patient, health care providers need to understand preferences based on personal and family views. To ensure a more peaceful death, many families believe that a loved one should not know that death is imminent. The moment of death and the patient’s last words are especially significant. In some cases, families prefer to care for the loved one at home rather than at a nursing home. They may ask a rabbi, priest, or others to pray for the patient.
Depending on the family religion, family members may wash and dress the body for burial. Jewish families never leave the body alone until after burial as a sign of respect. Because both Christians and Jews believe the body is sacred and should remain intact, autopsy and organ donation are uncommon.
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