Genetic, Psychosocial, and Cultural Influences

Assessing for variations in responseHealth perception-health management Nutritional-metabolic EliminationActivity-exerciseCognitive-perceptualSleep-restSelf-perceptionRole-relationshipSexuality-reproductiveCoping-stress toleranceValue-belief

Health perception – health managementAttitudes toward health (compliance)Alcohol, drugs / tobaccoAccess to care, insuranceUse of alternative therapies (cultural, spiritual)Explanatory models of illness / goals of treatment

Nutritional – metabolicGenetic differences in metabolismFat to muscle ratio (age, gender)Food-drug interactions

EliminationRenal and hepatic function

Cognitive – perceptualAbility to understandVisual acuity

Genetic variationsINH

Toxic in certain Caucasian Americans (slow metabolizers)

Beta-blockersIneffective in some African Americans

CodeineIneffective in some Asian Americans (not

converted to morphine)Coumadin

Toxic in certain Asian and African Americans

Things to watch for

PharmacogeneticsIndividual variation in response to drug

therapy.This variation is related to genetic alterations

known as polymorphisms.Some pharmacogenetic differences are

inherited along ethnic or racial lines.Other differences are unique to people and

not inherited. Genotype testing is now available for some

CYP450 enzymes.

PharmacogeneticsBut genetics isn’t the only factor. In a United

Kingdom study with DMARDs (disease-modifying anti-rheumatic drugs) in Southeast Asian immigrants, they were found to discontinue the drugs more often than Northern Europeans.

Communication and cultural differences in response to chronic disease may be as important as genetic response to the drugs. Reference: http://rheumatology.oxfordjournals.org/cgi/content/full/42/10/1197

EthnopharmacologyAnother name for another way to examine

differences in response to drug therapy.The difficulty lies in identifying the genetic,

cultural, racial and ethnic factors behind variations in response.

“Historically, most drug trials have been conducted using white men; the results have then been generalized to all patients receiving the drugs studied.”

http://employment.thresholds.org/pdf/Munoz_Hilgenberg_Paper.pdf

In a British study, 835 women who regularly used analgesics for headache were randomly assigned to one of four groups (43). One group received aspirin labeled with a widely advertised brand name. The other groups received the same aspirin in a plain package, placebo marked with the same widely

advertised brand name, or unmarked placebo.Branded aspirin worked better than unbranded

aspirin, which worked better than branded placebo, which worked better than unbranded placebo.

http://www.annals.org/cgi/content/full/136/6/471

An example: placebo effect

Interesting example…. The beta-blocker propranolol is more effective in

reducing blood pressure and heart rate in Chinese than in Whites.

Paradoxically, the Chinese subjects metabolized propranolol much more rapidly than the White subjects

Pharmacokinetic properties, therefore, do not explain the increased sensitivity of the Chinese

The mechanism for the increased sensitivity is not clearly determined, but could be because of a greater suppression of renin in the Chinese population

http://cobb.nmanet.org/images/uploads/Racial_and_Ethnic_Differences_in_Response_to_Medicine.pdf p.18

Another example…..There are general differences in the

pathophysiology of hypertension between Black and White populations.

Black hypertensives exhibit enhanced sodium retention, a higher incidence of salt-sensitive hypertension, expanded blood volume, more frequent proteinuria, and a higher prevalence of low blood renin activity

These factors may underlie some of the observed differences in the effectiveness of various antihypertensive drugs in Black populations. p.18

The spirit catches you and you fall down: a Hmong child, her American doctors and the collision of two cultures by Anne Fadiman (1997)

http://en.wikipedia.org/wiki/The_Spirit_Catches_You_and_You_Fall_Down

But what about culture?

Another culture….Barefoot doctors of China Their purpose was to bring health care to

rural areas where urban-trained doctors would not settle.

They promoted basic hygiene, preventive health care, and family planning and treated common illnesses

Mao Zedong’s famous healthcare speech in 1965 institutionalized these rural healthcare workers.

http://en.wikipedia.org/wiki/Barefoot_doctor

What about other cultures?America is a “melting pot” of cultures, yet…Often these cultures don’t “blend” but rather

retain some elements of their differences.But what is a culture? Is there Hispanic

culture? Are Africans the same as African-Americans?

Are their similarities and differences the result of genetics? Or culture? Or both?

Questions? Comments?