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*Ethnopharmacology:Cultural Issues & Genetic Influences

Dr. Barbara Jones Warren,PhD, APRN, BC

*Please note that this is the intellectual property of the authorand material is not to be copied, duplicated, or used without

permission of the author. Thank you.

Objectives

n Examine issues of culture andgenetics as they relate to care ofpersons by advanced practicenurses.

n Describe issues of culture as theyrelate to advanced clinicalinterviewing & assessmenttechniques.

Let’s Talk About Definitions

Office of the Surgeon General. (2001). Mental health: Culture, race, & ethnicity. Rockville, MD: DHHS.

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n Culture: norms, values, and beliefsthat provide meaning for anindividual, group, or community’slife.

n Ethnicity: common heritage sharedby a particular group.

n Race: often thought of as geneticdeterminants within an individual’sbiological make-up. However, themost Surgeon General states,“Different cultures classify peopleinto racial groups according to a setof characteristics that are sociallysignificant. In fact, there is researchthat indicates there are greatergenetic variations within a racialgroup than across racial groups.”

n Health: “word symbol” that providesforward movement of the personality andother ongoing human processes whichleads to creative, constructive, productive,personal, & community living.

n Environment: physiological,psychological, and social fluidity for theclient and APRN.

n Ethnopharmacology: the study ofpharmacologic responses for persons fromdifferent racial and ethnic backgrounds.

Campinha-Bacote, J. (2003). Presentation on Ethnic pharmacology: A neglected area of cultural competency in nursing education, practice, & research.

Peplau, H. Interpersonal Relations.

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Current State of the Knowledge

n There are biological basis forvariations or differences in metabolicresponse to agents.• Genetics and polymorphism in drug

metabolism• Multiple disease states• Drug to drug interactions

n Environmental• Diet, smoking, pregnancy, stress,

diurnal rhythmsWarren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting,

Cultural Issues in Mental Health: Part I, II.

Current State of the Knowledge

n Cultural• Attitudes, beliefs, family influences and

therapy expectations.• Genetic responses are variant and may

cause higher response & higher risk formore intense negative side effects. Thisis where cultural competence andphysiology meet ‡ create quality,culturally responsive care for clients.

Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting, Cultural Issues in Mental Health: Part I, II.

Biological Basis for Differences

n Genetics and polymorphism in drugmetabolism• Specific DNA regions on various

chromosomes influence hepaticmetabolism

• Polymorphism: defined at least 2 distinctgroups

Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting, Cultural Issues in Mental Health: Part I, II.

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Biological Basis for Differences

n Various types of hepatic metabolism– 2 phases• Acetylation: INH, hydralazine,

procainamide• Oxidation: P450 isozymes• Glucuronidation: lorazepam,

only phase II• Cholinesterase in plasma• Dehydrogenases: alcohol

Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting, Cultural Issues in Mental Health: Part I, II.

Cultural Communication

Cultural Competence is Critical forClients and FNPs

n This process includes:• Behavioral Perspective• Individual Perspective• Self or Outside Perspective

n All are related to biopsychosocialcomponents within persons.

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Cultural CompetenceProcess of knowing, appreciating, & valuingcultural differences and variations whileincorporating such into your area of nursingexpertise as well as in your relationships andinteractions with others.

RelationshipValue

Appreciation

Cultural

Variations

Cultural

Interview

Warren, B. J. (2003). Cultural and ethnic considerations. In D. Antai-Otong, Psychiatric nursing: Biological & behavioral concepts, (pp. 151-165). NJ: Thomson Delmar Learning.

n Critical to development of a successfulcultural clinical interview process.

n Involves the client & MH provider’s culturalperspectives re: healthcare practices, beliefs,and importance of the environment.

n This provides a unique experience,development of expectations and pattern ofinteractions.

n The APRN guides the:• Significant, therapeutic, interpersonal process• Forward movement of personalities involved in

the relationship

Interpersonal Relationship

Cultural Perspectives within theAPRN Care Process

n World Views

THINKING INTERACTING

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World Views: represents what a person values &how they function

ANALYTIC

RELATIONAL COMMUNITY

ECOLOGICAL

Warren, B. J. (2002). The interlocking paradigm of cultural competence: A best practiceapproach. Journal of the American Psychiatric Nurses Association, 8 (6), 209-213.

Clinical Interviewing

World Viewsrepresents what a person values & how they function

Analytic (systematic): OUTCOME ORIENTED

Relational (interactions with others):RELATIONSHIP-BASED

Community (needs of the group):TRANSENDENCE-MOTIVATED

Ecology (connection with the earth):ECOLOGY-BASED

Warren, B. J. (2002). The interlocking paradigm of cultural competence: A best practice

approach. Journal of the American Psychiatric Nurses Association, 8 (6), 209-213.

Cultural Interviewing Strategies

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n Involves the preservation of theclient’s culture in a recovery-basedcontext.

n Utilizes negotiation to develop andextend the healthcare process andprovide evidence-based holistichealth care for the client.

n Utilizes critical thinking regardingcultural competence in order torepattern the client’s approach toaddressing their health needs andsymptom management.

Dr. Madeline Leininger, 1995

Interviewing Strategies

• Holistic Perspective

• Mental Health &Wellness

• Spiritual Connection

• PhysiologicalComponents

Culture – Focused Interview

n Focuses on theinterpersonaldynamic processin order to helpthe client definehis or hersymptoms,needs.

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Culturally CompetentHealthcare Issues

n Genetic and ethnic influences.

n Cultural health beliefs and practices.

n Environmental variables (living, rearing,persons around a client).

Culturally CompetentHealthcare Issues [Cont.]

n Healthcare professionals’ culturalperspectives and cultural competenceknowledge.

n Client & others’ perspective & knowledgeof cultural processes.

Cultural Interview Guidelinesn LISTEN to the client.n EXPLAIN your

perception of what theclient said.

n ACKNOWLEDGE theimportance of theclient’s culturalperspectives.

n RECOMMENDATIONSare made according tothe APRNs expertiseand the client’s culturalhealth needs.

n NEGOTIATE to obtainsuccessful, culturallycompetent healthcare. Berlin & Fowkes, 1982

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Cultural Interviewing Suggestions

n Meaning of wellness &distress.

n How s/he describe thesymptoms of current distress.

n Feelings about seekinghealthcare, issues of stigma.

n How others who areimportant to the client feelabout s/he seeking help forillness/ distress.

n Cultural practices for treatingillness/ distress.

(Gaw, 2001)

Assess client’s cultural perspectives regarding:

*WHAT THEY NEED FROM YOU?

Culturally Competent Education* Provide Client Education Regarding:• Symptoms of their disorder/ distress.• Treatment approaches as they relate to their cultural

practices.• Daily schedule needs (e.g., dietary practices, work,

sleep, etc.)• Role & use of support systems (e.g., healthcare

professionals, family, significant others)• Through individual &/or group health sessions

(Colom, et al., 2003)

Brokering

n Negotiation is thekey for successfulevidence-basedholistic healthcareinterviewing,assessment,treatment &follow-up!

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Cultural Interviewing

n Interface of biological, psychological,and social theoretical evidence-basedtherapeutic foci into a highlyspecialized approach to client care.

n The focus is on the interaction andrelationship in order to obtain accurateclient assessment data.

Cultural Client Interviewing

Communication

Orientation

Significant Others

Health Beliefs

Education

Biopsychosocial Issues: Mind-body-spirit

Involves the interpersonal processes between you,the client, and others important for both of you!

Healthcare Professional’s CulturalPerspective

n Disparities in mental healthcare may beinfluenced by societal and providerperspectives as they relate to raciallyand ethnically diverse persons.

Institute of Medicine, Committee on Understanding andEliminating Racial and Ethnic Disparities in Healthcare. (2002).Unequal treatment: Confronting racial and ethnic disparities inhealthcare. Washington, DC: National Academy Press.

Institute of Medicine, Committee on Health and Behavior.(2001). Health and behavior: The interplay of biological,behavioral, and societal influences. Washington, DC: NationalAcademy Press.

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Biopsychosocial Issues &Medication Adherence

n Genetic and ethnicity influencesn Cultural health beliefs and practicesn Environmental variablesn Healthcare professionals’ cultural

perspectivesn Client’s perspective of recovery processn OUTCOME ‡ Treatment/action plan for

client.

Cultural Influences onDosing Decisions

Body Weight

Smoking & Alcohol Consumption

Diet & Nutritional Factors

ClinicianPrescribingPractices

ClientRace & Ethnicity

Age

Biological Sex

Frackiewicz, et., al. (1999). Review of neuroleptic dosage in different ethnic groups. In J. M. Herrera, et al.,(Eds.), Cross cultural psychiatry (Chapter 11). NY: Wiley

Client CulturalHealth Beliefs & Practices

n Cultural dietary practices may altermetabolism of medication and thusaffect medication affect andsubsequent client adherence.

(Gaw, 2001)

n 40% of HMO clients use herbs withouttheir provider’s knowledge.

(Bennett & Brown, 2000)

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Culturally Responsive Access toHealthcare for Clients

Available

Accessible Affordable

Acceptable

Appropriate

Cultural Responsive

Access

Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services. Cinti, OH: Author.

Client Recovery Processes

Client-ProviderCultural

Interactions

HealthcareSystem

Environment

Client Environmental Conditions

CulturallyCompetent

Assessment Strategies

EthnopharmacologyClient Influences

Psycho-TherapeuticInterventions

RecoveryProcesses

Hogan, M. H. (2003). Report of the President’s New Freedom Commission on Mental Health.Washington, DC: National Academy Press.

Warren, B. J. (2002). Interlocking paradigm of cultural competence. Journal of the American Psychiatric Nurses Association, 8(6), 208-213.

Cultural Assessment of ClientMedication Adherence

n Feelings about takingmedication

n Meaning of taking medicationn How others who are important

to you feel about you takingmedication

n Religious attitudes abouttaking medication

n Benefits of taking medicationn Any meaning re: color, size, or

form of medicationn Concerns of losing control

when using medication.(Gaw, 2001)

Assess client’s cultural perspectives regarding:

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Cultural Assessment of ClientMedication Adherence

• Symptoms of their disorder• Medication action and side effect profile• Influence of herbal preparations with

prescribed medication for their disorder• Daily schedule (e.g., dietary practices,

work, sleep, etc.)• Role & use of support systems (e.g.,

healthcare professionals, family,significant others)

• Through individual &/or group sessions(Colom, et al., 2003)

Provide Client Education Regarding:

Medication Adherence

n Influenced by genetic patterns,CYP2D6, specific alleles are nowbeing defined that are involved in themetabolic process.

n Influenced by dietary practicesCorn in Latina populations (slowsmedication metabolism).

Lin, K., Smith, M. W., & Mendoza, R. P. (1999). In Herrera, et al., (Eds.), Cross cultural psychiatry (pp. 45-52). New York: John Wiley & Sons.

Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.

Medication Adherence

n Influenced by use of herbalpreparations.

n Influenced by health care beliefsand practices.

Lin, K., Smith, M. W., & Mendoza, R. P. (1999). In Herrera, et al., (Eds.), Cross cultural psychiatry (pp. 45-52). New York: John Wiley & Sons.

Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.

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Biocultural Ecology

n INVOLVES:

n Pharmacogeneticsn Pharmacokineticsn Pharmacodynamicsn Biocultural Ecology:

• Skin Color and Biologic Variations• Diseases and Health Conditions• Variations in Drug Metabolism

Purnell, L., & Paulanka, P. (1998). Purnell’s model for cultural competence. In L. Purnell & P. Paulanka (Eds.).,Transcultural healthcare: A culturally competent approach (pp. 7-51). Philadelphia: Davis.

Pharmacology

n Medication Action:

• Target Effects• Unwanted SE• Toxic Effects• Adverse Effects

n Medication Mgt.:

• Prevention• Contraindication• Interactive SE

Metabolic Pathways

BREAKDOWN, DISTRIBUTION, FUNCTION

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Debrisoquine-Sparteine

n Medications metabolized through thispathway:• Antiarrhythmics• Beta-blockers• Antidepressants• Antipsychotics• Opioids

n African, Native, & Asian-Americansare more affected by their geneticvariations within this pathway.

Acetylation Pathwayn This pathway is an important factor

in the determination of the rate ofmetabolism.

n Definition of terms:• Extensive (“normal” reaction)

metabolizers• Slow (“prone to toxic reactions”)

metabolizersn Caucasian & African-Americans: 50% (slow)n Egyptians and Moroccans: 80% - 90%

(slow)n Asian-Americans: 5% - 15% (slow)

Mephenytoin

n Medications metabolized within thispathway• Antianxiety• TB• Caffeine• Cardiovascular• Tranquilizers

n Asian and European populations aremore susceptible to genetic variationswithin this pathway.

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Oxidation

n Research has identified specific CYP450isozymes involved in polymorphism.Genotyping is the current approach forDNA determining genetic variations.• 2D6: beta blockers, antipsychotics,

tricyclic antidepressantsn 7 alleles have been identified which will make

prescribing even more effective for personswith genetic variations

• There are 5 for Caucasian-Americans, 10 for Asian-Americans, and 17 for African-Americans

Oxidation

n CYP2C19: alleles 2 and 3 have beenidentified within this isozyme.• Medications: diazepam, imipramine,

citralopam, mephobarbital, omeprazole.• Poor Metabolizers include:

n India Indians, Japanese & other Asian-Americans: 15% - 21%

n Caucasian-Americans: 2% - 6%n African-Americans: 2%

Oxidation

n CYP1A2• Women have a poor metabolizer

response and this require less doses ofmedications

• Smoking effects are located here• Some carcinogens are associated with

this isozyme as well• Charbroiled meat can intensify this

response• Caffeine also affects

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Herbal Therapiesn Tricyclic

Antidepressants andAntipsychotics’actions are similarto these herbs:• Swertia Japonica• Kamikihi-to• Datura candida• Nigerian root extract• South American holly

Interlocking Paradigm of Cultural Competence

THERAPEUTICFACTOR

THEORYFACTOR

ForClinician

PROCESSFACTOR

ForClinician

WORLD-VIEWFACTOR

For Clinician &Client

Copyright B. J. Warren, 2001

Communities

World

Other Persons’World Views

ORIENTATIONFACTOR

For Clinician &Client

Process & Orientation Factors forAPRN & Client

CommunicationPatterns

Environmental& RearingOrientation

Significant Othersin the interactive

process

Health Beliefs

Education Level

Biopsychosocial Issues: Mind-body-spirit

Culturally Competent Healthcare

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Case Study(developed by Ms. Sarah Alley, RN, BSN)

n Mrs. Z is a 68 year old Japanese American who has lived alonefor the past 3-years since the death of her husband. Mrs. Z wasborn in Japan & moved to the U.S. with her husband 25 yrs ago.

n Mrs. Z is retired after working many years as a seamstress. Mrs.Z has been referred to you (PMHAPN) by her primary carephysician for evaluation after presenting with complaints ofdifficulty sleeping, frequent stomach aches & low energy.

n Physical exam & laboratory work were all WNL for the primarycare physician & your physical exam of Mrs. Z has producednormal findings as well.1.What genetic variables do you need to consider in this case?2.Think about differential diagnosis for your specialty practice.3.What referrals are needed that include other specialty APRNs? Remember you may notbe able to handle every disorder on your own, know the boundaries of your practice.Hint: APRN, PMH nurses.

Case Study, continued(developed by Ms. Sarah Alley, RN, BSN)

n Mrs. Z appears tired, her clothes are wrinkled & she has on twodifferent shoes. Mrs. Z is currently taking OTC ibuprofen formild arthritis in her hands, however, she is not taking any othermedications at this time.

n Upon further discussion with Mrs. Z, you find out that her dog of13 years passed away 3 weeks ago & her youngest daughterjust moved out of the house after graduating from college.

n Mrs. Z needs reminding of where the bathroom is after her visitwith you, although she went to the bathroom previously beforeher examination.

Perhaps a review of dementia and depression is needed.

Additional References(provided by Ms. Sarah Alley, RN, BSN)

American Psychiatric Association. (2000). Diagnostic andStatistical Manual of Mental Disorders – (DSM-IV-TR). (4th

ed.). Washington, D.C. : Author.Baker, F. M. & Bell, C. C. (1999). Issues in the Psychiatric

Treatment of African-Americans. Psychiatric Services,50 (3), 362-367.

Betchel, G.A., Davidhizar, R., Tiller, C. M. (1998). Patterns ofMental Health Care Among Mexican Americans. Journal ofPsychosocial Nursing, 36 (11), 20-23.

Haber, J., Krainovich-Miller, B., McMahon, A. L., Price-Hoskins, P.(1997). Comprehensive Psychiatric Nursing (5th ed.). St.Louis: Mosby Year-Book, Inc.

Keltner & Folks (2001). Psychotropic Drugs (3rd ed.). St. Louis:Mosby Inc.

Mohr, W.K. (1998). Cross-Ethnic Variations in the Care ofPsychiatric Patients. Journal of Psychosocial nursing, 36 (5),16-21.

Stahl, S. M. (2000). Essential PsychopharmacologyNeuroscientific Basis and Practical Applications (2nd ed.).New York: Cambridge Press

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Ethnicity and HealingEthnicity (e.g., culture) imprints every person…It bindsthose common roots and separates them from those withdifferent origins. It suffuses body and oral language, as wellas the way we take in, or distance ourselves from the worldand other people.

Ethnicity (e.g., culture) is a force in both the genesis andhealing of disease. It contributes to the uniqueness of theexperience of illness. It is the…obligation of every nurse tocomprehend and…empathize…with the cultural identityof those he or she purports to provide care for.

Pellegrino, E. (1992). Ethnicity and Healing. In M. G. Secundy, Trials, Tribulations, andCelebration: African-American Perspectives on Health, Illness, Aging, and

Loss, (p. xix). Yarmouth, ME: Intercultural Press.

COMMENTS, QUESTIONS

WORK THROUGH THE FOLLOWING CASE STUDY IN ORDER TOPRODUCE A CULTURALLY COMPETENT APRN PLAN FOR THE CLIENT:

CONTACT INFORMATION

Dr. Barbara Jones Warren614-292-4847

FAX: 614-292-4948

n E-MAIL:warren.4@osu.edu