According to a recent study in the Journal of the American Society of Nephrology (JASN), some ethnic groups can be found at the bottom, or missing, from waitlists for kidney transplants. Though the exact causes are not known, experts have a variety of theories and are working hard to address this issue.
At the University of Washington in Seattle, Yoshio Hall, M.D., and his colleagues were determined to fi nd some answers. In their study, they surveyed 503,090 non-elderly adults from different ethnic backgrounds who had started dialysis between the years of 1995 and 2006. In 2008, the researchers had some answers. Of all waitlisted patients, white non-Hispanics were 40% more likely to receive a transplant than African Americans, Hispanics, Asian Americans/Pacific Islanders, and others minorities. Also of note, the rates of deceased-donor transplantations after dialysis were lowest in American Indians/Alaska Natives (2.4%) and highest in non-Hispanic whites (5.9%) and Asians (6.4%).
Today, the reasons behind these discrepancies are still not completely clear, which highlights the need for further investigation. Some theories point to socioeconomic factors, while others suggest a lack of organ availability, or even cultural isolation.
Dr. Hall believes that more research and understanding could result in the reduction of racial, ethnic, and socioeconomic disparities for kidney transplants in the future.
In one of the first studies of its kind, researchers at the University of Michigan’s School of Public Health have illustrated how physical health outcomes within the black population vary based on environment.
The research compared two populations, African Americans and Caribbean blacks, and the varied relationships between ethnicity, nativity, depressive symptoms, and physical health in these two populations. According to the research, a Caribbean-born black person living in the United States has a higher chance of being physically healthy than an African American or a U.S.-born black person of Caribbean descent, which was the least healthy group.
The survey relied on participants’ self-ratings of their physical health, so depressive symptoms were also noted. The study also demonstrated how important linking the physical and mental areas of wellness were. In all three groups, increased depressive symptoms lead directly to predictable health outcomes.
The research also discovered the least healthy age for all groups ranged 45–59, a time when doctors expect people to be improving their health. Middle age is also when family, career, and social life typically converge, so health might be a last priority when these other obligations are more demanding.
This study gives researchers a better understanding of the health patterns within different racial groups, and how environment can have a major effect on a person’s health.
Childhood obesity is usually linked to overeating, fast food, and insufficient exercise. Now, researchers have found one more thing to add to the list. A study by the Children’s Hospital of Philadelphia has shown there are several genetic variants connected with adult obesity that are also detected in childhood obesity, including two new variants never associated with obesity before. These variants are said to increase the risk of obesity in children in the first few years of life. How these variants cause obesity is still not known, but according to the Associate Director of the Center for Applied Genomics, it is possible they affect the intestine. Childhood obesity has tripled in the United States over the past few decades, but human genetics have remained static, leading researchers to believe there are still environmental causes of obesity as well.
The researchers collected data from 14 studies conducted in the United States, Canada, Europe, and Australia. They scanned the genomes of 5,530 obese and 8,300 non-obese children. Findings displayed eight new signals of genetics associated with childhood obesity. For validation purposes, researchers studied these signals in 2,000 additional obese and 4,000 non-obese children; they found two signals associated with childhood obesity. Since it is possible for the signals to be picked up from the surrounding genes, additional research must be done in order to confirm the genes giving off the signals are actually the same genes responsible for childhood obesity. Additionally, further research could eventually lead to treatments for obese children.
For nurses treating a large number of Hispanic patients, it is an unfortunate reality that they will also encounter a large number of diabetics. Diabetes is one of the most persistent and apparent health disparities affecting Hispanic communities; they are nearly twice as likely to suffer from the disease than white non-Hispanics. Fortunately, Hispanic diabetics rarely face the fight against their disease alone, supported by strong family environments.
This study explored the impact of that family-patient dynamic among a small group of Hispanics who attend a diabetic support group meeting at First Christian Church in Marietta, Georgia. It included both diabetics and supportive non-diabetic family members.
All participants reported family as an important entity, which coincides with traditional values among Hispanic families that promote strong family ties and loyalty.1 Diabetic individuals in this study expressed their confidence toward family support, but the survey also found perceived cultural barriers to diabetes management might significantly affect adherence to following a diabetic diet. Handling social pressure and incorporating traditional foods into the diabetes meal plan are core cultural issues for many Hispanics.2
All subjects demonstrated some knowledge of diabetes and self-management, but both diabetics and non-diabetics revealed some misunderstandings regarding what causes the disease. Many participants expressed fatalistic attitudes, saying they believed that what happens in life is out of their control and in God’s hands. Fatalism (fatalismo) is frequently identified as a cultural perspective among Hispanics1 and an affecting factor in the health conditions of Hispanic patients with diabetes.3 Persons who adhere to fatalism may dismiss the idea that diabetes can be prevented or managed.
Project purpose and rationale
The purpose of this project was to better understand the beliefs, perceptions, and attitudes toward Type 2 diabetes among adult Hispanic individuals and their family members in a faith-based community and explore the impact that family members impose on a diabetic’s self-management of this disease.
To successfully manage Type 2 diabetes, individuals need to make a commitment to lifestyle changes such as healthy diet, physical activity, and preventive care in order to adhere to recommended treatment guidelines. These necessary changes can affect family members, which can circle back to the individual, as all family members are interdependent. Family plays a critical role in the health of each member,4 especially since healthy habits are often developed within the context of family.5
Current data indicates that the lifetime risk of developing Type 2 diabetes is greater for Hispanic men (54.5% risk) and Hispanic women (45.4% risk), compared to a 31.2% and a 26.7% risk among non-Hispanic white women and men, respectively.6 This alarmingly high risk rate among the Hispanic population is a public health concern, and even though evidence suggests that family psychosocial interventions can improve chronic illness outcomes, a number of authors have noted that research has so far neglected the role family plays in the management of Type 2 diabetes.7
Implementing the project
The intended sample size was 10 participants who have had Type 2 diabetes for at least one year from the WellStar Congregational Health Ministry and Kennesaw State University’s Project Initiative for Diabetes Education Advancement for Latinos (IDEAL), and one of their family members. With approval of the study from the Institutional Review Board at KSU, a student researcher collected data with support from a WellStar congregational nurse and Janice Long, Ph.D., R.N., an assistant professor of nursing at KSU and Director of Project IDEAL. In order to reach potential participants, the researchers attended diabetic support group meetings at the First Christian Church in Marietta, Georgia, and KSU Community Health Clinic MUST Ministries in September and October 2010. WellStar Congregational Health Ministry and KSU Project IDEAL facilitated the support groups for diabetic individuals and their family members.
At an August support group meeting at the First Christian Church, the WellStar congregational nurse made a verbal announcement to recruit the participants. Criteria for selection of participants were Hispanic adults 18 years or older, diagnosed with Type 2 diabetes for at least one year, and receiving family support to manage their disease. Those who met the inclusion criteria were asked to choose the family member who provided the most assistance in managing their disease (also 18 years or older) to participate in the survey as well.
Data was collected using instruments developed by the student researcher based on family support and diabetes literature, the investigator’s experience with Hispanic families with diabetes, and suggestions from nursing educators. Available to participants in English and Spanish, the surveys were the Diabetes Self-Management Questionnaire (DSMQ), Diabetes Family Support Questionnaire (DFSQ), and Demographic Profile. These three items were combined into two 43-item questionnaires, one for the diabetic and the other for the family member.
The Demographic Profile included questions on age, gender, ethnicity, country of origin, education status, income, marital status, household status, and length of stay in the United States. Diabetic specific questions included number of years with diabetes, mode of diabetic management, and health insurance. The four questions used to access acculturation level included language preference, language spoken at home, use of children as interpreters, and English-speaking ability. The 25 items for the DSMQ and DFSQ consisted of statements dealing with diabetes-related knowledge, self-management of the disease, family support behavior, perceived cultural barriers, acculturation, and depression. The student-developed questionnaires were not tested for reliability since the sample size was very small.
The last two items of the DSMQ and DFSQ were adapted from The Patient Health Questionnaire- 2 (PHQ-2) to screen for frequency of depressed mood over a two-week period. Researchers have suggested that when diabetes occurs concurrently with depression, diabetes management suffers, yet little is known about the effects of depression on diabetes self-efficacy.8
The 10–15 minute survey was translated to Spanish by a native speaker and tested on three native Spanish-speaking students from KSU. Persons completing the questionnaires were not asked for any personal identifying information. Each diabetic and family member was asked to complete a questionnaire independently during a support group meeting, while an interpreter was available for any needed translations.
The data was analyzed to calculate proportions, percentages, standard deviation, and mean. Because the sample data was small, internal consistency reliability and correlation were not deemed appropriate.
Evaluation and final project outcomes: diabetics
Eight diabetic individuals and six family members participated in the survey; not all family members were present at the support group meetings. All participants identified themselves as Hispanic, with length of time in the United States ranging from one year to 47 years. On average, diabetic patients were in their 60s, while the family members’ mean age was 47. The majority of the participants were married (71%). Only one participant lived alone; half lived with family or friends, and the rest with family or friends and children. About 86% of the participants preferred speaking Spanish, and all favored speaking it at home. The majority said they had an “average” English-speaking ability. Half of the family members had high school education or higher, while only 28.6% of the diabetic individuals had high school or additional education.
The diabetic participants had been diagnosed with diabetes for an average of almost 10 years (range: four to 21 years). Fifty percent reported they manage their diabetes with medication; slightly more than one-third controlled their diabetes with diet and exercise alone. Only one of the diabetic participants took insulin. More than half of the diabetic participants had health insurance. The diabetic participants were in agreement on most items dealing with self-management and family support behavior, and they felt family was an important entity. Furthermore, they agreed that family support is essential in motivating them to manage their diabetes. The diabetic participants reported feeling confident in their knowledge of testing blood glucose, taking diabetic medications as recommended, exercising, checking their feet, and following a diabetic meal plan. However, the diabetic individuals indicated they would feel selfish if changes in their diet and exercise patterns were different from the family’s routine.
One study shows that social support from family and friends was positively associated with testing blood glucose levels, following a diabetes meal plan, and checking feet, but was not significantly associated with other self-management behaviors.9 Nevertheless, the majority of the participants agreed that they received sufficient culturally specific education regarding a diabetic diet. (The fact that participants received such education can be associated with being a member of the diabetic support group for Hispanics at the First Christian Church.)
The majority of diabetic participants’ answers suggest that they had average knowledge of the following: normal blood glucose level, A1C goals for diabetic individuals, diabetes as a severe health problem, and the long term complications of diabetes. However, other research suggests that many Hispanic adults have limited knowledge about diabetes. Many participants also see their disease as a punishment from God (fatalismo) and feel they can do little to alter their fate, which may hinder Hispanic diabetic patients in successfully managing their disease.10 Participants’ answers about their knowledge of blood glucose levels were less confident when the diabetic individuals expressed these fatalistic beliefs.
Regarding perceived cultural barriers, the diabetic participants were mostly in agreement in suggesting that family support can also undermine individuals’ efforts to control their disease. Diabetic participants found it most difficult to stick with a diet different from their family diet; moreover, the survey depicts that their needs are secondary to the family’s needs. Fifty percent of the diabetic participants strongly agreed that their dietary restrictions conflicted with their food preferences. The majority (87.5%) of the diabetic participants were females. A Hispanic woman may be considered “self-indulgent” if she changes the family diet to support her diabetes meal plan; this negative perception could possibly contribute to poorer glycemic control.2 Another factor affecting home-based diabetic care, depression is two times more prevalent among persons with Type 2 diabetes and is more common among Hispanics than among non-Hispanics with the same condition.11 The PHQ-2 is used as the initial screening test for major depressive episodes in this study. The probability of a major depressive disorder among the diabetic individuals, on average, is 18%, and the probability of any depressive disorder, on average, is 36%. All the diabetic participants who at least identified one depressive symptom on the PHQ-2 strongly agreed that it is difficult for them to stick to a diet different from their family’s diet; these diabetic participants were all female. Eighty percent also indicated that they manage their diabetes with diet and exercise alone.
In 2004, the World Health Organization declared depression the second leading cause of disability among all health problems.12 In this study, diabetic individuals were more likely to be at risk of a depressive disorder than nondiabetic family members. This could reflect the fact that cultural barriers in management of diabetes might affect the relationship between family function and depression. The belief that Hispanic women seem “self-indulgent” when they change the family diet to support a diabetic meal plan may contribute to higher rates of depression among Hispanic women with diabetes. This is important to note since individuals with Type 2 diabetes who experience co-morbid depression manage their diabetes less effectively.12
Evaluation and final project outcomes: non-diabetics
Non-diabetic family members were in agreement on most items dealing with diabetes- related knowledge, self-management, family support behavior, and acculturation. All family members strongly agreed on these statements: family is important, they know how often their family member with diabetes checks his/her feet for wounds, and they get sufficient culturally specific education on the diabetic diet. Comfort with diabetes-related knowledge was also high. Most of the subjects said they believed that they knew normal blood glucose levels, understood that diabetes is a severe health problem, and were aware of the long-term complications of the disease. However, the knowledge level of the family members regarding A1C goals was lower, and many also held fatalistic beliefs.
Nearly every non-diabetic said they thought they knew how their diabetic family member managed his/her disease. When the non-diabetics were asked about their diabetic family member’s exercise habits, the answers were slightly less confident. The survey also indicated that most non-diabetic family members strongly agree that they are supportive in managing diabetes. Nevertheless, 40% of family members said diabetes had changed their relationships with their families.
Regarding non-diabetic family members’ perceptions of cultural barriers, 60% indicated that the dietary restrictions of their diabetic family member conflicted with their food preference. One corroborating study shows that family members can be confused and frustrated when trying to modify a typical Hispanic diet.2 Based on the PHQ-2, the probability of a major depressive disorder among family members is, on average, about 8%, and the probability of any depressive disorder is, on average, 15%.
Implementing project findings
On a local level, these research findings will be shared with support group leaders to examine and improve the current services offered to diabetic individuals and their family members by WellStar Congregational Health Ministry and Kennesaw State University’s Project IDEAL.
In a greater health care context, cultural and familial roles can either strengthen or undermine individuals’ efforts to control their diabetes. Factors affecting attitudes and behaviors toward self-management of diabetes, in this study, are rooted in Hispanic culture, such as fatalism (fatalismo) and traditional diet. Fatalism among Hispanics may require innovative program intervention, education, and motivation strategies for successful self-management of diabetes.
Nurses in faith-based community settings may need to assess for spiritual health to identify beliefs that can play a role in either preventing disease or identifying individuals that may be victims of their own beliefs. Community faith-based diabetic support groups can negotiate cultural barriers to achieve empowerment and feelings of self-efficacy.
Participants can be encouraged with alternative methods of preparing traditional Hispanic meals, modifying their typical diet, and involving both diabetic individuals and their family members in the transition. It is also important to note the link between depression and diabetic management, which demonstrates that depression and thus ineffective diabetic self-management can be prevented. Ultimately, patient- and family-centered culturally competent diabetes programs can enable Hispanic diabetics to make beneficial lifestyle changes.
References
Garcia, F. C. (1995). “Mexican American Values in the American Southwest.” Southwest Hispanic Research Institute. Working Paper Series. Albuquerque, New Mexico: University of New Mexico.
Early, K., Shultz, J., and Corbett, C. (2009). “Assessing Diabetes Dietary Goals and Self-Management Based on In-Depth Interviews with Latino and Caucasian Clients with Type 2 Diabetes.” Journal of Transcultural Nursing, 20, 371-381.
Caban, A., and Walker, E. A. (2006). “A Systematic Review of Research on Culturally Relevant Issues for Hispanics with Diabetes.” The Diabetes Educator, 32(4), 584–595. Retrieved from http://tde.sagepub.com.
Allender, J., Rector, C., and Warner, K. (2010). Community Health Nursing: Promoting and Protecting the Public Health, Philadelphia, PA: Lippincott Williams & Wilkins.
Campbell, T. L. (2006). “Improving Health Through Family Interventions.” Handbook of Families & Health: Interdisciplinary Perspectives (D. R. Crane and E. S. Marshall, eds), Thousand Oaks, CA: Sage Publications. 379–395.
Centers for Disease Control and Prevention. (2010). “Prevalence of Diabetes Among Hispanics in Six U.S. Geographic Locations.” Retrieved from http://www.cdc.gov/diabetes/pubs/factsheets/hispanic.htm.
Keogh, K., White, P., Smith, S., McGilloway, S., O’Dowd, T., and Gibney, J. (2007). “Changing Illness Perceptions in Patients with Poorly Controlled Type 2 Diabetes, a Randomized Controlled Trial of a Family-Based Intervention: Protocol and Pilot Study.” BMC Family Practice, 8, 36–10.
Coffman, M. (2008). “Effects of Tangible Social Support and Depression on Diabetes Self- Efficacy.” Journal of Gerontological Nursing, 34(4), 32–39. Retrieved from http://www.slackinc.com.
Rosland, A., Kieffer, E., Israel, B., Cofield, M., Palmisano, G., Sinco, B., et al. (2008). “When is Social Support Important? The Association of Family Support and Professional Support with Specific Diabetes Self-Management Behaviors.” Journal of General Internal Medicine, 23(12), 1992–1999.
Campos, C. (2007). “Addressing Cultural Barriers to the Successful Use of Insulin in Hispanics with Type 2 Diabetes.” Southern Medical Journal, 100(8), 812–520. Retrieved from www.sma.org.
World Health Organization. (2004). “WHO Initiative on Depression in Public Health.”
Fortmann, A. L., Gallo, L. C., Walker, C., and Philis-Tsimikas, A. (2010). “Support for Disease Management, Depression, Self-Care, and Clinical Indicators Among Hispanics with Type 2 Diabetes in San Diego County, United States of America.” Journal of Public Health, 28(3), 230–4. Retrieved from http://www.springer.com/medicine/health+informatics?SGWID=0-10062-0-0-0.
Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., et al. (2010). “Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population.” Annals of Family Medicine, 8(4), 348–353.
Miranda, A., Bilot, J., Peluso, P., Berman, K., and Van Meek, L. (2006). “Latino Families: The Relevance of the Connection Among Acculturation, Family Dynamics, and Health for Family Counseling Research and Practice.” Family Journal, 14(3), 268–273.
Snyder, L. (2008). “Insights for Creating Culturally Competent Health Care Programs in the Latino Community.” Diversity Factor, 16(1), 35-41. Retrieved from http://diversityfactor.rutgers.edu
Smokowski, P., Rose, R., and Bacallao, M. (2008). “Acculturation and Latino Family Processes: How Cultural Involvement, Biculturalism, and Acculturation Gaps Influence Family Dynamics.” Family Relations, 57(3), 295-308.
Nurses can play a key role in incorporating ethnopharmacology into everyday health care practice. Yet many nurses still know little to nothing about this emerging field of science.
Josepha Campinha-Bacote, PhD, MAR, APRN-BC, CNS, CTN, FAAN, the president and founder of Transcultural C.A.R.E. Associates in Cincinnati, is one of nursing’s leading authorities on ethnopharmacology. Yet 15 years ago, she says, she had never heard the term; a patient brought it to her attention.
Today, Campinha-Bacote, who has given more than 1,000 presentations on transcultural health care issues, always includes ethnopharmacology–also known as ethnic pharmacology, cross-cultural pharmacology, transcultural pharmacology and interethnic pharmacology–in her lectures.
“When I do [a presentation to] an audience of 500 to 600 and ask how many people have heard of ethnic pharmacology, only one or two say they know about it,” she says. Often the term is simply defined as the correlation between race/ethnicity and how a person’s body metabolizes medications. But that connection is just one small aspect of this growing field. Ethnopharmacology does deal with how physiological and genetic differences between racial and ethnic groups impact the effectiveness of pharmacological products. However, it also looks at how people’s cultural beliefs about their health have an impact on the medications they use and how they use them, as well as how racial bias and cultural attitudes affect the development and prescribing of certain drugs.
“I define ethnic pharmacology as the field of study that investigates the impact that culture, environment, genetics, biophysiology and psychosocial factors have on the prescribing, metabolism of and response to medications,” says Campinha-Bacote, who has also written extensively on the topic. Her most recent article, “A Culturally Conscious Model for Addressing Racial and Ethnic Disparities in Ethnopharmacology,” was just published in September’s issue of the Journal of Psychosocial Nursing and Mental Health Services.
Cora Muñoz, PhD, RN, a professor at Capital University School of Nursing in Columbus, Ohio, and Cheryl Hilgenberg, EdD, RN, CTN, a professor of nursing at Millikin University in Decatur, Ill., have also co-authored a paper on this topic. Their article, “Ethnopharmacology: Understanding How Ethnicity Can Affect Drug Response Is Essential to Providing Culturally Competent Care,” was published in the August 2005 issue of the American Journal of Nursing (AJN).
“The takeaway message is that all health care practitioners need to understand that [certain] medications are absorbed and metabolized differently by people of color,” Muñoz says. “This is supported by research in the past 15 years on some of the drugs, particularly the hypertension and psychotropic ones.”
The other key message, says Hilgenberg, is that health care practitioners must realize the necessity of doing a cultural assessment for every patient. “That [assessment should] take into consideration [the patient’s cultural] values and practices [and how they influence the effectiveness] of all our treatment [paths], not just medications.”
Genetics Makes a Difference
Even though the findings of the Human Genome Project show that all human beings are about 99% the same genetically, race and ethnicity do play a role in how a person’s body absorbs and metabolizes certain medications. But this impact isn’t always known, because most drugs are tested primarily on Caucasian males. For decades, racial/ethnic minorities and women have been excluded, or severely underrepresented, in clinical trials for new medicines.
Where to Learn What You Need to Know The following Internet resources are good starting points for learning more about ethnopharmacology:Transcultural C.A.R.E. Associates www.transculturalcare.net Dr. Josepha Campinha-Bacote’s Web site provides a wide range of information on many aspects of transcultural health care and cultural competence, including ethnic pharmacology. Scroll down to “Resources/Links” and click on “Ethnic & Ethno Pharmacology” to find an extensive list of articles, books, Web links and other resources. National Center for Complementary and Alternative Medicine http://nccam.nih.gov NCCAM, part of the National Institutes of Health, is a good resource for learning about herbal remedies, clinical trials underway and research grants. The 2005 AJN article “Ethnopharmacology: Understanding How Ethnicity Can Affect Drug Response Is Essential to Providing Culturally Competent Care” by Dr. Cora Muñoz and Dr. Cheryl Hilgenberg, is available online at www.nursingcenter.com/prodev/ce_article.asp?tid=595449.
As a result, Campinha-Bacote says, “All of these side effects and indications are ‘normed’ mainly on the white population. So you can imagine why there are going to be all these other side effects on different [minority] populations, because [the drug] hasn’t been tested [on them].”
Barbara Jones Warren, PhD, PMH-APRN, BC, an associate clinical professor at the Ohio State University College of Nursing in Columbus and executive nurse for the Ohio Department of Mental Health, explains that a person’s “genetic loading” is the key. “If you are talking abut individuals, no one–unless you get a genetic profile–knows what his or her genetic loading is. Based upon genetic loading, for the most part we are 99.9% alike genetically. It is that one-tenth that makes the difference and causes individuals to react differently to medications. While it doesn’t sound like much, that tenth of a percent .”
For example, says Warren, who is of African American and Native American descent, “Certainly I react differently to meds based on the genetic loading from both of [those two ethnicities].”
These small but crucial genetic differences can also have an effect on how a minority patient’s body reacts to the often-substituted generic forms of prescription drugs. Campinha-Bacote believes this is a factor that many clinicians do not take into account when prescribing medications.
The problem is that primary care providers often prescribe the trade name medication, but a pharmacist may fill the prescription with its generic form. Generic brands have “fillers” in them, Campinha-Bacote explains, which can change the effectiveness of the medication for some groups of people.
“While up to 80% or 90% [of what’s in the generic brand] is the drug, [there can also be] fillers in it. One of the fillers that is lactose,” she says. “Certain ethnic groups, specifically Hispanics and African Americans, are lactose intolerant. So you can see [why a patient] might say, ‘I do well on Motrin but not Advil.’ The average doctor or nurse might say, ‘They are the same–they are both ibuprofen.’ But for some people the trade name drug works more effectively.”
Physicians may also give patients samples of brand name medications. “And if it works, then they go to the pharmacy and get the generic form,” Campinha-Bacote says. “Then they go back to the doctor or nurse [practitioner]’s office because they are not doing well on the medication and you wonder why. It is because they were switched from a trade to a generic form of the drug.”
The Role of Culture
Culture plays a major role in shaping people’s health beliefs and practices, including their attitudes about taking medicine. This, in turn, can have an impact on a patient’s adherence to a prescribed medication regime.
“You have to look at the cultural beliefs and values and then the whole connection to pharmacology,” Warren says. “That is just as important [as race and ethnicity]–what are the cultural beliefs that [influence] why people take a medication or why they don’t.”
Muñoz agrees, adding that “dietary factors and environmental factors [also play a role]. There are multiple factors [involved].”
Still another consideration is the emergence of new immigrant populations whose cultures are unfamiliar to American health care professionals. “For example, in Columbus we have an increasing number of people from Somalia and other African countries,” Muñoz says.
Since nurses are on the front lines of patient care, they are uniquely positioned to gather and assess this essential cultural information. “[Nurses need to know how to] include questions in their cultural assessment that will elicit responses that will give them cultural data,” Muñoz comments. “If [cultural considerations] are not included in the questions they ask the patients, generally [the patients will not volunteer that kind of information].”
When conducting a cultural assessment, how the nurse phrases the questions can be critical. “[One] culturally sensitive technique is to frame questions in the context of other patients or family members,” says Campinha-Bacote. “For example, a nurse can say, ‘I know another patient who thinks that they will lose control if they take a psychiatric drug. Do you think that?’ or ‘What does your mother think of taking medication?’ Attributing explanations to another person can help patients disclose health beliefs and practices that they may initially feel uncomfortable expressing.”
Knowing how to ask the right kind of questions can ultimately affect how well a medication is able to help a patient. “They might not tell you about the side effects,” Campinha-Bacote notes, “and then you keep increasing the dose and that can be a problem.”
The cultural assessment should also seek information about the patient’s use of traditional medicines, such as herbal remedies, to treat their illness. In some cases, these herbal medications can interact negatively with a physician-prescribed pharmaceutical, causing adverse effects.
Muñoz says patients may not readily tell their physician that they are taking these traditional remedies, for several reasons. For example, they may not offer the information because they are not asked about it directly, or they may simply be embarrassed to discuss it with a physician who is not familiar with their culture.
A clinician’s beliefs and biases about a racial, ethnic or cultural group can also influence how medication is prescribed and therefore, how effective it is for a patient. Campinha-Bacote points to a study that looked at how psychotropic drugs were prescribed to European American versus African American teenagers.
Both groups of teens were tested and had the same “psychotic score.” Yet, even though all of the adolescents had severe mental illness, the black youths were more likely to be prescribed psychotropic medications than the white youths.
“Even when you have two identical groups with the same level of psychotic symptoms, the psychiatrists perceived African American adolescents to be more aggressive and more psychotic, so they prescribed the antipsychotic [drugs] more often,” Campinha-Bacote explains. “Biases and the skills in how you assess different cultural groups can affect the prescribing of medication.”
Expanding the Research
Ethnopharmacology is still a new and evolving science. In recent years a growing amount of research on the topic has emerged and more studies are being added as awareness continues to increase.
“[Some] practitioners [still] seem to think that since medications go through clinical trials they should be effective for all people in the same way. That is a myth; they are not,” Muñoz says. “The clinical trials [have been] primarily [conducted] on the white population, mostly men, and [the results are] generalized to women and minorities.” But now, she continues, researchers across the health care spectrum are realizing that this approach “is not appropriate anymore. Fortunately, [more pharmaceutical companies] are recruiting minorities into their clinical trial studies, so we should be able to find out whether or not medications are effective across the board.”
Over the last five to six years there has been a lot research focusing on metabolic issues in individuals across cultural groups, according to Warren. Much of this work, she adds, is being done by multidisciplinary teams of researchers, including nurses. And that means culturally sensitive minority nurse scientists can make particularly important contributions.
Barbara Jones Warren PhD, PMH-APRN, BC
“I think when [researchers] are working in groups and are looking at whatever the phenomenon is, they certainly [need] to look [at cultural issues] to see if people are reacting differently. There are a lot of clinical trials where nurses are the project managers, so that is an excellent opportunity to bring [those issues] up,” she explains. “[Nurses] need to say, ‘We have to make sure that we get enough [minority] individuals in the study to be able to really look across the [cultural] groups and see what are the similarities and what are the differences.’”
Clinical trials also need to be specific in how they categorize people, says Hilgenberg. “It is important to realize that even in the U.S. Census we tend to divide people into these huge groups–Asian, Hispanic, black and white–but there are great variations even within those groups,” she points out. For example, within the “Hispanic” category, “Puerto Ricans might [have different cultural issues] and respond differently [to a drug] than Mexican Americans or South American Hispanic people. We need to be more precise in how we really describe ethnicity.”
Every person is different, Hilgenberg stresses. “But I think [this kind of] research alerts you to different health care risks and needs in patients [from different ethnic groups] and [the need] to be more tuned in to those differences [when you are doing] your assessments.”
As the American population becomes increasingly diverse, patients do not want to all be treated alike, she adds. “They want their values and practices respected, which might not be those of the nurse or the patient next to them. The whole idea of continually individualized care, and taking into account the cultural aspect, has become more and more important.”
The Nurse’s Role
Since nurses are responsible for monitoring the effectiveness, side effects and adverse effects of medications on patients, they can play a key part in bringing the science of ethnopharmacology forward. Muñoz underscores that nurses have a very important role as patient advocates, which makes them natural candidates to use this science in their practice.
“The nurse can assume the role of advocating with the physician as far as what medications might be most effective for the patient, knowing the patient’s cultural and ethnic background,” she says. “The physicians prescribe, but they are not there 24/7 to see if there is a positive or negative clinical response. It’s the nurse’s job to [monitor that information] and report it to the physician.”
How can nurses learn more about ethnopharmacology? Campinha-Bacote, whose Web site has a whole section devoted to the subject (see sidebar), says there are enough lay articles available in the literature for nurses to familiarize themselves with the basics. In fact, she adds, there is no reason today to be uneducated about this topic. “Just read a little bit,” she advises. “I suggest journals such as the AJN, which have easy articles [to understand] and other journals for student nurses and staff nurses.” Just because the average staff RN doesn’t have prescriptive authority, that doesn’t mean he or she doesn’t need to be knowledgeable about the cultural aspects of pharmacology, Campinha-Bacote maintains. “You cannot say, ‘I am not prescribing it, [so I don’t need to know],’ because you are [administering] it. And if there is a lawsuit and you are the one who gave [the medication to the patient], then you can be sued too.”
Muñoz believes nursing students at both the undergraduate and graduate level should be learning about ethnopharmacology while in nursing school. “That training gives them a good foundation,” she says. “When they are in practice there is also a need for continual training, because it is not possible to know everything about the values and practices of all cultures.”
To be culturally competent is an ongoing process, Muñoz concludes. “Hopefully new graduates [will] have the foundation in their curriculum,” she says. “And when they are [practicing nurses], hospitals will hopefully continue to provide this training, not only for [their nursing staff] but for all people who are involved in health care service.”
