Effect of acculturation and health beliefs on utilization of health care services by elderly women who immigrated to the USA from the former Soviet Union.

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Effect of Acculturation and Health Beliefs on Utilization of Health Care Services by Elderly Women Who Immigrated to the USA From the Former Soviet Union a

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Lyubov A. Yarova , Eleanor Krassen Covan & Elizabeth FugateWhitlock

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Applied Gerontology Program, School of Health and Applied Human Sciences, University of North Carolina Wilmington , Wilmington , North Carolina , USA Accepted author version posted online: 31 May 2013.Published online: 02 Aug 2013.

To cite this article: Lyubov A. Yarova , Eleanor Krassen Covan & Elizabeth Fugate-Whitlock (2013) Effect of Acculturation and Health Beliefs on Utilization of Health Care Services by Elderly Women Who Immigrated to the USA From the Former Soviet Union, Health Care for Women International, 34:12, 1097-1115, DOI: 10.1080/07399332.2013.807259 To link to this article: http://dx.doi.org/10.1080/07399332.2013.807259

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Health Care for Women International, 34:1097–1115, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2013.807259


Effect of Acculturation and Health Beliefs on Utilization of Health Care Services by Elderly Women Who Immigrated to the USA From the Former Soviet Union LYUBOV A. YAROVA, ELEANOR KRASSEN COVAN, and ELIZABETH FUGATE-WHITLOCK Applied Gerontology Program, School of Health and Applied Human Sciences, University of North Carolina Wilmington, Wilmington, North Carolina, USA

In this mixed methods study, researchers explored what conditions influence women’s use of professional health care services, and how sociocultural environments and acculturation affect utilization of health care services. We recruited 15 women in the Ukraine, 15 women who immigrated from the former Soviet Union, and 10 female U.S. citizens. Data include open-ended interviews, a “general information” questionnaire, and the Language, Identity and Behavioral Acculturation scale. Acculturation levels and length of residency in the United States were not consistent predictors of health-seeking behaviors for immigrants. The stronger predictor of health beliefs and health related behaviors among all participants was their mothers’ health beliefs and health related behaviors. In this study, an examination was conducted to determine conditions that influence the use of professional health care services by three groups: immigrants from the former Soviet Union (FSU), current Ukrainian residents, and American citizens. Since the population is aging worldwide, it is important to better understand how attitudes toward health care change with age and to explore ways of improving health care services for an elderly population. The United States is a country of immigrants who have diverse cultural backgrounds. Access to culturally sensitive health care may be one of Received 20 March 2013; accepted 5 May 2013. Address correspondence to Lyubov A. Yarova, Applied Gerontology Program, School of Health and Applied Human Sciences, University of North Carolina Wilmington, 601 S. College Road, Wilmington, NC 28403-5625, USA. E-mail: [email protected] 1097


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the crucial factors affecting utilization of health care services. To create and deliver these tailored services, we must first understand that there may be common factors that motivate immigrants from different countries to accept and utilize professional support. While general issues of immigrant health gain more attention in sociomedical sciences, the gender aspect of the problem remains in the shade (Remennick, 2003). Approximately 80% of all immigrants and refugees worldwide are women (Meleis, Lipson, Muecke, & Smith, 1998). Since the collapse of the Soviet Union, approximately 2.66 million people have migrated to Western countries, with most migrating to Germany, Israel, and the United States (Tishkov, Zayinchkovskaya, & Vitkovskaya, 2005). The Statistical Yearbook of the Immigration and Naturalization Service indicates that unlike other immigrant populations, midlife women make up a significant portion of these immigrants (U.S. Immigration and Naturalization Service, 2000). As this population of immigrant women ages, health care 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 (Resick, 2008). Few studies have been conducted to examine health-related attitudes and behaviors among elderly women who have immigrated to the United States from the former Soviet Union. Previous researchers on Russian speaking women in Israel showed that immigrants are preoccupied with immediate problems of survival and adjustment; they tend to neglect essential self-care and delay medical visits (Remennick, 2003). Other researchers who examined Russian and Ukrainian immigrant women in the age group 20+ in the United States also found no use of preventive health care services such as high blood pressure and cholesterol screening, Pap smears, mammography, and self-breast exams among Russian and Ukrainian immigrants (Ivanov & Buck, 2002). In literature reviews regarding access to health care, Loue and Sajatovic (2012), Shpilko (2006), and Remennick (2003) indicated barriers that might prevent elderly female immigrants from utilizing health care services. These barriers are financial, cultural, language differences, and trouble understanding the health care system in the host country (Shpilko, 2006). Scholars point out that other obstacles that affect women’s opportunities to utilize health care services are frequently related to lack of understanding by health care providers in the country of destination about the health beliefs, values, and practices that the new arrivals bring with them from their country of origin (Meleis et al., 1998). Lipsitz (2005) noted that many elderly women from the former Soviet Union do not trust physicians and Western medications; they often prefer folk medicine and nonconventional therapies. Loue and Sajatovic (2012) indicated that immigrants may be less likely than native-born individuals to utilize preventive care services, such as disease screening, because they are not suffering from pain and do not


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have any symptoms. Day and Cohen (2000) emphasize that culture is an important factor in determining health care use because cultural beliefs act as a crucial self-identifying component for the elderly. According to a World Health Organization (WHO, 2009) report, women’s health and perception of their own well-being are profoundly affected by the ways in which they are treated and the status they are given by society a as whole. In some cultures, include Slavic cultures, women are considered inferior and are expected to place the health concerns of their family members before their own (Loue & Sajatovic, 2012). Many Russian speaking women perceive a focus on selfcare, including seeking preventive health services, as excessive and selfish (Remennick, 2003). Covan (1997), who studied the impact of cultural priorities on elderly women, emphasizes that women receive ambiguous honor for the caregiving responsibilities they perform at the expense of meeting their own needs. Previous researchers argued about other variables that might affect health related behaviors of female immigrants. Length of residence and the proportion of the lifetime spent in the host society are frequently used measures of acculturation (Searle & Ward, 1990; Shen & Takeuchi, 2001). Acculturation is a complex set of intercultural interactions through which a person (a) does or does not acquire the customs of another culture, and (b) does or does not retain norms held by their culture of origin (Mendoza, 1984). Literature indicated that to assess acculturation of immigrants from different countries, researchers used numerous elements such as language use, generational status, preferences for food, and media sources (RodriguezReimann, Nicassio, Reimann, Gallegos, & Olmedo, 2004). In literature from research articles, however, little has been reported about how acculturation affects self-perception on one’s own health. Shapiro and colleagues (1999), who studied Vietnamese immigrants, reported that immigrants who were the most acculturated or most bicultural were healthier and least depressed (Lai, Tsang, Chappell, Lai, & Chau, 2007). Another finding shows that in spite of assimilation and acculturation, immigrants’ main cultural beliefs generally remain unchanged (Henderson, 1996), and acculturation levels were not consistent predictors of utilization of health care services among women (Meleis et al., 1998). Thus, the current understanding of the mechanisms by which acculturation affects the well-being or health of immigrants still remains significantly limited (Jasinskaja-Lahti & Liebkind, 2007; JasinskajaLahti, Liebkind, Jaakkola, & Reuter, 2006; Shen & Takeuchi, 2001). Our purpose is determine how different sociocultural environments and acculturation affect utilization of health care services by Ukrainian women who have migrated to the southern coast of the United States and what conditions influence them in utilization of professional health care services. Ukraine was one of the primary satellite states of the former Soviet Union and shares Russia’s eastern border for approximately 1,400 miles.

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BACKGROUND The author of the current study, being a FSU immigrant herself, who lived in the Ukraine for 37 years, can attest that the FSU health care system is different from its American counterpart in many ways, one of which is that medicine in the FSU, though limited, is free and available to all citizens regardless of their incomes. In comparison with the U.S. health care system, where patients have options in choosing health care providers, FSU patients are assigned to a specific doctor and to a specific hospital or clinic without any consideration for patients’ preferences. These conditions make competition between doctors impossible and, as a result, have led to stagnation of progress, negligence to the needs of patients, and a system of bribes that patients must offer in order to receive adequate attention. Another distinctive feature of the FSU health care system is the creation of clinics within industrial workplaces where the supervisors who monitor workers’ production also monitor the health of the workers with annual checkups. These industrial units also maintain sanatoria and dispensaries where workers may rest during their vacations and receive free preventive treatments for some occupational diseases. Many scholars (Duncan & Simmons, 1996; Smith, 1996) suggested that the FSU medical system fostered the dependence of its citizens on physicians, making it difficult for them to make decisions about self-management of health care or to employ healthy lifestyles choices once they immigrated to the United States (Ivanov, Hu, & Leak, 2010). Doctors from the former Soviet Union are tolerant of the preferences of some patients to use combinations of synthetic drugs and traditional herbs for treatment of illnesses. Previous researchers found that the majority of Ukrainian/Russian practitioners reported that they would switch their patients to herbal treatments whenever possible, typically for long-term and preventative care (Franic & Kleyman, 2012). Herbal medicine was practiced by Slavics for years, and FSU immigrants bring facets of their culture to their new country (Franic & Kleyman, 2012). Previous scholars determined that FSU immigrant women are more likely to use culturally based health care such as herbs and teas, and to postpone using formal health care services until they have exhausted all other customary practices (Ivanov et al., 2010). After the collapse of the Soviet Union and its health care system, the quality of medical services was poor; the medical equipment was outdated; and patients were and are still disappointed and mistrust authorities who are not able to provide decent medical services for the general population. After more than 20 years, there is still no uniform system of health care in many independent countries that were part of the FSU. The health care system breaks up into two parts. One, paid—for rich citizens—and another, state and free—for the poor (Mechanik, 2011). According to a 2010 WHO report, Ukraine’s health care system does not have the capacity for prevention and health promotion of noncommunicable diseases, and the female death rate from these diseases


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is 64% in contrast with 36% in the United States; life expectancy in Ukraine for females is 74 years compared with 81 years in the United States (WHO, 2011). The author of the current study intends to understand health perceptions of the FSU women immigrants who experienced different historical events during their life periods including starvation after World War II, the collapse of the Soviet Union, formation of new independent countries within the FSU, and life after immigration and identify conditions that may influence this group in utilization of professional health care services.

THEORETICAL FRAMEWORK The researcher used Young’s (1981) choice-making model of health care seeking behavior as a guide for the study. According to this model, the individual’s health care choices depend on four components: (a) gravity of illness, which is based on the assumption that the culture classifies illnesses by level of severity; (b) knowledge of home treatments, which depends on an individual’s awareness of an efficiency of home remedies and, as a result, choosing them over professional health care services; (c) faith in remedy, which is based on the individual’s belief of efficacy of the treatment and where this belief is absent, the treatment will be not utilized; and (d) the accessibility of treatments, which incorporates the individual’s evaluation of the cost of the health care services and the availability of those services (Rebhan, 2012). Previous researchers determined that culture shaped people’s perception about the severity of diseases. Some women believe that if conditions become chronic and last for a long time, they may become normalized and thus will be perceived as less serious (Currie & Wiesenberg, 2003). Others do not see any reason to go to doctors to utilize preventive care services because they do not suffer from pain and do not have symptoms (Loue & Sajatovic, 2012). Kleinman, who examined cultural diversity in health care beliefs, found that if some Taiwanese people were aware of effective remedies for the treatments, they would use them before seeking professional medical help (Kleinman, 1980). Accessibility of treatment is related to the health care usage. There may be several specific barriers for immigrants that can affect utilization of health care services. Researchers who studied Chinese immigrants in Canada found that these barriers include language difficulties and discomfort with discussing one’s cultural health practices with medical professionals (Lai, Tsang, Chappell, & Lai, 2007). The life course perspective was also used as a guiding framework for this study to explain how period effects and cohort influence participants’ beliefs and health related behavior. This approach was used by many previous researchers because the life course perspective is explicitly dynamic: rather than focusing on one segment of the life of an individual or a cohort, it attempts to reflect the life cycle in its entirety (Bengtson, Burgess, & Parrott, 1997).

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METHOD A total 40 women at the ages 50 and older were enrolled in this study. We recruited 15 women in the Ukraine, 15 immigrants from the FSU, and 10 women who were born and live in the United States. The criteria for the selection included the following: (a) women; (b) 50 years and older; (c) who currently live in Ukraine; (d) who emigrated from the FSU and currently live in North Carolina, USA; and (e) who were born in United States and currently live in North Carolina. Data were collected by using the following techniques: (a) an openended interview, (b) a questionnaire of “general information,” and (c) the Language, Identity, and Behavioral Acculturation scale (LIB). The open-ended interviews with participants was audiotaped, and data from the questionnaire of “General Information” was coded in the codebook and used for analysis of demographic and other social variables. The LIB was used to measure acculturation and adaptation of women immigrants from the FSU who currently live in North Carolina. This scale was developed by Birman (Birman & Trickett, 2001) and has been translated into Russian and tested with Russian population by previous scholars (Ivanov et al., 2010) in order to assess acculturation to the Russian and American cultures independently (Birman, Trickett, & Vinokurov, 2002). The informed consent and questions for the open-ended interview were translated into the Russian language by the researcher whose native language is Russian. Interviews with participants were conducted in their preferred language: Russian/Ukrainian or English. As the researcher was born and raised in Ukraine and she is a current member of the Ukrainian Association of North Carolina, the sample collection of elderly women in Ukraine and in the United States was based on her social network. As a first step of the snowball sample collection, a phone contact with 40 women was attempted in order to select women who indicated that they were willing to participate in the study about women and health care. All interviews were conducted in participants’ homes or in locations that they choose to assure their privacy. The complete interview process took around 1 hour. The researcher obtained each participant’s permission to record responses on an audio recorder but did not record the names of participants. This study was confidential. Participants were not identified as individuals in any published or presented materials. Open-ended interviews were conducted with all participants in order to identify important common patterns that cut across variations and answer the study question, “What conditions influence women to use or to avoid using professional health care services?” The interpretation of the open-ended interview was supported with information obtained by the questionnaire “general information” and coded to the codebook. With the group of immigrants, in addition to the open-ended interviews and questionnaires, the LIB scale was also given. The scale includes language, identity, and behavior subscales.



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The language subscales consist of nine parallel items asking respondents to rate their ability to speak and understand Russian and English. The identity acculturation subscales consist of eight parallel statements regarding the degree of identification with each culture (e.g., “I consider myself American/ I consider myself Russian”). The behavioral acculturation subscales ask participants to rate the extent to which they engage in behaviors associated with each culture (e.g., language, media, music, entertainment, food) in nine parallel items. The response format for each subscale of the LIB consists of a 4-point Likert scale ranging from “not at all” to “very well, like a native” (Birman, Trickett, & Buchanan, 2005). Mean scores for each subscale were used in the analysis of the LIB scale, with higher scores indicating greater acculturation, as did previous researchers (Ivanov, Hu, & Leak, 2010). Then the mean scores of the LIB scale were compared with data from the codebook to determine how acculturation interacts with sociodemographic variables and affects utilizing health care services in the United States by Russian speaking immigrants. The SPSS version 18, chi square test was also used to determine if there is a difference between cultural beliefs and length of residence in the United States and where women avoid using health care services. All collected data were translated back from Russian to the English language in order to complete the study.

RESULTS Characteristics of the Sample The sample included three groups of female participants, age 50+: those who were born and live in the United States (n = 10), who live in Ukraine (n = 15), and immigrants from the FSU (n = 15) who currently live in eastern North Carolina (Table 1). The group of immigrants was represented by women who are currently married to American men, who received their green card through the lottery program, who came to the United States via work visa, and who were invited to move to the United States by their adult children who had immigrated to the country earlier. Fifty-three percent of immigrants had lived in the United States more than 10 years. Sixty percent of the immigrants held a master’s degree, compared with 40% of women who currently live in Ukraine and 20% of American women. One hundred percent of the participants from the American group had medical insurance (private, Medicare, or Medicaid) in contrast with 60% of immigrants and 40% of Ukrainians. The group of American participants more actively engaged in promotion of health behaviors such as screening (100%) and physical exercise (70%), compared with 67.7% of immigrants and 67.7% of Ukrainian women who perform screening and 53% of immigrants and 66.7% of Ukrainians who exercise regularly.

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TABLE 1 Characteristics of the Sample Americans


Characteristic

FSU immigrants

Ukrainians

(n = 10)

%

(n = 15)

%

(n = 15)

%

1 3 4 2

10.0 30.0 40.0 20.0

1 — 5 9

6.7 — 33.3 60.0

2 — 7 6

13.4 — 46.7 40.0

3 2 5

30.0 20.0 50.0

2 5 7

20.0 33.3 46.7

5 1 9

33.3 6.7 60.0

— 1 9

— 10.0 90.0

1 13 1

6.7 86.7 6.7

1 13 1

6.7 86.7 6.7

6 4 —

60.0 40.0 —

— 8 7

— 53.3 46.7

— 5 10

— 33.3 66.7

4 4 — 2 10 7 7

40.0 40.0 — 20.0 100.0 70.0 70.0

3 6 2 3 10 8 8

20.0 40.0 13.3 20.0 66.7 53.3 53.3

5 5 2 5 10 13 10

33.3 33.3 13.3 33.3 66.7 86.7 66.7

9 3 2

90.0 30.0 20.0

8 7 5

53.3 46.7 33.3

6 2 7

40.0 13.3 46.7

10 4 —

100.0 40.0 —

7 2 6

46.7 13.3 40.0

6 — 9

40.0 — 60.0

8

80.0

10

66.7

5

33.3

5 2 1 2

50.0 20.0 10.0 20.0

4 7 4 —

26.7 46.6 46.6 —

4 11 — —

26.7 73.3 — —

Education High school Technical school Associate’s degree Master’s degree Work status Full-time Part-time Retired Financial status Impoverished Working class Middle class Health status Excellent Good Fair Illnesses Arthritis HBP Heart disease Other Undergoes mammograms Undergoes pap smear tests Performs physical exercise Vitamins/food supplements Yes Other Nothing Health insurance Private Medicare/medicate None Trusts doctors? Yes Who health is most significant? Own health is no. 1 Children’s health is no. 1 Husband’s health is no. 1 Relatives’ health is no. 1

Perceptions of Own Health To analyze the data, three age groups were defined among immigrant, Ukrainian, and American participants: 50–59 years old, 60–69 years old, and 70 years old or older. Examining open-ended interviews shows that differences in health beliefs and health related behaviors of participants are



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associated with diverse cultural backgrounds and with their age and period effects. Based on self-evaluation of their own health, most immigrant participants aged 50–59, as well as Ukrainian participants in the same age group, self-rated their health as “good” and admitted that they do not spend much time taking care of their health because they “do not have problems with health and do not think about it” (Interview no. 8). Participants stated that they try to follow a healthy lifestyle which, by their definition, includes a balanced diet, vitamin consumption, physical activity, and regular check-ups. Most of them, however, declared that they should take better care of their health: We take care of our health when we start losing it. I go for an annual check-up at our outpatient hospital as everybody does at work because it is a requirement of our employer. (Interview no. 27)

In opposition to younger participants, most immigrants aged 60–69, just as Ukrainians in these age groups, had begun paying more attention to their health; they used herbal teas as preventive treatments, preferred to get vitamins from natural sources such as fruits and vegetables, and tended to rely more on conventional medicine. Reasons that lead them to pay more attention to their health were increased amount of free time—“you work less or you are retired and you have time to think of yourself” (Interview no. 6)—development of chronic conditions, and recognition that they are not invincible, as they believed at a younger age. The groups of immigrants, as well as Ukrainians aged 70 and older, had very similar perceptions of their well-being. They self-rated their health condition higher than participants in the 60–69 year age group. Most immigrants in their seventies were mothers of Ukrainian immigrants and were invited to move to the United States by their adult children who had already settled in the new country. They did not have medical insurance; they shared a household with adult children and were financially dependent on them. One 75-year-old woman stated the following: All my choices depend on my daughter’s ability to pay for doctors. I talk to God every day and ask Him to give me more healthy days in my life. (Interview no. 11)

Ukrainian participants also did not complain about their health and stated that they still can survive without doctors because they follow a balanced diet, do not take artificial vitamins, do physical exercise, keep busy, and have a positive attitude toward life. Women in their seventies believed that people of their generation who were born before and during World War II “are physically and emotionally stronger” because they have gone through

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“a hard life” (Interview no. 21) Some of them also believed that they were healthier than people of younger generations because they had eaten natural food and stayed physically active: After WWII people did not have anything to eat. When spring came, we ran on the bank of the Dnieper River and we ate grass, some kind of yellow very sweet little flowers, floating flowers of water lilies, flowers of Acacia. . . . . Oh, we ate anything we could find. Famine was extreme. . . . We ran all day, rode a bicycle, swam, and could cross the Dnieper River. Can you find a child now who can swim cross the Dnieper River? (Interview no. 21)

American participants at all ages self-rated their healthiness higher than immigrants or Ukrainians. Taking care of their own health includes the same approach, but, in contrast, most American participants did not have concerns about the sufficiency of synthetic vitamins and food supplements in their daily diet compared with Ukrainians and immigrants.

Caregiving Responsibilities: Is It Selfish to Take Care of One’s Own Health? Ranking in order of what is more significant for participants, 46.6% of immigrants and 73.3% of Ukrainians at all ages placed “taking care of their children’s health” in first place as opposed to 20% of American women. American participants’ caregiving responsibilities shifted from “children who are now grown and who live independently to take care of their own health” (Interview no. 34) to that of their husbands. One woman, who monitored her husband’s health and scheduled doctors’ appointments for him, believed that “men don’t want to admit that they are vulnerable” (Interview no. 33). Another woman stated that she had to be involved in her husband’s health care because “he is not a very compliant patient”: He will lie to the doctor and he doesn’t remember what the doctor says, so I have to go with him. (Interview no. 32)

Fifty percent of American participants stated that taking care of their own heath was number one for them, compared with 26.7% of Ukrainians and FSU immigrants who ranked taking care of their own health as less important than their children’s or husbands’. One 75-year-old Ukrainian woman talked about how her mother took care of her husband after World War II, when food was scarce and later: “She tried to provide the best food for my dad who must survive because he kept the house and provided the family with food and money” (Interview no. 23). A 64-year-old woman said, “Taking


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care of my health is in last place for me” (Interview no. 25), surprised that for her 90-year-old mother taking care of own health is a major priority:


As I remember, she took more care of my dad and herself than about us children. She said that the children ran around all day and they could find something to eat. . . . I think she loved herself. . . . I wonder why she did not teach me how to love myself too. (Interview no. 25)

Some immigrant and Ukrainian participants felt that taking care of themselves first could be considered by others as selfish. When they were living in the Soviet Union, the idea of individual responsibility was not welcome; people had to rely on authority: I think we were not trained to take care of ourselves. When I received my first job at a factory, the first thing I saw on the factory’s gate was a poster with a motto “Think about needs of your nation at first and then think about yourself!” These words seem stuck in my head forever. (Interview no. 25)

Immigrants and Ukrainian participants showed the same attitudes toward family caregiving responsibilities. Most of them put “taking care of their own health” in the last place in contrast to Americans.

Cohort Differences Regarding Health Beliefs and Behavior There were differences in health beliefs and health related behaviors among participants in the age 50–59 birth cohort and participants at ages 60 and older. For the question, “If you have a health problem, what will you usually do first?” most immigrants and Ukrainians responded that behavior depends on the seriousness of the health condition. Ukrainian participants in these ages indicated their preferences of commercial drugs rather than alternative treatments: I do not use herbs because I think it is very long process before you can feel any positive effect. . . . . We always want everything and now. (Interview no. 26)

Most immigrants stated that they have some concern about taking American drugs because of their multiple side effects. Some women preferred to take the same drugs that they used in the Soviet Union. One participant, who had lived in the United States for 18 years, tried to answer more precisely “What is in her self-treatment ‘first aid’ kit?”; she started sorting through her cabinets:

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Ok, let’s go and see what I have here. . . . Oh, it is my favorite ointment I bought on my last visit to Ukraine; it helps in healing wounds, I love it . . . Here is vitamin C . . . also from Ukraine. . . . Here is my magic balm which also I brought from Ukraine. . .. Oh, WOW! I did not suspect I have everything here from Ukraine [laughs]. (Interview no. 10)

Many immigrants preferred to use a Vietnamese balm which was well liked in the FSU as “first aid” for pain reliever, headache, or cold. They also tried herbal teas that most “brought from Ukraine or ordered online through Russian distributers” (Interview no. 5); the FSU immigrants also used other folk remedies and stated that if they did not work, that they would seek professional medical help. However, most declared that they did not like to visit U.S. doctors. Immigrants and Ukrainians in the age 60–69 birth cohort and older preferred herbs or other natural ingredients because they are safer for health than synthetic drugs. Their beliefs in the superior results of alternative medicine seem influenced by period effects. After World War II not many commercial drugs existed; herbs and folk remedies were always available and free: When I had a bad cold, my mother gave me 2–3 drops of pure kerosene to drink. She used yarrow and oak bark to treat diarrhea. . . . There was nothing available after WWII and people treated themselves with herbs. (Interview no. 24) Oh, my mother was a big fan of folk medicine. She treated my throat with eucalyptus oil, sage, and chamomile inhalations. These remedies were very effective and I used them also as a treatment for my child and my grandbaby as well. (Interview no. 17)

More than 93% of immigrants and 86% of Ukrainian women clearly demonstrated the effects of their mothers’ influences on their health beliefs and health related behaviors. A 70-year-old Ukrainian participant stated, “my mother lived 95 years and she did not take any pills” (Interview no. 21). Another remembered her mother “walked barefoot in wintertime and swam in an ice hole at age 77 to treat her blood pressure without medications” (Interview no. 20): When she was 89 she felt down and broke her leg. . .. We called the doctor, who prescribed her some drugs. Later, we found under her mattress all those pills; she took none of them. . . . I try to avoid using drugs also. (Interview no. 20)

American participants at all age groups generally tended to seek professional help rather than use self-treatments or herbs or folk remedies. They showed health related behaviors similar to those of their mothers as do Ukrainian


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and FSU immigrants. One 70-year-old American woman, who preferred to consult with medical professionals regarding health problems, said that her mother did not consider self-treatment and was very alert about even minor symptoms:


My childhood was during the time when doctors made house calls. My brother and I were growing up during the polio epidemic. We would either go to the doctor’s office or have a home visit. (Interview no. 30)

Utilizing Health Care Services The researchers found differences in the degree of satisfaction with health care services and the professional level of medical personnel. Eighty percent of American participants and 66.7% of FSU immigrants stated that they trust their American health care providers, whereas only 33.3% of Ukrainian participants were pleased with the professionalism of their doctors. Immigrants in the 50–59 year age group were less trustful of physicians compared with older participants, and 57.1% of them were dissatisfied with doctors’ approach in treatment because “they do not use alternative treatments and have only two decisions: to stuff you with tablets as much as possible without concern for side effects or to offer surgery” (Interview no. 5). Most participants in this age group had private medical insurance and stated that they have regular checkups, mammograms, and Pap smear tests. The most common reasons to avoid doctors mentioned by 57% of these participants are mistrust of U.S. doctors. Former Soviet Union (FSU) immigrants in their sixties and seventies showed more trust toward U.S. health care providers in contrast to Ukrainian participants who belong to the same age groups and seem very impressed with the high quality of U.S. medical services and politeness of medical personnel “who will tell you 100 times ‘I am so sorry’ or ‘are you okay?’” (Interview no. 2). Most of these women never experienced such treatment in their native country and appreciated a chance to have better health care now than they had in the past: I was admitted to the best clinic in my home town in Ukraine in the [19]90s where I was scheduled for surgery. There were some hospital “rules” which required me to bring to the hospital a pillow, bed linen; thread for the surgeon to sew my wound closed, 10 pairs of disposal surgeon’s gloves, 5 IV systems, 10 syringes, gauze. . . . The hospital had nothing after the Soviet Union crashed. (Interview no. 2)

More than 60% of participants in this age group however, did not have medical insurance and stated that the cost for medical services is not

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affordable. Some immigrants scheduled dental work or medical tests in their home country when they had an infrequent opportunity to visit. The most common barrier preventing this age group of immigrants from using health care services was money. The length of residence in the United States, which varied between 1.7 years and 33 years, did not appear to significantly change the attitudes of FSU immigrants toward their own health and the utilization of health care services. One 50-year-old participant who had lived in the United States for at least 18 years related her story: I always was an active person when I lived in Ukraine and I continue to lead a physically active lifestyle here. I did not like to use pills when I lived in Ukraine. I still oppose using drugs here. (Interview no. 10)

A 65-year-old participant, who had lived in the United States for 6 years, admitted that she began to pay more attention to her own health and more often used preventive treatments. She explained that changes in her attitude were affected more by caregiving duties than the length of residency: My husband is a cancer and heart attack survivor. I want to prolong his life and at the same time I wish to avoid the health problems that he has; I started paying more attention to my health. I do not think that the American lifestyle affects my attitude. (Interview no. 6)

Comparing data collected from Ukrainian participants and immigrants, we see that it is clear that women from both groups have very similar health beliefs and health related behaviors; they participated in preventive care such as mammograms (Ukrainians 66.7%, immigrants also 66.7%) and Pap smear tests (Ukrainians 86.7%, immigrants 53.3%). A chi-square test was used to examine the difference between length of residence in the United States and utilizing health care services. The results of the test indicated that the difference between the two variables was not significant (p > .05). As previous studies of U.S. immigrants suggest, there is a relationship between the level of acculturation and health behaviors (Ivanov et al., 2010), we used the LIB; (Birman & Trickett, 2001). The mean scores for the six subscales (Table 2) indicate the levels of acculturation. The higher the score points, the greater acculturation. The Russian language has a higher mean score among participants.

DISCUSSION Guided by Young’s (1981) choice-making model of health care seeking behavior we determined that most participants, regardless of their different cultural backgrounds, level of education, and financial capabilities begin to pay more attention to their health when they were close to age 60 or earlier if


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TABLE 2 Mean Score for Acculturation Variables Acculturation variable


English Language Identity Behavior Russian Language Identity Behavior

M

SD

2.24 1.95 2.77

0.91 0.95 1.04

3.90 3.64 2.38

0.30 0.60 0.95

they develop some health issues. Knowledge of home treatments and faith in remedy is also associated with utilization of health care services. Our finding is supported by previous researchers who found that acculturation generally does not significantly change health beliefs of immigrants who often move toward treatment based on the cultural ideas and beliefs they learned in early life (Evan & Cunningham, 1996). Our finding correlates with other studies and illustrates that lack of money and insurances influences utilization of health care services by FSU immigrants (Ivanov et al., 2010). Among participants in the 50–59 year age group, the most common reason to avoid using professional help was mistrust of U.S. doctors, and among immigrants 60 years or older, the biggest concern in utilizing health care services was money. Language was not mentioned by participants as a barrier to utilizing health care services. Those participants who immigrated to the United States and married American men received access to adequate health care services, including assistance with English language translation, from husbands, husbands’ relatives or friends, as well as women who were reunited with their immigrant children and received aid from them as well. The greatest difficulties in utilizing health care services are experienced by women who won green card lotteries and came to the country with limited knowledge of the English language. Researchers of the current study concluded that cohort and period effects influence women’s perception of their own health and their willingness to use professional health care services. In order to determine how diverse cultural background might influence utilization of professional health care services, we included in the study a group of American women and found a difference in attitudes toward health among immigrants, Ukrainians, and American participants. Ranking in order what is more significant, FSU immigrants and Ukrainian participants put “taking care of their own health” in last place in contrast to Americans. Immigrants and Ukrainian women seem to view themselves as secondary and subservient to the needs of their close ones, as givers rather than receivers of care and attention (Hopper, 1993). Such a viewpoint, “a focus on self-care as excessive and selfish”


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(Remennick, 2003, p. 160), might be formed not only by traditional roles of women in Slavic culture but by period effects as well. Ukrainian immigrants at ages 65 and older survived several famines after, World War II and were viewed by their own parents who barely were able to feed all their children as nothing more than an “extra mouth.” During adulthood they were viewed by the Soviet government as nothing more than “a tiny, dusty detail in a huge ideological machine,” which could be easily replaced. The popular motto, “Think about needs of your nation first and then think about yourself!” was expected to affect self-identity and self-esteem of participants in the ages 60 and the older cohort as well. Immigrants and Ukrainian participants belonging to this cohort also more readily use herbal therapies as preventive care because they were raised during a time when “nothing was available after WWII and people treated themselves with herbs” (Interview no. 24). Period effects also influenced health related behaviors of American participants who were born after World War II and were children during the polio epidemic at its peak in the 1940s and 1950s (Walene, 1988). At this time mothers of most American participants did not use alternative treatments such as herbal teas or folk remedies for managing symptoms of unknown diseases. They actively utilized health care services likely to more sufficiently protect their children from infections. We concluded that acculturation level and length of residency in the United States are not consistent predictors of engaging in health seeking behavior for this sample of immigrants. A stronger predictor of health beliefs and health related behaviors of participants was their mothers’ health beliefs and health related behaviors; mothers and daughters have very similar approaches in using health care services, and this approach seems to remain relatively stable, regardless of geographical location or length of residency in another country.

Limitations and Recommendations There are several limitations to the study. First, we used a snowball sample collection, and the results of the study cannot be generalized for the entire population of all FSU immigrants who live in the United States. Second, the sample size for each age group was not big enough and represents participants with very similar sociodemographic characteristics. Despite these limitations, the study contributes new findings that can be useful for U.S. health care professionals. Providing culturally competent and culturally appropriate health care might include a more tolerant attitude by U.S. physicians toward cultural beliefs of the FSU immigrants in their herbal practices and also offering them alternative treatments in combination with synthetic drugs. This expansion of treatments may require “over the horizon” education and a more open-minded approach among those in the medical community.


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In addition, future research is needed to determine conditions that affect the interpersonal relationships among FSU immigrants and their health care providers.


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