1. Cultural diversity and Medication Safety

2. Agenda – 9/25/07 Article presentations
Narayanasamy (2003) - Gina
de Chesnay, Ch. 8 - Gina
Chesnay, Ch Gina
Leininger (1993).- Susie
Salimbene, S. (1999) – Susie
Wheeler (2004) – Susie
Cultural diversity and medication safety

3. Assumptions
Ethnic culture affects beliefs about health, illness, medications, interactions with healthcare providers, & comply with prescribed med. as well as response physiologically to med.
Culturally competent care involves knowledge not only of pt’s beliefs and values about health care and illness, but also of their responses to treatment

4. Beliefs about health, illness, medications
White
Intolerance to pain
High expectation to be cured or well managed through technology, powerful drugs
Management of microbes > bolster resistance to them
Asians
Drug’s safety profile > its effectiveness
Use lower doses and fewer reported side effects
Quick remove of S/S does not equal to a permanent cure
Drug’s safety profile > its effectiveness -> use lower doses and fewer reproted side effects

5. Interaction with healthcare providers
Language barrier
Nonverbal communication
Trusting relationships
Attire, attitude
Family involvement
Decision maker
Attire, appearance, attitude of health care providers are important in Asian population

6. Adherence to prescribed medications
Beliefs on the medication
Discontinue the med when symptoms ease
Thwart the acceptance of drugs with a delayed onset of action
Stop taking the med. – esp if the dis is not common in their original country
S/S reliefed -> discontinue the med –African Americans and Native Americans often doubt the need for medications when S/S ease; it is not good for antibiotics
Stop taking the med if the dis is not common in their original country ie. Chinese does not believe dietary requirements is important for DM
Being culturally competent involves knowledge not only of pat’s beliefs and values about health and illnss, but also of their responses to treatment

7. Physiologic response to medications
Genetic polymorphisms
3-5% of whites compare to 15-20% of Asians are poor metabolizers of drugs affected by mephenytoin polymorphism ie. Diazepam, imipromine
Asians and Eskimos need lower doses of anxiolytics than white
Diet and tobacco use can influence a gene’s expression, which can in turn alter a drug’s effect
Polymorphisms (multiple forms of enzymes used for drug metabolism) affect the metabolism of medications Asians, Indians, and Pakistanis require lower doses of lithium and antipsychotic drugs.

8. Pharmacology Pharmacokinetics Pharmacodynamics Absorption Metabolism
Distribution
Elimination
Pharmacodynamics
Mechanism of action
Effects at the target site
Drug metabolism involves two phases, an oxidation phase (phase 1) and conjugation (phase 2) ,
Genetic abnormalities in the CYP (cytochrome P-450) enzymes are not only extremely common but have profound implications for drug response. Enzymes are responsible for the phase 1 metabolism of many drugs ie antipsychotic and antidepressants. Drug metabolism affects drug plasma levels at a given dosage.

9. Culture & lifestyle factors
Preference -Ways of taking the med. ie. Oral, injection,
Rituals ie. Fasting -> affects drug absorption
Fear- Concerns about addictive effects -> cut the dose
Fasting -> medicaiton schedules or interfere with drug absorption

10. Medicine example- Psychotropic agents
Antipsychotics
Typical – thorazine, haldol
Atypical – Risperdal, Clozaril,
Antidepressants- tricyclic antidepressants
Anti-anxiety
Mood stabilizer - Lithium
Effectiveness and side-effects
Lithium – similar dosage-> Blacks reported more lethargy and dizziness than whites does

11. Medicine example- Antihypertension
ACE (angiotensin-converting enzyme) inhibitor – work better for whites than blacks
Captopril (Capoten)
Enalapril
Losartan
Thiazide diuretics – better for blacks than whites
Hydrochlorothiazide (Esidrix and others)
Calcium channel blockers

12. Non-adherence to treatment
Interpretation of the drug effects including side effects
Positive or negative
Culture-bound syndromes complicate evaluation of drug response- inadvertent misdiagnosis, ineffective treatment, & inappropriate prescribing
Others -language barrier, clinician’s beliefs and preconceptions, and pt’s distrust of the health care system
Bipolar Chinese pt rarely complained of “missing the highs” and regarded polydipsia, polyuria, and weight gain as part of the therapeutic effect. Meanwhile attributed lethargy and poor memory to the drug

13. Roles of the care provider
Therapeutic range of the medication and the risk of toxicity – serum level of the medication and the side effect
Skill in communication – attitude, terminology
Touchy subject - fear of offending people
Avoid a “we/they” attitude
Respect
Individual difference
Asian cultures value patience and modesty; rarely complains, likely to express their problems in behavioral or somatic terms rather than in emotional ones.
Blacks – hypertension = high blood; anemia= low blood

14. Prepare for next week Article presentations Ethics
de Chesnay, Ch. 11- Gigi /Heaven
Purnell & Paulanka (2005) – Gigi
Munoz, C. & Hilgenberg, C. (2005). -Gigi
Ethics