Topic is on: Ethnopharmacology short discussion

Lippincott Williams & Wilkins and Wolters Kluwer Health, Inc. are collaborating with JSTOR to digitize, preserve and extend access to The American Journal of Nursing.

http://www.jstor.org

Wolters Kluwer Health, Inc.

CE Credit: Ethnopharmacology Author(s): Cora Muñoz and Cheryl Hilgenberg Source: The American Journal of Nursing, Vol. 105, No. 8 (Aug., 2005), pp. 40-49 Published by: Lippincott Williams & Wilkins Stable URL: http://www.jstor.org/stable/29745831 Accessed: 25-06-2015 15:29 UTC

REFERENCES Linked references are available on JSTOR for this article:

http://www.jstor.org/stable/29745831?seq=1&cid=pdf-reference#references_tab_contents

You may need to log in to JSTOR to access the linked references.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/ info/about/policies/terms.jsp

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected].

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

?Continuing ce 3a Education ?_^

By Cora Mu?oz, PhD, RN, and Cheryl Hilgenberg, EdD, RN, CTN

thnopharmaco ogy Understanding how ethnicity can affect drug response is essential to providing culturally competent care.

AJN ?

August 2005 ? Vol. 105, No. 8 http://www.wningc9nt0r.com

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

Overview: Ethnopharmacologic research has revealed that ethnicity significantly affects drug

response. Genetic or cultural factors, or both, may influence a given drug's pharmacokinetics

(its absorption, metabolism, distribution, and elimination) arid pharmacodynamics (its mecha?

nism of action and effects at the target site), as well as patient adherence and education. In

addition, the tremendous variation within each of the broader racial and ethnic categories ? defined by the U.S. Census Bureau (categories often used by researchers) must be consid- -?---?---?-----?-?

ered. Nurses need to become knowledgeable about drugs that are likely to elicit varied responses in people with different ethnic backgrounds, as well as the potential for adverse effects. The existing ethnopharmacologic research focuses primarily on psychotropic and anti

hypertensive agents, as does this article. Cultural assessment of every patient is vital; thus

Leininger's Sunrise Model and Giger and Davidhizar'sTrans?ultural Assessment Models are brief ly described as well.

The relatively new field of ethnopharmacology is hampered by a lack of clarity caused, in

part, by the fact that some researchers use the words race, ethnicity, and culture synony?

mously, even though they have quite distinct

meanings. For example, the term Hispanic can refer

to Puerto Ricans, Mexicans, Peruvians, and

Chileans, among many others, and describes more

than 38 million Americans.1 But some researchers have used the term to denote a racial category, despite the fact that Hispanics can be of any race. Such imprecision has raised quite valid questions about the accuracy of some data.

This imprecision also reflects a scientific uncer?

tainty: it's impossible to know a person's genotype simply by looking at her, or the degree to which environment affects someone's genes merely by

knowing his nationality. Nurses have made signifi? cant efforts to clear the confusion, but an important question remains: how is a "culturally competent" nurse to understand the ways in which drug response is affected by ethnicity?that amalgam of

genetic and cultural influences that makes up a human life?

As the U.S. population becomes more diverse

ethnically, such questions have become more press?

ing. Cultural competence, defined as the process of

Cora Mu?oz is a professor at Capital University School of Nursing, Columbus, OH. Cheryl Hilgenberg is a professor at the Millikin University School of Nursing, Decatur, IL. Mu?oz discloses that she received an honorarium and expenses for participating in an invita? tional session for physicians, pharmacists, and psychiatric nurses held in Miami, PL, and sponsored by AstraZeneca, which manufactures Inderal, a drug mentioned in this article. Contact author, Cora Mu?oz: [email protected]. The authors of this article have no other signifi? cant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

learning to "work within the cultural context" of the

patient,2 involves knowledge not only of patients' beliefs and values about health and illness, but also of their responses to treatment, including drug ther?

apies. Ethnopharmacology is the study of the effect of ethnicity on responses to prescribed medication, especially drug absorption, metabolism, distribution, and excretion. The field incorporates pharmacoge netics, the study of genetic variations in responses to

drugs. The value of cultural competence has been well

documented, and the need for it is becoming increas?

ingly urgent. In 2000, according to the U.S. Census

Bureau, the national population stood at about

281,422,000; of this total, 12.5% self-identified as

Hispanic or Latino; 12.3%, as black or African

American; 3.6%, as Asian; and almost 1% as American Indian or Alaskan native.3 The most recent data show that some population groups are continu?

ing to grow much faster than others. For example, between April 2000 and July 2003, the growth rates for Hispanic and Asian Americans were reported to be 13% and 12.5%, respectively, compared with a

growth rate of 3.3% for the total population.4 Although sometimes used interchangeably, the

terms race, culture, and ethnicity have distinct

meanings. Dorland's Illustrated Medical Dictionary defines race as "a class of persons of a common

lineage; in genetics, races are considered as popula? tions having different distributions of gene frequen? cies"; the term generally reflects the geographic origins of ancestry. Although the usefulness of the classification has been debated, given the ambi?

guity of even self-defined racial identity,5,6 the term remains widely used in clinical research. Leininger has described culture as an integrated system of

[email protected] AJN ?

August 2005 ? Vol. 105, No. 8 41

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

learned beliefs, values, and customs common to a

particular group of people; typically these are

passed down from generation to generation.7

Ethnicity can refer to shared cultural bonds, a com?

mon genetic heritage, or both.

Although varied responses to other treatment modalities no doubt exist, this article focuses on sim? ilarities and differences in how people from various ethnic groups respond to prescribed medications.

(Interactions that may occur between prescribed drugs and herbal or "folk" remedies are beyond the

scope of this article.)

? A person can be an ultrarapid

metabolizer of some drugs and a normal or poor

metabolizer of others.

VARIATIONS IN DRUG RESPONSES Studying how ethnicity affects drug response is

challenging, in part because of the tremendous vari? ations that exist within each ethnic group. Many studies have used broad categories when classifying participants without differentiating among sub?

groups (for example, using the term "Asians" to refer to people of Korean, Chinese, Japanese, Indian, Pakistani, and Vietnamese ancestry, among

others). Also, as Burchard and colleagues have

observed, findings of ethnic differences can create more anxiety than they allay, given the United States' long history of prejudice and discrimination

against racial and ethnic minorities.8 And some

questions have been raised about the accuracy of data collected, partly because the definitions of race and ethnicity are not consistent.5,6

Historically, most clinical drug trials have been conducted using white men; the results have then been generalized to all patients receiving the drugs studied. As Dawkins and Potter point out, this has been the case even when the targeted disorder or ill?

ness is most prevalent in groups other than white men.9 Nevertheless, data have been accumulating that strongly suggest that ethnicity influences

response to certain medications,1011 a fact of which

many clinicians remain largely unaware.

Within the last 15 years, ethnopharmacologic research has uncovered significant differences in

I how people in diverse ethnic groups metabolize cer? tain drugs,10 with regard to both pharmacodynam ics (a drug's mechanisms of action and its effects at the target site) and pharmacokinetics (the "move?

ment" of drugs, referring to drug absorption, metabolism, distribution, and elimination).12 Research has shown that genetic variations in cer?

tain enzymes may cause differing drug responses

(although the precise mechanism is unknown); also, certain ethnic groups have more of these variations

than others do. (See "Medication Selection by Genotype," May 2004.) Moreover, factors such as diet and tobacco use can influence a gene's expres?

sion, which can in turn alter a drug's effect.12 Most

ethnopharmacologic research to date has focused on drugs in two classes: psychotropic agents and

antihypertensive agents. (One possible reason for the focus on antihypertensives may be the relatively high incidence of hypertension and cardiovascular disease in some minority populations. For example, according to the American Heart Association, the

prevalence of high blood pressure among non

Hispanic blacks is almost 39%, compared with 27% among non-Hispanic whites.13)

PSYCHOTROPIC AGENTS Most psychotropic drugs are metabolized in the liver in two phases, an oxidation phase (phase 1) and a conjugation phase (phase 2). One group of

enzymes, the cytochrome P-450 (CYP) enzymes, has been the focus of much research because these

enzymes are responsible for the phase 1 metabolism of many widely prescribed drugs, including most

antipsychotics and antidepressants. There are many

CYP enzyme subgroups; these are typically identi? fied by letters and numbers (for example, CYP2).

Many studies have indicated that genetic abnormal? ities in the CYP enzymes are not only extremely common but have profound implications for drug response.12,

14, 15 And as Keltner and Folks have

noted, it appears that the "genetic ability to pro? duce" these enzymes "will vary by race or ethnic

group."16 For example, genetic changes in certain CYP

enzymes, including CYP2D6, have been shown to affect the rate of drug metabolism, which in turn affects drug plasma levels at a given dosage. The CYP2D6 gene is "unique in that the gene is often

duplicated or multiplied."12 People who have more than two functional copies of the CYP2D6 gene have faster than normal enzyme activity and are

known as "ultrarapid metabolizers," whereas those

with two nonfunctional copies of the gene have slower than normal enzyme activity and are known

as "poor metabolizers."1217 Ultrarapid metabolizers

will metabolize a drug quickly, resulting in lower serum concentrations, whereas poor metabolizers

42 AJN ?

August 2005 ?Vol. 105, No. 8 http://www.nursingcenter.com

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

metabolize the drug more slowly, resulting in higher serum levels at the same dosage. Luo and colleagues found that the frequency at which genetic abnor?

malities occur in these enzymes varied significantly among four ethnic groups: 18% of Ethiopian Jews and 13% of Sephardic Jews had more than two functional CYP2D6 genes and were predicted to be

ultrarapid metabolizers; only 6% of Yemenite Jews and 4% of Bedouin Arabs shared the mutation.17

(Depending on which genes have abnormalities, a

person can be an ultrarapid metabolizer of some

drugs and a normal or poor metabolizer of others.) In an important early study, Lin and Poland

examined the effects of haloperidol in three groups of healthy volunteers, which they identified as

"Caucasians," "American-born Asian Americans," and "foreign-born Asians."18 (More details on the

subjects' nationalities were not reported.) When administered specified doses of haloperidol, both Asian groups had significantly higher serum con? centrations of the drug than the white group did, even when body surface area was considered.

The same researchers then conducted a second

study in Asian and white patients diagnosed with

schizophrenia, administering haloperidol in fixed doses for two weeks and then in variable doses determined by clinical response for 10 weeks.18

They found that when haloperidol was given in variable doses, Asians required lower doses than whites did; when it was given at fixed doses, Asians showed significantly more extrapyramidal symp? toms than whites given the same dose. A longitudi? nal study also determined that the dosage of

haloperidol that provided the optimal response with minimal extrapyramidal symptoms was signif? icantly lower for Asian patients than for whites.19

Differences in clinical responses also occur within ethnic groups. Researchers have tended to use broad categories of race and ethnicity based on those used by the U.S. Census Bureau. (In 2000 these were white, black or African American, Asian, native Hawaiian and other Pacific Islander, and American Indian and Alaskan native; people who identify as Hispanic or Latino may be of any race.) But a tremendous number of subgroups exist, and studies have found marked differences in health status among them. For example, one recent

study found significant differences in risk for hyper? tension among various Pakistani ethnic groups (Muhajir, Punjabi, Sindhi, Pashtun, and Baluchi), even after adjusting for sociodemographic and other major risk factors (response to pharma

cotherapy was not included in the investigation).20 Systematic investigation of variations in drug response among specific ethnic subgroups would lead to improved clinical understanding and thus better patient care.

Actions for Nurses ? Learn about drugs that are likely to elicit varied

responses in people from different ethnic groups, as well as the potential for adverse effects.

? Conduct a cultural assessment with each patient. ? Ask the patient direct, specific questions to reveal

the presence or absence of potential adverse effects of medications.

? Monitor the patient and document findings carefully; it may be possible to maintain therapeutic benefit at a lower dosage of a given drug.

? Keep cultural context in mind when planning educa? tion for patients and families.

Traditional antipsychotics include chlorpro mazine (Thorazine), fluphenazine (Prolixin, Permitil), and haloperidol (Haldol). Research has

suggested that Hispanics may require lower doses of antipsychotic medications than whites do. A ret?

rospective study by Ruiz and colleagues examined data from a group of foreign-born Hispanic and Asian patients diagnosed with schizophrenia.21 The researchers converted dosages of traditional

antipsychotic agents to "chlorpromazine equiva?

lents," and found that the Hispanic patients required lower dosages compared with a control

group of "general" patients. (The researchers did not specify the antipsychotic agents; the general patient group was "drawn from a large multiethnic

community.") Another study of 398 outpatients receiving antipsychotic medications, including haloperidol, fluphenazine, chlorpromazine, and thioridazine (Mellaril), found that blacks were at

greater risk for developing tardive dyskinesia than whites were.22 A literature review by Tran and col?

leagues supported this conclusion.23

Newer, "atypical" antipsychotic agents such as

risperidone (Risperdal), clozapine (Clozaril), and

olanzapine (Zyprex, Zydis) have been subjected to limited ethnopharmacologic study. From anecdotal and research data available, Frackiewicz and col?

leagues reviewed the effects of both traditional and newer antipsychotics in Asians, Hispanics, blacks, and whites.24 They determined that the newer med? ications "may be preferable in the treatment of eth? nic minorities" because they caused fewer

extrapyramidal and other adverse effects. In one

study, Korean American and white patients were

given therapeutic doses of clozapine; their

responses were subsequently measured using the

Brief Psychiatric Rating Scale.25 The Korean American group responded better than the white

[email protected] AJN ?

August 2005 ? Vol. 105, No. 8 43

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

group did, even though they received lower doses and showed lower serum concentrations of the

drug; however, the Korean Americans also had a

higher incidence of anticholinergic and other adverse effects. And in reviewing the effectiveness of olanzapine, Tran and colleagues asserted that the

drug "offers significant advantages over many

existing antipsychotics" in black patients.23 For

example, olanzapine was associated with fewer

involuntary movements in blacks than was

haloperidol. It should be noted that, in another review,

Frackiewicz and colleagues cautioned that some

findings suggest that the differences in drug responses in blacks (and other minority groups) "may be due to clinician biases and prescribing practices rather than to pharmacokinetic or phar

macodynamic variability."24 Others have made sim?

ilar observations; future researchers should control

for this possibility.

In one study, blacks appeared to have a greater risk of

delirium caused by tricyclics than whites did.

Tricyclic antidepressants. A literature review by Lawson found that blacks given tricyclics were

likely to have faster therapeutic responses, have

higher serum concentrations, and report more

adverse effects than whites were.26 A review by Strickland and colleagues reported similar find?

ings.27 For example, blacks appeared to have a

greater risk of delirium caused by tricyclics than whites did.

Although the research in Hispanic populations has been limited and much of it was conducted in the 1980s, there is some evidence that adverse effects of tricyclics occur at much lower dosages in

Hispanics than in whites. In a literature review, Mendoza and colleagues describe a retrospective

study conducted in 1982 of Hispanic (primarily Puerto Rican) and "Anglo" women who were

given tricyclics.28 Dosages given the Hispanic women were half those given to Anglo women, yet comparable outcomes were achieved; however, the

Hispanics reported adverse effects more often.

Greater tissue sensitivity in Hispanics and Asians to

tricyclics may explain why these populations achieve therapeutic responses to these drugs at

lower dosages than those required for whites.29

Newer antidepressants such as the selective sero?

tonin reuptake inhibitors are now being widely pre? scribed, but as yet very few ethnopharmacologic studies have been conducted.

Lithium. There is evidence that blacks may require lower doses of lithium (Eskalith and others) than white patients do. In one study, Strickland and

colleagues examined the effects of lithium in 12 black and 22 white patients with bipolar disorder.30 All were in remission. Although patients in both

groups received similar daily dosages, blacks

reported more lethargy and dizziness than whites did. Plasma concentrations of the drug were similar in the two groups, but erythrocyte lithium concen? trations were 60% higher in blacks than in whites.30 And in 1980 Okpaku and colleagues found that serum lithium levels remained higher in healthy black volunteers than in healthy white volunteers 25 hours after receiving lithium, although the sam?

ple size (N = 8) was small.31 Given lithium's narrow

therapeutic range and the severity of symptoms of lithium toxicity, research is needed to examine the risk of toxicity in populations that demonstrate lithium sensitivity.

ANTIHYPERTENSIVE DRUGS The role of CYP enzymes in the metabolism of anti

hypertensives is not yet well understood. But ethnic variation in drug response has been demonstrated for many such agents, according to a review by

Burroughs and colleagues in 2002.10 For example, captopril (Capoten), an angiotensin-converting

enzyme (ACE) inhibitor, has reportedly been found to be less effective in blacks than in whites.32 The effectiveness of another ACE inhibitor, enalapril, was evaluated in white and black patients with left ventricular dysfunction.33 The patients, who self

identified as white (n = 1,196) or black (n = 800), were matched for important variables such as age,

sex, and left ventricular ejection fraction and then

randomly assigned to receive enalapril or placebo. At one year, the white patients showed significant reductions in blood pressure, and the black patients did not; the black patients also had higher rates of

hospitalization and death. Another study found that losar?an, an angiotensin II receptor antagonist,

was less effective in lowering blood pressure in blacks than in whites, when taken alone.34

Conversely, the thiazide diuretics appear to be more effective antihypertensives in blacks than in whites. When used alone, hydrochlorothiazide (Esidrix and others) has been found to be more effective in treating hypertension in blacks than in

whites, according to the review by Burroughs and

44 AJN ?

August 2005 ? Vol. 105, No. 8 http://www.nursingcenter.com

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

colleagues.10 One double-blind study of 1,292 men with hypertension found that younger black

patients were more responsive to hydrochloroth iazide and calcium channel blockers than were

white patients.35 And a recent consensus statement

from the Hypertension in African Americans

Working Group of the International Society on

Hypertension in Blacks37 acknowledged that both thiazide diuretics and calcium channel blockers are

likely to be more effective in treating hypertension in black patients than in white patients.

Studies on the use of ?-blockers for the treat? ment of hypertension have also shown ethnic variation in drug response.35,36 The aforementioned

consensus statement also cautions that monother

apy with ?-blockers is likely to be less effective in

treating hypertension in blacks than in whites.37 In a recent literature review, Schaefer and colleagues

reported that studies have shown that blacks may need higher doses of ?-blockers, including propran olol (Inderal), than those typically prescribed for whites.38 In contrast, studies have shown that

Asians usually require lower doses of propranolol than whites do to achieve a therapeutic response.

CULTURAL AND LIFESTYLE FACTORS Tobacco and alcohol use, both of which may be influenced by cultural and genetic factors, may affect an individual's drug response. Strickland and

colleagues noted that the use of tobacco or alcohol

may increase or decrease the rate at which a drug is metabolized and cleared.27 A review by Frackiewicz and colleagues stated that smoking has been shown to decrease serum levels of traditional antipsy chotics such as chlorpromazine and fluphenazine; this may be caused by the effects of smoking on liver enzymes.24 For example, in one man with

schizophrenia the plasma levels of olanzapine dropped and his condition rapidly worsened when his smoking increased from 12 to 80 cigarettes a

day.39 The researchers hypothesized that heavy smoking activated the liver enzyme CYP1A2, the

main enzyme involved in olanzapine metabolism. And in another study, plasma levels of clozapine in smokers were approximately 80% of the levels in nonsmokers.40 A literature search revealed no rele?

vant research on smoking in different populations. A related concern is adherence to treatment. One

large study of people with hypertension found that

Hispanics were less likely than blacks or whites to continue taking medication as prescribed, although the researchers could not account for the differ? ence.41 Lin and Smith, in discussing how adverse effects often contribute to nonadherence, point out

that some drug effects "could be interpreted as either negative or positive" depending on the

patient's beliefs and expectations.12 For example,

Resources

Center for CrossCubural Research www.ac.wwu.edu/-culture

The Cross Cultural Health Care Program www.xcubure.org

Diversity Rx

www.diversityrx.org

National Center for Cultural Competence http://guochd.georgetown.edu/nocc

Transcuhural CAR.E. Associates www.transcuburalcare.net

Transcuhural Nursing Society www.tcns.org

discussing one research team's study of Chinese

patients who were bipolar and receiving lithium, they note the finding that "unlike Western patients, the Chinese rarely complained of 'missing the

highs' and regarded polydipsia, polyuria, and

weight gain as part of the therapeutic effect." But the Chinese patients also attributed lethargy and poor memory to the drug, although the control

group experienced these symptoms at similar rates.

If such issues are not taken into account, clinicians

might misinterpret a pattern of poor compliance by a particular group as decreased drug efficacy.

Culture-bound syndromes can further compli? cate evaluation of drug response.28 Culture-bound

syndromes are specific clusters of symptoms or pat? terns of behavior that are considered abnormal

within a given ethnic group but are much more common in some groups than others. It's not yet clear whether culture-bound syndromes overlap with established psychiatric diagnoses or are dis? tinct. One example, according to the U.S. surgeon

general, is ataque de nervios (literally, attack of

nerves), specific to Hispanics; its symptoms may include "screaming uncontrollably, crying, trem?

bling, verbal or physical aggression, dissociative

experiences, seizure-like or fainting episodes, and

suicidal gestures."42 Clinicians' unfamiliarity with a

particular culture-bound syndrome may lead to inadvertent misdiagnosis, ineffective treatment, and

inappropriate prescribing. Other factors that may affect drug response and

adherence to treatment include language barriers, clinicians' beliefs and preconceptions, and patients' distrust of the health care system. For example, Lin and Smith report that studies have shown that black psychiatric patients have been more likely to be diagnosed with schizophrenia than whites with

[email protected] AJN ?

August 2005 ?Vol. 105, No. 8 45

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

the same symptoms, and this has been linked to cli? nician bias.12 Moreover, according to the U.S. sur?

geon general, blacks are more likely than whites are to receive higher dosages of psychotropic drugs, even though research indicates that blacks metabo? lize such drugs more slowly.43 This can lead to more severe adverse effects and less stringent adherence.

? Some patients will have ther?

apeutic responses at lower

doses than those typically recommended; careful moni?

toring may help prevent

unnecessary increases in

dosage and adverse effects.

NURSING IMPLICATIONS Nurses need to be knowledgeable about drugs that may elicit varied responses in patients from dif? ferent ethnic groups, especially the variations in

therapeutic dosages and adverse effects. Some

patients will have therapeutic responses at lower doses than those typically recommended; careful

monitoring may help prevent unnecessary increases

in dosage and adverse effects. For example, among

Hispanic patients receiving traditional antipsy chotics, symptoms may be managed effectively at lower doses than those typically prescribed.21 Black

patients on lithium need to be monitored for symp? toms of drug toxicity, because serum levels of the

drug may be higher than in white patients given the same dosage.30 For the same reason, Japanese and Taiwanese patients may require lower dosages of lithium.44

The practice of making therapeutic substitutions with medications in the same drug category to con? tain costs should be approached with caution.

Noting that drugs in the same class may vary in how they are metabolized, the review by Burroughs and colleagues called the practice of therapeutic substitution "clinically risky for patients in differ? ent nonwhite racial and ethnic groups."10 And of course, no two people are alike. Thus nurses must

also be alert to individual variations in drug response and be prepared to initiate discussion with the primary provider and others on the team.

Skill in communicating with patients from vari? ous cultures is essential. It's best to ask patients spe? cific questions about possible adverse effects, rather

than asking general questions or waiting for the

patient to voice concerns. For example, Spector noted that most Asian cultures highly value

patience and modesty, adding that "the typical Chinese patient rarely complains."45 Pi and Gray observed that Asians with psychological complaints "are likely to express their problems in behavioral or somatic terms rather than in emotional ones."46

Careful observation and specific questions may be

necessary to elicit important information. A nurse

interviewing a Chinese American patient receiving haloperidol might ask, "Have you noticed any unusual, involuntary movements?" to determine

the presence or absence of extrapyramidal effects.

The importance of considering culture when

assessing and teaching patients and families is well

recognized. Two useful, basic questions are "What

do you think caused your health problem?" and "What treatment do you think will help you?"

Several cultural assessment tools have been

developed. Leininger's Sunrise Model focuses on seven major areas: educational; economic; familial and social; political; technologic; religious and

philosophic; and cultural values, beliefs, and prac? tices. It also considers how lay and professional beliefs and practices affect the patient's experiences of health and health care. Examples of questions a nurse might ask include47: ? In what ways have family members or friends

influenced your life, especially regarding your health? How have they cared for you, and how would you like them to care for you now?

? How have your spiritual beliefs helped you to face crises or to heal when you or your loved ones are ill?

? In your daily life, do you use a lot of "high-tech" equipment or appliances? How do you think the

equipment used here helps or hinders your care?

Similarly, Giger and Davidhizar's Transcuhural Assessment Model considers six areas: communica?

tion, space, social organization, time, environmen?

tal control, and biologic variations.48 It too offers numerous sample questions. For example, an

assessment of a patient's communication style includes voice quality, pronunciation and enuncia?

tion, use of silence, and use of nonverbal cues; an

assessment of the patient's relationship to space includes considering his comfort with proximity to other people and objects and preferred distance

during conversation. (For more on cultural assess?

ment, see Resources, page 45.)

Determining the patient's language preferences for spoken and written communication is the first

step. A language barrier that impedes a nurse's abil?

ity to obtain an accurate patient history can con?

tribute to misdiagnosis; one that hampers patient and family teaching can undermine management of

46 AJN ?

August 2005 ?Vol. 105, No. 8 http://www.nursingcenter.com

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

the patient's illness. For example, a patient who

can't understand the instructions for his drug regi? men may not adhere to it; if this isn't recognized, the drug regimen may be needlessly altered. Patients and families also need to know how to

identify the major adverse effects of the drugs they're taking and instructions regarding whom to contact if such effects occur.

If an interpreter is needed, one should be pro? vided by the facility. (The Office of Minority Health's National Standards for Culturally and

Linguistically Appropriate Services in Health Care

[www.omhrc.gov/clas/finalculturalla.htm] states

that using the patient's friends or family members as interpreters is not recommended; one reason

is that the patient may not be comfortable disclos?

ing certain symptoms or behaviors to them.) In some cases the patient may be fluent in speaking a

language but not in reading or writing it. Nurses

may also need to become aware of the different terms patients use to describe their illnesses. In our experience, for example, African American

patients often refer to hypertension as "high blood" and anemia as "low blood."

A cultural assessment can yield other important information such as dietary preferences, customs

related to alcohol and tobacco use, and the use of herbal products. Finally, to become culturally compe? tent, nurses also need to explore their

own perspec?

tives, including any assumptions or misconceptions

they may have. ?

Complete the CE test (or this article by using the mail-in form available ?n this issue, or visit NursingCenter.com's "CE Connection" to take the test and find other CE activities and "My CE Planner/

REFERENCES 1. U.S. Census Bureau. Young, diverse, urban: Hispanic popu?

lation reaches all-time high of 38.8 million, new Census Bureau estimates show. 2003. http://www.census.gov/ Press-Release/www/releases/archives/hispanic_origin_ population/001130.html.

2. Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. / Nurs Educ 1999;38(5): 203-7.

3. U.S. Census Bureau. Geographic comparison table. GCT P6. Race and Hispanic or Latino: 2000. 2000.

http://factfinder.census.gov/servlet/GCTTable?_bm=y& geo_id=01000US&-_box_head_nbr=GCT-P6&> ds_name=DEC_2000_SFl_U&-_lang=en&-format=US-9& _sse=on.

4. U.S. Census Bureau. People: race and ethnicity. 2004.

http://factfinder.census.gov/jsp/saf?/SAFFInfo.jsp?_pageId=tp 9_race_ethnicity.

5. Denberg TD. Questioning race-based hypertension manage? ment. Arch Intern Med 2003;163(14):1744-5; author reply 1745.

6. Schwartz RS. Racial profiling in medical research. N Engl J AW2001;344(18):1392-3.

7. Leininger M. The theory of culture care and the ethnonurs

ing research method. In: Leininger M, McFarland MR, edi? tors. Transcuhural nursing: concepts, theories, research, and

practice. 3rd ed. New York: McGraw-Hill; 2002. p. 71-98.

8. Burchard EG, et al. The importance of race and ethnic

background in biom?dical research and clinical practice. N EnglJ Med 2003;348(12):1170-5.

9. Dawkins K, Potter WZ. Gender differences in pharmacoki netics and pharmacodynamics of psychotropics: focus on women. Psychopharmacol Bull 1991;27(4):417-26.

10. Burroughs VJ, et al. Racial and ethnic differences in

response to medicines: towards individualized pharmaceuti? cal treatment. / Nati Med Assoc 2002;94(10 Suppl):l-26.

11. Nicol MJ. The variation of response to pharmacotherapy: pharmacogenetics?a new perspective to "the right drug for the right person." Medsurg Nurs 2003;12(4):242-9.

12. Lin KM, Smith MW. Psychopharmacotherapy in the con? text of culture and ethnicity. In: Ruiz P, editor. Ethnicity and

psychopharmacology. Vol. 19, no. 4, Review of Psychiatry, Oldham JM, Riba MB, editors. Washington, D.C.: Ameri? can Psychiatric Press; 2000. p. 1-36.

13. American Heart Association. Number of adults in U.S. with

high blood pressure rose in last decade. 2004. http:// www.americanheart.org/presenter.jhtml?identifier=3024254.

14. Lin KM, et al. The evolving science of pharmacogenetics: clinical and ethnic perspectives. Psychopharmacol Bull

1996;32(2):205-17. 15. Solus JF, et al. Genetic variation in eleven phase I drug

metabolism genes in an ethnically diverse population. Pharmacogenomics2004;5(7):S95-931.

16. Keltner NL, Folks DG. Psychotropic drugs. 3rd ed. St. Louis: Mosby; 2001.

17. Luo HR, et al. Polymorphisms of CYP 2C19 and CYP 2D6 in Israeli ethnic groups. Am J Pharmacogenomics 2004; 4(6):395-401.

18. Lin KM, Poland RE. Pharmacotherapy of Asian psychiatric patients. Psychiatr Ann 1989;19(12):659-63.

19. Lin KM, et al. A longitudinal assessment of haloperidol doses and serum concentrations in Asian and Caucasian

schizophrenic patients. Am J Psychiatry 1989;146(10): 1307-11.

20. Jafar TH, et al. Ethnic subgroup differences in hypertension in Pakistan. / Hypertens 2003;21(5):905-12.

21. Ruiz S, et al. Neuroleptic dosing in Asian and Hispanic out?

patients with schizophrenia. Mt Sinai] Med 1996;63(5 6):306-9.

22. Glazer WM, et al. Race and tardive dyskinesia among out?

patients at a CMHC. Hosp Community Psychiatry 1994; 45(l):38-42.

23. Tran P, et al. Treatment of the African-American patient with novel antipsychotic agents. In: Herrera JM, et al., edi? tors. Cross cultural psychiatry. Chichester, England: John

Wiley and Sons; 1999. p. 131-8.

24. Frackiewicz E, et al. Review of neuroleptic dosage in differ? ent ethnic groups. In: Herrera JM, et al., editors. Cross cul? tural psychiatry. Chichester, England: John Wiley and Sons; 1999. p. 107-30.

25. Matsuda KT, et al. Clozapine dosage, serum levels, efficacy, and side-effect profiles: a comparison of Korean-American and Caucasian patients. Psychopharmacol Bull 1996;32(2): 253-7.

26. Lawson WB. Clinical issues in the pharmacotherapy of African-Americans. Psychopharmacol Bull 1996;32(2):275 81.

27. Strickland TL, et al. Psychopharmacologic considerations in the treatment of black American populations. Psychopharma? col Bull 1991;27(4):441-8.

28. Mendoza R, et al. Ethnic psychopharmacology: the

Hispanic and Native American perspective. Psychopharma? col Bull 1991;27 {4) A49-61.

29. Wood AJ, Zhou HH. Ethnic differences in drug disposition and responsiveness. Clin Pharmacokinet 1991;20(5):350-73.

[email protected] AJN ?

August 2005 ? Vol. 105, No. 8 47

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

30. Strickland TL, et al. Comparison of lithium ratio between African-American and Caucasian bipolar patients. Biol

Psychiatry 1995;37(5):325-30. 31. Okpaku S, et al. A pilot study of racial differences in ery

throcyte lithium transport. Am J Psychiatry 1980;137(1): 120-1.

32. Kudzma EC. Drug response: all bodies are not created

equal. AmJNurs 1992;92(12):48-50. 33. Exner DV, et al. Lesser response to angiotensin-converting

enzyme inhibitor therapy in black as compared with white

patients with left ventricular dysfunction. N EnglJ Med

2001;344(18):1351-7. 34. Flack JM, et al. Efficacy and tolerability of eplerenone and

losartan in hypertensive black and white patients. / Am Coll Cardiol 2003;41(7):1148-55.

35. Materson BJ, et al. Single-drug therapy for hypertension in men?a comparison of six antihypertensive agents with

placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N EnglJ Med

1993;328(13):914-21. 36. Preston RA, et al. Age-race subgroup compared with renin

profile as predictors of blood pressure response to antihy? pertensive therapy. Department of Veterans Affairs

Cooperative Study Group on Antihypertensive Agents. JAMA 1998;280(13):1168-72.

37. Douglas JG, et al. Management of high blood pressure in African Americans: consensus statement of the Hyper? tension in African Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med 2003;163(5):525-41.

38. Schaefer BM, et al. Gender, ethnicity, and genes in cardio? vascular disease. Part 2: implications for pharmacotherapy. Heart Dis 2003;5(3):202-14.

39. Chiu CC, et al. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit

2004;26(5):579-81. 40. Haring C, et al. Dose-related plasma levels of clozapine:

influence of smoking behaviour, sex and age. Psychopharma cology (Berl) 1989;99 Suppl:S38-40.

41. Sudano JJ, Jr., Baker DW. Antihypertensive medication use in Hispanic adults: a comparison with black adults and

white adults. Med Care 2001;39(6):575-87. 42. U.S. Public Health Service. Surgeon General's Report. Fact

sheets: Latinos/Hispanic Americans. 2001. http://www. mentalhealth.samhsa.gov/cre/fact3.asp.

43. U.S. Public Health Service. Surgeon General's Report. Fact sheets: African Americans. 2001. http://www.mentalhealth. org/cre/factl.asp.

44. Lin KM, et al. Ethnicity and psychopharmacology. Cult Med Psychiatry 1986;10(2):151-65.

45. Spector R. Cultural diversity in health and illness. 5th ed.

Upper Saddle River, NJ: Prentice Hall Health; 2000. p. 209 29.

46. Pi EH, Gray GE. Ethnopharmacology for Asians. In: Ruiz P, editor. Ethnicity and psychopharmacology. Vol. 19, no. 4, Review of Psychiatry, Oldham JM, Riba MB, editors.

Washington, D.C.: American Psychiatric Press; 2000.

p. 91-113.

47. Leininger M. Culture care assessments for congruent com?

petency practices. In: Leininger M, McFarland MR, editors. Transcultural nursing: concepts, theories, research, and

practice. 3rd ed. New York: McGraw-Hill; 2002. p. 117-43.

48. Giger JN, Davidhizar RE. Transcultural nursing: assessment and intervention. 4th ed. St. Louis: Mosby; 2004. p. 3-19.

Continuing Education

GENERAL PURPOSE: To provide registered professional nurses with current information on ethnopharmacology, including how ethnicity affects responses to prescribed

medication.

LEARNING OBJECTIVES: After reading this article and tak? ing the test on the next page, you will be able to: ? discuss the trends and concepts that contribute to

understanding ethnopharmacology. ? describe the effects of specific drugs on various racial and ethnic groups as presented in this article. ? outline the efficacy

of several types of drugs on var? ious racial and em nie groups, as well as how cul? ture can affect drug therapy.

To tore conKmndj ?docotiou (CE) croo?, fmow those

1? After reading this article, darken the appropriate boxes (numbers 1-17) on the answer card between pages 48 and 49 (or a photocopy). Each question has only one correct answer.

2. Complete the registration information (Box A) and help us evaluate this offering (Box C).* 3. Send the card with your registration fee to: Continuing Education Department, Lippincott Williams & Wilkins, 333 Seventh Avenue, 19th Floor, New York, NY 10001. 4. Your registration fee for this offering is $22.75. If you take two or more tests in any nursing journal published by Lippincott

Williams & Wilkins and send in your answers to all tests together, you may deduct $0.75 from the price of each test.

Within six weeks after Lippincott Williams & Wilkins receives your answer card, you'll

be notified of your test results. A passing score for this test is 13 correct answers (76%). If you pass, Lippincott Williams & Wilkins will send you a CE certificate indicating the number of contact hours you've earned. If you fail, Lippincott Williams &

Wilkins gives you the option of taking the test again at no additional cost. All answer cards for this test on 'Ethnopharmacology" must be received by August 31, 2007.

This continuing education activity for 3.5 contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing nursing education (CNE) by the American Nurses Crederv tialing Center's Commission on Accreditation and by the American Association of Critical-Care Nurses

(AACN 00012278, category O). This activity is also provider approved by the California Board of Registered Nursing, provider number CEP 11749 for 3.5 contact hours. Lippincott

Williams & Wilkins is also an approved provider

of CNE in Alabama, Florida, and Iowa, ana holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA W75. All of its home study activities are classified for Texas nursing continuing education requirements as Type 1.

*/n accordance with hwa Board of Nursing administrative rules governing grievances, a copy of your evaluation of mis CNE offering may be submitted to the hwa Board of Nursing.

48 AJN ?

August 2005 ? Vol. 105, No. 8 http://www.nursingcenter.com

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions

HOURS

Ethnopharmacology 1. The study of generic variations in responses to drugs is most accu? rately termed

a. ethnopharmacology.

b. cultural competence. c.

pharmacogenetics. d. transcultural pharmacology.

2? According to Hie article/ between April 2000 and July 2003 which of the following groups grew in popu? lation the fastest?

a. Native Alaskans b. African Americans c. Asian Americans d. Hispanic Americans

3? According to Leininger, an inte? grated system of learned beliefs/ values, and customs common to a

particular group of people

a. ethnicity.

b. race.

c. lineage.

d. culture.

4. The cytochrome P-450 enzymes a. are responsible for the phase 2 metabolism of many common drugs. b. can alter drug response

when

genetically abnormal. c. do not

typically affect plasma levels

of psychotropic drugs. d. can be altered by specific lifestyle practices.

5. When Un and Poland studied the effects of nolopondol in noolftiy participants/ mey louna me lowest serum concentrations of the drug among

a. whites. b. American-born Asian Americans. c. African Americans. d. foreign-born Asian Americans.

6. According to this article, at least one study of the use of traditional antipsyctioncs demonstrated that

a. black patients were at lower risk for developing tardive dyskinesia than whites were.

b. black patients required lower doses than "general" patients (those from a multiethnic control group) did. c. Hispanic patients were at greater risk for developing tardive dyskinesia than whites were.

d. Hispanic patients required lower doses than "general" patients did.

7. In a study of clozapine (Glozaril) use by Korean Americans and whites, the Korean Americans

a. had a higher incidence of anti cholinergic effects. b. received higher doses of the drug. c. showed a poorer therapeutic response. d. showed higher

serum concentra?

tions of the drug.

8. In a study by Tran and col? leagues, which drug caused fewer involuntary movements in blacks

man naioponaoi aiar a. fluphenazine (Prolixin, Permitil) b. clozapine (Clozaril) c. olanzapine (Zyprexa) d. risperidone (Risperdal)

9. Two literature reviews of the use of tncyclics have indicated that, in comparison with whites, blacks have

a. slower therapeutic

responses. b. a greater risk of delirium. c. lower serum concentrations.

d. more reluctance to report adverse

effects.

10? According to a study by Strickland and colleagues, blacks

taking lithium reported which of the following adverse effects more often than whites did?

a. oliguria b. constipation c. rapid pulse d. lethargy

11 ? Which type of antihypertensive agent has generally been found to be more effective in bracks than in whites?

a. thiazide diuretics b. angiotensin-converting enzyme

(ACE) inhibitors c. ?-blockers d. angiotensin II receptor antagonists

12. Whichtype of drug is likely to be more effective in treating hyper? tension in blacks than in whites?

a. ?-blockers b. centrally acting adrenergics c. calcium channel blockers d. ACE inhibitors

13. Studies have shown which group to require lower doses of propranolol (Inderal) to achieve a

therapeutic response than whiles do?

a. blacks b. Hispa nies c. American Indians

d. Asians

14. A study by Sudano and col? leagues demonstrated lowest

aanerence 10 a arug r?gimen among

a. blacks.

b. Hispanics. c. whites.

d. Asians.

15. According to Spector, cultural values held by people from which group make mem less likely to report adverse effects?

a. blacks b. Hispanics c. whites d. Asians

16. One good way to assess the neaim oeiiers or a panenr rrom

another culture is to a. ask the patient, "What treatment do

you think will help you?" D. research the patient's culture using the library and Internet. c. determine, based on the patient's health status, how self-care can help. d. discuss with the

family how culture

shapes the patient's health beliefs.

17? It is recommended that nurses who encounter a language barrier when trying to talk with a patient

a. check the chart for a contact per? son.

b. try to communicate with gestures. c. use an interpreter provided by the facility. d. screen the patient's visitors for an

interpreter. T

ain9hvw.com AJN ?

August 2005 ? Vol. 105, No. 8 49

This content downloaded from 206.224.223.239 on Thu, 25 Jun 2015 15:29:16 UTC All use subject to JSTOR Terms and Conditions