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.”
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.
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 [is very important].”
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 commonly used] 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.”
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.”
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 [for all populations] 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.
“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.”
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.”