Transcript Ethnopharmacology: Cultural Issues & Genetic Influences

*Ethnopharmacology:
Cultural Issues & Genetic Influences
Dr. Barbara Jones Warren,
PhD, APRN, BC
*Please note that this is the intellectual property of the author
and material is not to be copied, duplicated, or used without
permission of the author. Thank you.
Objectives
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Examine issues of culture and
genetics as they relate to care of
persons by advanced practice
nurses.
Describe issues of culture as they
relate to advanced clinical
interviewing & assessment
techniques.
Let’s Talk About Definitions
Office of the Surgeon General. (2001). Mental health: Culture, race, &
ethnicity. Rockville, MD: DHHS.
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Culture: norms, values, and beliefs
that provide meaning for an
individual, group, or community’s
life.
Ethnicity: common heritage shared
by a particular group.
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Race: often thought of as genetic
determinants within an individual’s
biological make-up. However, the
most Surgeon General states,
“Different cultures classify people
into racial groups according to a set
of characteristics that are socially
significant. In fact, there is research
that indicates there are greater
genetic variations within a racial
group than across racial groups.”
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Health: “word symbol” that provides
forward movement of the personality and
other ongoing human processes which
leads to creative, constructive, productive,
personal, & community living.
Environment: physiological,
psychological, and social fluidity for the
client and APRN.
Ethnopharmacology: the study of
pharmacologic responses for persons from
different 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.
Current State of the Knowledge
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There are biological basis for
variations or differences in metabolic
response to agents.
• Genetics and polymorphism in drug
metabolism
• Multiple disease states
• Drug to drug interactions
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Environmental
• Diet, smoking, pregnancy, stress,
diurnal rhythms
Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting,
Cultural Issues in Mental Health: Part I, II.
Current State of the Knowledge
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Cultural
• Attitudes, beliefs, family influences and
therapy expectations.
• Genetic responses are variant and may
cause higher response & higher risk for
more intense negative side effects. This
is where cultural competence and
physiology 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
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Genetics and polymorphism in drug
metabolism
• Specific DNA regions on various
chromosomes influence hepatic
metabolism
• Polymorphism: defined at least 2 distinct
groups
Warren, B. J. & Jann, M. W. (2003). Presentation @ Sharing Our Skills Meeting,
Cultural Issues in Mental Health: Part I, II.
Biological Basis for Differences
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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 for
Clients and FNPs
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This process includes:
• Behavioral Perspective
• Individual Perspective
• Self or Outside Perspective
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All are related to biopsychosocial
components within persons.
Value
Relationship
Cultural
Interview
Appreciation
Cultural
Variations
Cultural Competence
Process of knowing, appreciating, & valuing
cultural differences and variations while
incorporating such into your area of nursing
expertise as well as in your relationships and
interactions with others.
Warren, B. J. (2003). Cultural and ethnic considerations. In D. Antai-Otong, Psychiatric nursing:
Biological & behavioral concepts, (pp. 151-165). NJ: Thomson Delmar Learning.
Interpersonal Relationship
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Critical to development of a successful
cultural clinical interview process.
Involves the client & MH provider’s cultural
perspectives re: healthcare practices,
beliefs, and importance of the environment.
This provides a unique experience,
development of expectations and pattern of
interactions.
The APRN guides the:
• Significant, therapeutic, interpersonal process
• Forward movement of personalities involved in
the relationship
Cultural Perspectives within the
APRN Care Process
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World Views
THINKING
INTERACTING
World Views:
represents what a person values &
how they function
ANALYTIC
ECOLOGICAL
Clinical Interviewing
RELATIONAL
COMMUNITY
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.
World Views
represents 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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Involves the preservation of the
client’s culture in a recovery-based
context.
Utilizes negotiation to develop and
extend the healthcare process and
provide evidence-based holistic
health care for the client.
Utilizes critical thinking regarding
cultural competence in order to
repattern the client’s approach to
addressing their health needs and
symptom management.
Dr. Madeline Leininger, 1995
Interviewing Strategies
• Holistic Perspective
• Mental Health &
Wellness
• Spiritual Connection
• Physiological
Components
Culture – Focused Interview
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Focuses on the
interpersonal
dynamic process
in order to help
the client define
his or her
symptoms,
needs.
Culturally Competent
Healthcare Issues
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Genetic and ethnic influences.
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Cultural health beliefs and practices.
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Environmental variables (living,
rearing, persons around a client).
Culturally Competent
Healthcare Issues [Cont.]
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Healthcare professionals’ cultural
perspectives and cultural competence
knowledge.
Client & others’ perspective & knowledge
of cultural processes.
Cultural Interview Guidelines
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LISTEN to the client.
EXPLAIN your
perception of what the
client said.
ACKNOWLEDGE the
importance of the
client’s cultural
perspectives.
RECOMMENDATIONS
are made according to
the APRNs expertise
and the client’s cultural
health needs.
NEGOTIATE to obtain
successful, culturally
competent healthcare.
Berlin & Fowkes, 1982
Cultural Interviewing Suggestions
Assess client’s cultural perspectives regarding:
*WHAT THEY NEED FROM YOU?
Meaning of wellness &
distress.
 How s/he describe the
symptoms of current distress.
 Feelings about seeking
healthcare, issues of stigma.
 How others who are
important to the client feel
about s/he seeking help for
illness/ distress.
 Cultural practices for treating
illness/ distress.
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(Gaw, 2001)
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
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Negotiation is the
key for successful
evidence-based
holistic healthcare
interviewing,
assessment,
treatment &
follow-up!
Cultural Interviewing
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Interface of biological, psychological,
and social theoretical evidence-based
therapeutic foci into a highly
specialized approach to client care.
The focus is on the interaction and
relationship in order to obtain accurate
client assessment data.
Cultural Client Interviewing
Involves the interpersonal processes between you,
the client, and others important for both of you!
Communication
Significant Others
Health Beliefs
Education
Orientation
Biopsychosocial Issues: Mind-body-spirit
Healthcare Professional’s Cultural
Perspective
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Disparities in mental healthcare may be
influenced by societal and provider
perspectives as they relate to racially
and ethnically diverse persons.
Institute of Medicine, Committee on Understanding and
Eliminating Racial and Ethnic Disparities in Healthcare. (2002).
Unequal treatment: Confronting racial and ethnic disparities in
healthcare. 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: National
Academy Press.
Biopsychosocial Issues &
Medication Adherence
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Genetic and ethnicity influences
Cultural health beliefs and practices
Environmental variables
Healthcare professionals’ cultural
perspectives
Client’s perspective of recovery process
OUTCOME  Treatment/action plan for
client.
Cultural Influences on
Dosing Decisions
Biological
Sex
Body Weight
Smoking &
Alcohol Consumption
Age
Diet & Nutritional
Factors
Clinician
Prescribing
Practices
Client
Race & Ethnicity
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 Cultural
Health Beliefs & Practices
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Cultural dietary practices may alter
metabolism of medication and thus
affect medication affect and
subsequent client adherence.
(Gaw, 2001)
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40% of HMO clients use herbs without
their provider’s knowledge.
(Bennett & Brown, 2000)
Culturally Responsive Access to
Healthcare for Clients
Appropriate
Available
Acceptable
Cultural
Responsive
Access
Accessible
Affordable
Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services.
Cinti, OH: Author.
Client Recovery Processes
Ethnopharmacology
Client Influences
Client-Provider
Cultural
Interactions
Psycho-Therapeutic
Interventions
Recovery
Processes
Client Environmental
Conditions
Healthcare
System
Environment
Culturally
Competent
Assessment Strategies
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 Client
Medication Adherence
Assess client’s cultural perspectives regarding:
Feelings about taking
medication
 Meaning of taking medication
 How others who are important
to you feel about you taking
medication
 Religious attitudes about
taking medication
 Benefits of taking medication
 Any meaning re: color, size, or
form of medication
 Concerns of losing control
when using medication.
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(Gaw, 2001)
Cultural Assessment of Client
Medication Adherence
Provide Client Education Regarding:
• 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)
Medication Adherence
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Influenced by genetic patterns,
CYP2D6, specific alleles are now
being defined that are involved in the
metabolic process.
Influenced by dietary practices
Corn in Latina populations (slows
medication metabolism).
Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.
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.
Medication Adherence
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Influenced by use of herbal
preparations.
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Influenced by health care beliefs
and practices.
Herrera, et al., (1999). Cross cultural psychiatry. New York: John Wiley & Sons.
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.
Biocultural Ecology
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INVOLVES:
Pharmacogenetics
Pharmacokinetics
Pharmacodynamics
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
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Medication Action:
• Target Effects
• Unwanted SE
• Toxic Effects
• Adverse Effects
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Medication Mgt.:
• Prevention
• Contraindication
• Interactive SE
Metabolic Pathways
BREAKDOWN, DISTRIBUTION, FUNCTION
Debrisoquine-Sparteine
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Medications metabolized through this
pathway:
• Antiarrhythmics
• Beta-blockers
• Antidepressants
• Antipsychotics
• Opioids
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African, Native, & Asian-Americans
are more affected by their genetic
variations within this pathway.
Acetylation Pathway
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This pathway is an important factor
in the determination of the rate of
metabolism.
Definition of terms:
• Extensive (“normal” reaction)
metabolizers
• Slow (“prone to toxic reactions”)
metabolizers
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Caucasian & African-Americans: 50% (slow)
Egyptians and Moroccans: 80% - 90%
(slow)
Asian-Americans: 5% - 15% (slow)
Mephenytoin
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Medications metabolized within this
pathway
• Antianxiety
• TB
• Caffeine
• Cardiovascular
• Tranquilizers
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Asian and European populations are
more susceptible to genetic variations
within this pathway.
Oxidation
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Research has identified specific CYP450
isozymes involved in polymorphism.
Genotyping is the current approach for
DNA determining genetic variations.
• 2D6: beta blockers, antipsychotics,
tricyclic antidepressants
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7 alleles have been identified which will make
prescribing even more effective for persons
with genetic variations
• There are 5 for Caucasian-Americans, 10 for AsianAmericans, and 17 for African-Americans
Oxidation
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CYP2C19: alleles 2 and 3 have been
identified within this isozyme.
• Medications: diazepam, imipramine,
citralopam, mephobarbital, omeprazole.
• Poor Metabolizers include:
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India Indians, Japanese & other AsianAmericans: 15% - 21%
Caucasian-Americans: 2% - 6%
African-Americans: 2%
Oxidation
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CYP1A2
• Women have a poor metabolizer
response and this require less doses of
medications
• Smoking effects are located here
• Some carcinogens are associated with
this isozyme as well
• Charbroiled meat can intensify this
response
• Caffeine also affects
Herbal Therapies
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Tricyclic
Antidepressants and
Antipsychotics’
actions are similar
to these herbs:
• Swertia Japonica
• Kamikihi-to
• Datura candida
• Nigerian root extract
• South American holly
Interlocking Paradigm of Cultural Competence
Other Persons’
World Views
Communities
THEORY
FACTOR
For
Clinician
WORLD-VIEW
FACTOR
For Clinician &
Client
World
THERAPEUTIC
ORIENTATION
FACTOR
FACTOR
For Clinician &
Client
PROCESS
FACTOR
For
Clinician
Copyright B. J. Warren, 2001
Process & Orientation Factors for
APRN & Client
Biopsychosocial Issues: Mind-body-spirit
Communication
Patterns
Significant Others
in the interactive
process
Environmental
& Rearing
Orientation
Education Level
Health Beliefs
Culturally Competent Healthcare
Case Study
(developed by Ms. Sarah Alley, RN, BSN)
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Mrs. Z is a 68 year old Japanese American who has lived alone
for the past 3-years since the death of her husband. Mrs. Z was
born in Japan & moved to the U.S. with her husband 25 yrs ago.
Mrs. Z is retired after working many years as a seamstress. Mrs.
Z has been referred to you (PMHAPN) by her primary care
physician for evaluation after presenting with complaints of
difficulty sleeping, frequent stomach aches & low energy.
Physical exam & laboratory work were all WNL for the primary
care physician & your physical exam of Mrs. Z has produced
normal 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 not
be 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)
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Mrs. Z appears tired, her clothes are wrinkled & she has on two
different shoes. Mrs. Z is currently taking OTC ibuprofen for
mild arthritis in her hands, however, she is not taking any other
medications at this time.
Upon further discussion with Mrs. Z, you find out that her dog of
13 years passed away 3 weeks ago & her youngest daughter
just moved out of the house after graduating from college.
Mrs. Z needs reminding of where the bathroom is after her visit
with you, although she went to the bathroom previously before
her examination.
Perhaps a review of dementia and depression is needed.
Additional References
(provided by Ms. Sarah Alley, RN, BSN)
American Psychiatric Association. (2000). Diagnostic and
Statistical 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 of
Mental Health Care Among Mexican Americans. Journal of
Psychosocial 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 of
Psychiatric Patients. Journal of Psychosocial nursing, 36 (5),
16-21.
Stahl, S. M. (2000). Essential Psychopharmacology
Neuroscientific Basis and Practical Applications (2nd ed.).
New York: Cambridge Press
Ethnicity and Healing
Ethnicity (e.g., culture) imprints every person…It binds
those common roots and separates them from those with
different origins. It suffuses body and oral language, as well
as the way we take in, or distance ourselves from the world
and other people.
Ethnicity (e.g., culture) is a force in both the genesis and
healing of disease. It contributes to the uniqueness of the
experience of illness. It is the…obligation of every nurse to
comprehend and…empathize…with the cultural identity
of those he or she purports to provide care for.
Pellegrino, E. (1992). Ethnicity and Healing. In M. G. Secundy, Trials, Tribulations, and
Celebration: 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 TO
PRODUCE A CULTURALLY COMPETENT APRN PLAN FOR THE CLIENT:
CONTACT INFORMATION
Dr. Barbara Jones Warren
614-292-4847
FAX: 614-292-4948
E-MAIL:
[email protected]
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