The Meaning of Health Among Midlife Russian-Speaking Women

Written By: Sam Savage

Published Date: September 28, 2008 Last Edited: September 28, 2008

By Resick, Lenore Kolljeski

Purpose: To explore the meaning of health among midlife Russian- speaking women from the former Soviet Onion. Design and Methodology: A hermeneutic phenomenological design was used. Study participants included 12 Russian-speaking women ages 40-61, who also spoke English and had migrated to the United States after 1991.

Findings: These themes were identified: health as being highly valued, though less of a priority during immigration; being a stranger and seeking the familiar; grieving and loss and building a new life; experiencing changes and transitions; trusting self; and the importance of hope.

Conclusions: Although health was less of a priority during the immigration process, the women valued and were knowledgeable about health, participated in self-care practices, trusted their own abilities to make self-care decisions, and sought health-related information. This is a vulnerable population at risk for the onset of chronic medical conditions associated with the process of aging, past exposures, the tendency to avoid health screening, and current stressors related to immigration and family responsibilities. Implications include the need for interventions to build trust, assess self-care practices, and understand values and beliefs concerning health screening. Future research recommendations include replication with other samples within this population and exploring curative beliefs and practices more fully. Ultimately, this study design could be applied to other immigrant populations in Western cultures.

Clinical Relevance: Midlife Russian speaking women from the former Soviet Union are a vulnerable group at risk for the onset of chronic medical conditions associated with aging, past exposures, the tendency to avoid health screening, and current stressors related to immigration and family responsibilities.

[Key words: immigrant or refugee health; meaning of health, Russian-speaking women, midlife women, hermeneutic phenomenology, immigration, emigres]

Since the collapse of the former Soviet Union (FSU) in 1991, migration to the West has increased dramatically. Data sources show that since 1992, approximately 2.66 million people have migrated from the Commonwealth of Independent States (CIS) to Western countries with most migrating to Germany, Israel, and the United States (Tishkov, Zayinchkovskaya, & Vitkovskaya, 2005). Unlike other immigrant populations, midlife women make up a significant portion of these recent emigres (U.S. Immigration and Naturalization Service, 2000). As this population of immigrant midlife Russian- speaking women ages, healthcare providers in host countries are challenged to provide this population with culturally appropriate disease prevention and health promotion interventions that mediate the effect of chronic disease conditions associated with aging.

The purpose of this study was to describe the essence of the meaning of health for midlife Russian-speaking women and to provide an interpretive understanding of the ways in which they managed health during immigration. This research was guided by features of descriptive and interpretive phenomenology (Cohen, Kahn, & Steeves, 2000).

The terms immigrant and emigre are used interchangeably to refer to those who have emigrated either with refugee or with immigrant status. Russian-speaking immigrant women are identified as self- defined English-speaking women who claim the Russian language as the dominant language in their country of origin. The Russian language is the dominant language across the FSU and the “main axis of identity” for an otherwise diverse group of immigrants (Remennick, 1999a, p. 458).

Background

Approximately 80% of all immigrants and refugees worldwide are women (Meleis, Lipson, Muecke, & Smith, 1998). Although historically, a large percentage of international migrants have been women, only recently have immigrant women’s health issues emerged as public health issues (Remennick, 1999a; 2003). In a review of literature by Aroian, Chiang, and Chiang (2003) regarding gender and psychological distress, the majority of the study findings indicated that psychological distress was significantly greater for immigrant women. Immigrant women often experience barriers to accessing and receiving health care (Meleis et al., 1998). These barriers are frequently related to lack of understanding by healthcare providers in the country of destination about the health beliefs, values, and practices that the new arrivals bring with them from the country of origin (Meleis et al., 1998). The explanatory models of health, disease, and illness of the immigrant women might not be congruent with the biomedical model prevalent in Western cultures (Meleis et al., 1998).

Previous studies of Russian-speaking emigres have included older immigrants (Aroian, Khatutsky, Tran, & Baksan, 2001; Benisovich & King, 2003), stress related to immigration (Leipzig, 2006; Miller & Chandler, 2002), and onset of disease related to the Chernobyl disaster (Foster & Goldstein, 2007). The literature includes studies about midlife Russian-speaking women who have migrated to Israel (Remennick, 1999b; 2003), help-seeking patterns of Russian-speaking parents in Israel (Shor, 2007); health of Russian-speaking immigrants in Germany (Kirkcaldy et al., 2005), primary healthcare challenges of Russianspeaking emigres in Sweden (Blomstedt, Johansson, & Sundquist, 2007), and well-being in Finland (JasinskajaLahti & Liebkind, 2007). Little has been reported about health within the context of immigration from the perspective of midlife Russian-speaking women who have migrated to Western cultures.

Research Design and Methods

A hermeneutic approach (Cohen et al., 2000) was used to explore the meaning of health among midlife Russian-speaking women within the context of immigration; 12 women from ages 40-61 who migrated from FSU between 1992 and 2001 participated in the study. All of the participants were professionals with university-level degrees from their homeland and self-defined as speaking and understanding the English language. Eleven of the 12 participants were married and reported that they were ethnically but not religiously Jewish before immigration or at the time of this study. One of the participants was single and not of Jewish descent. The majority of the interviews took place in the homes of the participants; three women were interviewed in the workplace; and one interview took place in a private dining area. All the study participants lived in an urban community in the Northeastern region of the United States with the largest foreign-born population from Russia (Migration Information Source, 2004). No research could be found about the group in this particular location. The researcher, although not Jewish, nor Russian speaking, is midlife, second generation American born of Eastern European ancestry and has lived and worked as an advanced practice nurse in this community for over 25 years.

Purposive and “snowball” sampling techniques were used (Polit & Hungler, 1999) for this study. Data were collected until saturation (Denzin & Lincoln, 1994) was reached.

Recruitment took place through written advertisements in English and in Russian. Permission from the university’s internal review board was obtained, and a consent form was provided in English and in Russian. All study participants agreed to be audiotaped. Before beginning the interviews, the researcher bracketed her presuppositions by writing her own answers to the interview questions to ensure that preconceptions of the researcher did not influence participants during the study (Le Vasseur, 2003). All interviews were conducted in English.

The interview began with a demographic questionnaire followed by a semi-structured list of questions by the investigator. The interview was focused on three open-ended questions:

1. What is the meaning of health among midlife Russianspeaking immigrant women in the United States?

2. How has immigration influenced the experiences, values, and practices concerning the health of midlife Russian-speaking women in the United States?

3. What are the health experiences of midlife Russianspeaking immigrant women in the United States?

The researcher used journaling to provide a record of the decision trail during this study. An example of an early journal entry was a reflection on how the researcher conducted the interview so as not to “lead” the interview by supplying “lost” words for study participants when expressing themselves but needing time to find the word to use.

Using the method of phenomenological analysis described by Barritt, Beekman, Bleeker, and Mulderj (1984; 1985), the investigator began data analysis by listening to the audiotapes and reading each transcription verbatim several times line by line, highlighting the whole and parts of the sentences, and assigning tentative themes to these passages, using words as close as possible to those used by the participants themselves. The researcher identified common themes or substantive codes in all the transcripts of the interviews. After each identified theme (or substantive code), the researcher wrote the supporting phrases from the transcription. The identified themes, as well as a critical evaluation of the investigator’s interview process evident in the transcripts, were discussed in the interpretive process with a researcher consultant to ensure accuracy of coding and theme identification, clustering, and analysis. Data were managed both manually and by use of the software NVivo(c) (2002, QRS International). The identified themes served as topics for discussion at the second interview which was scheduled 3-4 weeks after the initial interview with the study participants. The purpose of the second interview was to confirm meaning, to clarify understanding, and to ask additional questions to ensure that the clusters and themes from the first interview appropriately captured the meaning that the participant sought to convey. Participants were asked if they had anything to add or to remove from their descriptions. One informant asked that information about her daughter not be included. Conducting the second interview assisted in ensuring trustworthiness of the findings.

Because of work schedules and travel to care for family out of state, only 9 of the 12 study participants were available for the second interview. These three initial interviews contained no new themes and were consistent with the other nine initial interviews. Because a second interview was not possible, the researcher explored the descriptions with 2 of the 9 study participants who were interviewed twice. No new descriptions were added in the second interviews.

The thematic analysis of transcripts after the second interview was once again discussed with a researcher consultant to ensure accuracy of coding and identification of themes, clustering, and analysis. Based on this process, the themes were organized into a written account that described the essence of the meaning of health among the study participants and an interpretive understanding of the ways in which they managed health during the immigration process.

Findings

The following themes were identified: health as being highly valued, though less of a priority during immigration; being a stranger and seeking the familiar; grieving and loss and building a new life; experiencing changes and transitions; trusting self; and the importance of hope. In order to maintain confidentiality, pseudonyms are used in the quoted passages below.

Health as being highly valued, though less of a priority during immigration. All study participants emphasized the value they placed on health: “[Hjealth is everything, very important.””‘Be healthy.’ It’s the first wish for everybody in your family and for everyone you want to say something good. Not wealth. Not beauty. But healthy” (Raisa).

Health, although valued, was not a priority of focus during the immigration experience. “Looking back … I realize I was really healthy [during migration] because without this health, I wouldn’t be able to survive. I needed a lot of energy” (Nadya).

When a person is healthy [during immigration], person doesn’t think of it. (Fekla)

We think about everything [during immigration]-children and our parents. To stay alive. When we have everything for living … then we will think of health. (Hanna)

I don’t remember the time around immigration-I was so stressed. (Evgenia)

[T]he mother always think about her children and older people … to help first your family … it’s human nature … to keep safe her children, her family, close family. (Raisa)

I am working … my children and my mom 1 have to think about too. I have to clean … wash … do everything. (Caterina)

Being a stranger and seeking the familiar. During the interviews, the women spoke of first impressions of the Western culture as being very different than expected.

[I]t is a different world … life in Russia … I couldn’t believe the amount of paper in the mail [in the United States)… I was thinking it must be a rich country that can waste so much paper… Everything works-lots of food, everything so clean. (Evgenia)

I was shocked to see how dirty the streets-how friendly the dogs were. (Bella)

I couldn’t believe it-there were no drunks in the streets. (Hanna)

I was shocked by the buses … helping elderly to enter the bus … people with wheelchairs can enter a bus … this would never happen in Russia … never. (Tatyana)

[F]irst time I came here … I was real impressed … everybody smiles … and I said, “such good people, they smile at me … they like me … so nice,” then I started hating smiles. I thought, “Its not sincere, why are they smiling, it’s not sincere….” You know, when you are in [a] different position from them and they smile at you, you say, “it’s not honest, not sincere.” My feeling was that Russian people are open people and sincere…. In Russia, if they don’t like you, they don’t smile at you. If they do like you, they smile. (Hanna)

I thought I had family here, someone familiar … but I understand this is not family anymore … because we changed, they had changed. It was not what we thought. (Naydia)

I went a lot to Russian stores just to buy something I recognize from Russia. (Vera)

Grieving and loss and building a new life. The women spoke of grieving and loss involved in the decision to migrate to the West to seek a better life and future:

[I]n Russia … our generation was very lost generation, completely … we did not achieve anything … only to survive … I got such a great education … and I wanted a job … I really wanted a job. …but in Russia no one needs [our] brain at all. (Bella)

I was a person who spent a lot of time preparing for my job [in the FSU] … I study a lot. I did not think I could get the same job in the US … in the US I felt like zero … it was a big difference for me … some just looking down at me [eyes tearing] … but, sometimes you just cannot stay where you are born. (Hanna)

My father is very depressed because the idea to come here was mine … it is very painful … he did this for grandson to have a better life. (Vera)

On the plane … my parents looked so scared … I was thinking, my dear mom, will you ever be able to forgive me for this? That I am pulling you from your roots and trying to put the old tree in the new soil? (Fekla)

It is another life here. It is painful … but I try to see as a new life. (Tatyana)

Experiencing changes and transitions. The women described both external and internal forces influencing the experiences of health. Those family members who migrated to the West before 1991 and whom the new arrivals were meeting in the host country, were not perceived as understanding the changes or supporting the emotional needs and priorities of the newly arrived family members. Dasha’s description summarizes what many of the women expressed: “[I]t is like they [those family members who migrated before 1991] are from different country … Russians don’t understand how it is different … there are more changes every year after 1991.”

The women described many transitions in their roles including helping maturing children and aging parents.

My children now have children. They work all day. I help take care of the baby and do work for money too. It’s very hard being with [grandchild] all day. (Evgenia)

I have mama here and mother-in law here, both are getting older and I am busy… they go to doctors and treatment. I do everything they need … no time for me. (Caterina)

Age, past environmental exposures, and migration were reported as affecting health.

Stresses, stresses, stresses … I got blood sugar [diabetes] from stresses. That’s age. Immigration for our age is not good … It’s so hard. It’s our choice. (Katya)

[D]ifferent women have different problems … because we live from ’86 to ’95 in Kiev, and Chernobyl [is] 60 miles from Kiev. Maybe this is problem. In Russia I did not hear so many breast cancers. Maybe this breast cancer spread and they died … but I met these people more often [in the United States] than Russia that’s cured from breast cancer … in Russia we did not know a good diagnosis. (Galena)

Age and maturity were also identified as strengths during the migration process. Vera described a commonly reported experience:

I was not afraid … because we lived in the kind of life you had in Ukraine, kind of not afraid of anything that it’s very hard…. But I was afraid to be a failure … it was too late for me … I thought people come to America to start a new life … I thought that I was too old to start over.

Trusting self. Trusting oneself to make decisions was important to the study participants in terms of self-management of health. The women reported a lack of trust in healthcare professionals and health-related treatments. One said, “I don’t trust… difference between Russian and American people, that American people trust doctor … follow advice. We did not trust anybody in Russia.”

Lack of trust of pharmaceuticals or “chemicals” was commonplace. It was not unusual for the women to report that they ordered natural herbs, roots, and cosmetics from Russian catalogs. Dasha said, “I always have something [herbs, medication from Russian] at home.” Katya said, “Pills seem like a chemical thing and I [am] afraid of some of them.”

Participants believed that Americans considered doctors “good” if the doctors gave pills to do the healing. In contrast, in the Russian culture, doctors were considered good if they did not use pills to do the healing. Fekla said, “In Russia, if the doctor is good, he will give you less medicine. Here the opposite, here pills … if the doctor gives you pills, he is considered a good doctor.”

Nearly all the women reported that they did not always follow the treatment plan of their physicians. Instead, they relied on their own plan of care. Many of the women reported they often stopped taking prescription medications or adjusted the dose on their own after reading about or experiencing side effects.

I have books. I have lots of books. I know what I am taking. If I see it is not for me, I’m not going to take it … because I read side effects. I said no. I said if I want to live, I can change my life. So I made exercise, no sweets. I feel good again. (Katya) Physicians whose first language was Russian were sought for discussion of questions related to diagnosis and treatment options. Nadya summarized what other participants reported concerning the importance of understanding the language in order to make an informed health-plan decision.

I’m getting older and I’m trying to go deep in what is going on, what they’re telling me. I need to get all information. I try to find Russian doctor. I can get detailed information in Russian, because I am afraid that I can miss something important… even assuming that I am speaking good English … I am afraid I will miss some detail which can be important. I’m trying to get information to be absolutely clear what’s going on.

Seeking information about a diagnosis was reported to be common in the FSU and in the host country. Bella summarized what other women also reported:

People are trying to fight the diseases themselves. That’s why over here Russian women are not coming to doctor’s offices … 80% of them already know how to treat their diseases, disregarding what the doctor will say. This is not because they know everything much better than doctor. No, it’s kind of self-defense issues that they brought from Russia, because if you do not understand how to treat yourself, there is a good chance you will die.

Participants spoke of their distrust for American-born physicians related to communication issues. Another reason for distrust of American healthcare professionals was the perception that medicine is a business and that physicians are focused on making money rather than caring for people. The women reported that although they did not always follow the treatment plan, they did not openly challenge the treatment plan with the physician.

The importance of hope. Hope was mentioned by nearly all the women in the context of a better future and as being an important reason to migrate. They also emphasized the importance of not taking hope away from a person who had been diagnosed with a malignancy: Galena described how hope was related to the decision to migrate, “[I]t can’t be worse than I have in my natural country … I am thinking it will be better. It’s not possible to be worse … I was hoping for something better.”

In the FSU, discovery of a malignancy was reported by all the women to be considered fatal. According to the women, cancer was a diagnosis feared by most of them. The women reported that patients in the FSU are not routinely told by the healthcare provider if they have a confirmed malignancy. Family members are told that a patient has a malignancy but not the patient. One participant said, “[A]s far as you don’t know [about a diagnosis of cancer], there is some hope … if you know that you will die … maybe you won’t fight against something.”

In regard to beliefs related to not seeking routine preventive screening: All the women in the study also reported that routine health screening in the FSU was considered by Russian people to be “just looking for trouble.”

[Y]ou go to the doctor just when you are sick. (Raisa)

[Having routine screening done] is just looking for trouble … if you are going to look for a problem, eventually you will find one. (Dasha)

Discussion

The findings show that within the context of immigration, health was less of a priority for the midlife Russianspeaking women in this study. However, the women described health as highly valued in the Russian culture. The study participants were knowledgeable about health-related issues and treatments, participated in self-care practices, trusted their own abilities to make self-care decisions, and sought health-related information when they were unsure.

The high value placed on health within the context of the Russian culture is consistent with other studies of Russian-speaking participants (Lipson, Weinstein, Gladstone, & Sarnoff, 2002). However, in contrast to the reported findings of older Iranian immigrants in Sweden (Emami, Benner, & Ekman, 2001), a multiethnic group in the Pacific Northwest (Woods et al., I988) and of American midlife women (Maddox, 1999), none of the participants in this study directly mentioned a spiritual component when describing health. Of the 11 participants who reported that they were ethnically Jewish, all reported that they did not actively practice the religion. The secular identification rather than religious identification of being Jewish concurs with other studies of Russian-speaking emigres (Birman & Tyler, 1994).

As noted by Lipson et al. (2002), during this study the participants also did not always focus on the open-ended questions that were asked. Instead, they took the focus of the topic to those areas they wanted or needed to talk about. For example, other themes not directly related to health arose such as those of being a stranger and seeking the familiar. This development is consistent with findings reported by Aroian, Morris, Patsdaughter, and Tran (1998).

Loss and grieving of the former life coincided with building a new life in a new land for self and family. The women in the study were highly educated and had a strong identity with their former professions. All reported that they were currently employed in another field and in a lesser position than they had attained in the FSU. These findings were similar to those reported by Miller and Chandler (2002) who studied acculturation and depression in midlife Russian-speaking women. In fact, feelings of loss and depression were commonly reported in studies of Russian-speaking emigres conducted in other parts of the United States (Aroian et al., 1998; Lipson et al., 2002). The study participants, like those in the study by Lipson et al. (2002), indicated that they relied on self- care and trusted their own self-care first in the health process. This trust in self-care indicates that these women believed that they could control some aspects of their own health in regard to health-restoring behaviors.

The midlife women reported caring for aging parents. This finding correlates with other studies that show that older Russians relied primarily on their children for support, even though the children had less time and support from other family members than they did in the FSU (Aroian et al., 2001; Remennick, 1999b).

The findings in this study concur with those of Russian-speaking women in Israel (Remennick, 2003) in regard to the avoidance of routine screening for a latent or early malignancy. Like the finding reported by Lipson et al. (2002), the women in this study also associated newly diagnosed cancers with past exposures to pollution and living in the FSU during the Chernobyl nuclear disaster in 1986.

The study participants stated that they were not afraid to leave their homeland; although the decision to leave was associated with much stress, loss, and grief, the women had made the choice to migrate because of the hope for a better future not only for themselves, but especially for their children. The migration from the homeland involved moving toward the future by acting in the present and remembering the past.

Limitations

The findings of this study cannot be extrapolated because of constraints imposed by the nature of the group, the immigration cohort they represent, the community in which they live, and the voluntary nature of participation in this research study.

Recommendations

Implications for clinical practice include the finding that although the women did not challenge the treatment plan prescribed by a healthcare provider, they often chose not to follow the prescribed plan of care. These findings indicate that health care providers caring for Russian-speaking immigrant women need to be focused on interventions to build trust, assess self-care and curative practices, and explore values and beliefs concerning health screening. Future research recommendations include: replicating and using longitudinal designs with other samples within this population who have migrated to other Western nations and exploring self care and curative practices.

Conclusions

The findings of this study show that although the Russian- speaking midlife immigrant women in this study value and are knowledgeable about health, participate in self-care practices, trust their own abilities to make self-care decisions, and seek health-related information, health is less of a priority during the immigration process. Findings show that this is a vulnerable population at risk for the onset of chronic disease conditions associated with the process of aging, past exposures, the tendency to avoid health screening, and current Stressors related to migration and family responsibilities.

Clinical Resources

* Information related to cultural beliefs and health care needs of immigrants and refugees: http://www.ethnomed.org

* The Global Commission on International Migration information: http://www.gcim.org

* Minnesota’s refugee health program information on comprehensive health screening and follow-up related to immigrant and refugee health: http://www.health.state.mn.us/divs/idepc/refugee/topics/ immigrant.html

* Essential data and information on migration worldwide: http:// www.migrationinformation.org

* Multilingual health information for refugees and healthcare providers: http://www.rhin.org/default.aspx

* A resource for health-related materials for refugees and immigrants: http://www.sunyit.edu/library/culturemed/

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Lenore Kolljeski Resick, PhD, FNP-BC, Epsilon Phi and Eta, Associate Professor, Director Nurse-Managed Wellness Center and Director of Family Nurse Practitioner Clinical Specialty, Master of Science in Nursing Program, Duquesne University School of Nursing, Pittsburgh, PA. The author acknowledges Drs. Joan Such Lockhart, Eileen Zungolo, and Juliene Lipson for their guidance during this research study. Correspondence to Dr. Resick, 525 Fisher Hall, 600 Forbes Avenue, Pittsburgh, PA15282. E-mail: [email protected]

Accepted for publication March 27, 2008.

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