Chapter 7 with relevant notes.

Chapter 7 Cultural and Ethnic Influences in Pharmacotherapeutics U.S. Demographics  Consistent with the growth of the foreign-born population is the growth in the number of people who have limited English proficienc ...

Chapter 7 Cultural and Ethnic Influences in Pharmacotherapeutics U.S. Demographics  Consistent with the growth of the foreign-born population is the growth in the number of people who have limited English proficiency (LEP), defined by the U.S. Census Bureau as any person age 5 and over who reported speaking English “less than very well.”  Being in the LEP category and having minority status have been shown to be risk factors for low health literacy. These factors make it difficult for patients to understand English and result in confusion over medical language, difficulty in completing forms, and/or possibly limited access to health-care providers.  All of these barriers make communication errors between the patient and provider.  Health literacy and English language proficiency have been shown to be strong factors in the delivery of high-quality health care. Prescribers have a duty to ensure that patients understand how to take medications.  Other patient factors that increased these odds were a history of disability, low education level, low income, and recent immigration. U.S. Demographic Groupings  Readers should understand, however, that these are artificial groupings and that people listed within a specific group may be very different from one another; for example, Japanese, Chinese, Vietnamese, Filipinos, and Asian Indians are all grouped under the umbrella category “Asian,” yet within these ethnic groups there are differences in the manner in which they metabolize certain drugs. Health Disparities in the US  CDC defines health disparities as “differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes”.  Influences on these differences are socio-political-historical background; social policies that influence individual health-care interactions; financial and organizational structures in the healthcare system that promote illness and poorly controlled chronic disease instead of prevention the settings in which health care is delivered, which focus mainly on acute care versus promoting the health of communities and populations; and the nature of the health-care workforce, which at this time does not reflect the current racial and ethnic minority makeup of the US.  Health care practitioners must be aware of local, state, and national statistics that describe health disparities and work toward the reduction, and ultimately the elimination, of these disparities with the goal of improving the overall health of patients, the communities they live in, the nation, and the world. Cultural Influences on Care  Knowing who makes the decisions in the family about health care and if this person supports the use of the prescribed drug and the plan of care, how the patient and family members view health and illness and their views on the management plan, and cultural factors that may createchallenges in adhering to the treatment plan are all important to helping clients improve and/or maintain their health.  Cultural heritage plays an important role in helping to explain values, attitudes, beliefs, customs, language preferences, and behaviors that influence prescription choices and they may supersede cultural and racial differences. Transcultural Nursing Care Theories  Cultural awareness allows the provider to be aware of and open to the differences between patients, regardless of their culture.  Cultural Care Sunrise model: focuses on assessing the patient in his or her environmental context, which includes 7 major areas: technological, religious, social and kinship, cultural value, political/legal, and economic and educational factors. o Purnell expands to include health-care practices, attitudes toward health-care practitioners, high-risk health behaviors, and knowledge about current health disparities for diverse ethnic and cultural groups.  Several studies have shown that patients do not adhere to medications for several reasons, such as economic factors (high co-payments or lack of prescription coverage from health insurance), prescriptions delivered electronically, and new prescriptions. Standards of Cultural Competency  The main factor affecting health disparities is the cultural competence of the health practitioners.  The new focus on national accreditation standards for professional licensure in the fields of medicine and nursing, as well as health-care policies recently passed by Congress, such as the Affordable Care Act, have also added to the importance of cultural and linguistic competency as part of high-quality health care and services in hopes of decreasing and eradicating health disparities.  The definition of culture as “the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics”.  Culture is further defined as a dynamic concept in which individuals may self-identify with more than one culture over the course of their lifetimes.  Key to the understanding of the treatment plan is the patient’s ability to understand what the health-care provider wishes to communicate through oral and written methods.  Immigrants have increased the number of people who are categorized as LEP. Prescribers must be aware of how well these groups are able to participate in the health-care visit, understand written and verbal instructions, and interact with the English-speaking majority.  The Census Bureau determines LEP by asking three questions on its yearly American Community Survey and the decennial census: (1) whether there is someone in the household who speaks a language other than English, (2) what the foreign language is (write-in response), and (3) degree of English-speaking ability (self-rated as very well, well, not well, and not at all). Respondents who self-identify themselves as anything other than “very well” are required to have an interpreter. Providers must familiarize themselves with changing trends in their local service areas to be able to meet the needs of LEP patients and fully understand and communicate all pertinent information regarding the treatment plan.  Providers must ensure that proper interpreter services are used to meet the CLAS Standards or risk losing Medicaid and Medicare funding. LEP patients who utilize interpreter services, rather than ad hoc interpreters such as family members, engage in more recommended preventive health services, make additional office visits, and fill more prescriptions.  Becoming culturally competent involves having not only an understanding of the patient’s culture but also knowledge of one’s own culture and personal values and the ability to detach from preconceived ideas and beliefs that can influence attitudes and behaviors toward patients from diverse backgrounds.  Ethnocentrism can influence the relationship between the patient and the prescriber by creating barriers to providing culturally competent care. Eliminating Health Disparities  Although health indicators such as life expectancy and infant mortality (markers that are often used as proxy measures to compare the health and well-being of populations across and within countries) have improved for the majority of nonminority Americans, ethnic and racial minorities continue to experience a disproportionate burden of preventable diseases, death, and disability.  Non-Hispanic blacks are more likely to have severe asthma, have more asthma control problems, and visit the emergency department more often, all of which influence asthma morbidity and mortality.  In order to positively influence the health of patients, and ultimately populations, health-care practitioners must be aware of socioeconomic, personal, and cultural factors that may affect adherence to treatments.  The World Health Organization and the CDC recognize several factors, called determinants of health, that influence health disparities and contribute to a person’s current health status: (1) biology and genetics, (2) individual behavior, (3) social environment, (4) physical environment, and (5) health services (CDC, 2013). The interrelationship of these factors requires practitioners to be aware of physical, psychological, spiritual, cultural, and environmental factors, as well as to be conscious of the social and political context in which health can be optimized and/or threatened. Ethnopharmacology  The study of racial differences in drug metabolism and response.  Practitioners may be aware and guidelines may sometimes specify that certain drugs are less or more efficacious or may have different side effects with certain racial groups.  The pharmacokinetic factors that can be expected to potentially exhibit racial differences are (1) bioavailability for drugs that undergo gut or hepatic first-pass metabolism, (2) protein binding, (3) volume of distribution, (4) hepatic metabolism, and (5) renal tubular secretion. African Americans Cultural Factors Demographics o 13.6% of the population o As a group, AAs are young and more likely to be unmarried, and female. o 55% live in the South.  Education and Employment o 82.5% high school diploma o 13.3% bachelor’s degree o 6.8% advanced degree o Unemployment rate 2x higher than whites  Family Relationships o Over half raised in single family homes o Grandmother is often the major decision maker. o Ever alert for signs of discrimination, they may see health-care providers as “outsiders” in health decisions.  Health-Care Utilization o Employer-sponsered health insurance 46.7% and uninsured 18.8%. o AAs used hospital clinics and ERs as their care providers more than other ethnic groups. o Many AAs have a long-standing distruct of the modern health-care system, in part due to the Tuskgee experiment with syphilis.  Health Status and Other Biological Variables o Life expectancy is shorter than the average American’s by 4.7 years. o Health disparities rated to the rate of preterm birth, low birth weight, and infant mortality. o Maternal mortality is over twice those of other ethnic groups. o SIDS was the 3rd leading cause of death for AA infants under the age of 12 months.  Many AA elders believe that infants sleep better in the prone position and mothers have a hard time conforming to the “Back to Sleep” movement for supine positioning. o Patterns of illness in the AA population include a higher prevalence of coronary heart disease, HTN, CVA, obesity, DM II, and HIV.  CHD related to AA diet which contains more animal fat, less fiber, and fewer fruits and vegetables and includes traditional items like chitterlings, fried okra, ham hocks, corn, mustard, collard and kale greens, which are often cooked with pork fat.  Practitioners need to understand that changing cooking and eating habits may be difficult, for the negative view of obesity that predominates in American culture may not be shared by AAs: a bigger body habitus is often viewed as a healthy body – especially in women. o AAs also have the lowest immunization rates for infections like tetanus and 2nd lowest for flu and pneumonia vaccines. o Even though AAs only make up 12.6% of the population, they account for 44% of new HIV cases. o Lower pain tolerance to hear and cold; no differences in ischemic pain, or pain threshold. o Increased risk of being diagnosed with schizophrenia.  Health Beliefs and Practices o Health is a gift from God, and illness and suffering are God’s will or are caused by evil influences.o Rely heavily on the healing powers of religious ritual and the advice of their religious leaders. Racial Differences in Drug Pharmacokinetics and Response  In an extensive review of ethnic variation and the significance of CYP 2C9 and CYP 2C19, Rosemary and Adithan (2007) discovered that the presence of CYP 2C9 *2 and *3 alleles required a 29% reduction in warfarin dose in African Americans.  Some black persons may be ultrarapid metabolizers of substrates of CYP 2D6. The prevalence of ultrarapid CYP 2D6 metabolizers among the African American population is 3.4%, similar to Caucasians, but the prevalence of ultrarapid CYP 2D6 metabolizers among Africans of Ethiopian descent is 29%.  The impact of ethnic differences is seen in the case of codeine metabolism, where codeine is metabolized into morphine at a more rapid pace, leading to higher serum morphine levels and risk for morphine toxicity.  Hypertension has a high prevalence in African Americans. One reason behind this phenomenon appears to be salt sensitivity (Weinberger, 1993), which is often cited as the reason to use diuretics as first-line therapy for this ethnic group.  The utilization of beta-adrenergic blockers in African Americans with heart failure is supported by Yancy, Laskar, and Eichhorn (2004) and Shekelle, et al (2003). Following a review of the literature, the authors recommended that, barring specific contraindications, beta-andrenergic blockers be used for any patient with left ventricular dysfunction in heart failure. Additionally, beta-adrenergic blockers used in conjunction with angiotensin converting enzyme (ACE) inhibitors in African Americans can be effective in treating heart failure (Yancy et al, 2004). American Indian/Alaska Native Groups Cultural Factors  Demographics o More than 560 tribes are recognized by federal or state governments and, in addition, there are others that are not so recognized. o 1.6% of the population o Tend to be young, undereducated, and poorer than the rest of the US population. o Divided population, with 60% living in urban areas and fewer than a quarter living on the reservation and tribal lands.  Education and Employment o 81% < have a high school diploma, 11.2% bachelor’s degree, 6.1% have a graduate degree. o Unemployment rate is 14.6% (2nd highest after AA).  Family Relationships o Average American Indian family household has four to five members, making it the largest family size of any of the ethnic minority groups. Women head 25% of the households and the nuclear family is often comprised of extended relatives living under one roof, including relatives from both parental sides. o Members usually assume leadership and decision-making roles. Some tribal groups are matriarchal while some are patriarchal, with the leadership and the health decisionmaking coming from the sex that matches the leadership orientation, often with the help of spiritual leaders or medicine people. o Many tribes have an established clan system whereby members of the tribe help to rear children, participate in general family life and customs of the tribe, and help make decisions for members of the clan. o Prescribers should try to determine the unique histories, environments, and cultural beliefs of the specific tribal groups from which their patients originate in order to understand the family structure, decision making, and leadership style of AI/AN patients so as to ensure optimal treatment plans.  Health-Care Utilization o Approximately 70% of all members of the group who claim American Indian heritage receive IHS (Indian Health Service) funded care. o Only 22% of AI/AN live on the reservations or trust lands and an overwhelming 60% live in metropolitan areas away from IHS sites. Since 1972, the IHS has expanded its funding of health-related activities in off-reservation settings to help meet the needs of patients living away from reservations or trust lands. o According to the IHS, 41% of AI/AN reported having private health insurance coverage, 36.7% relied on Medicaid coverage, and 29.2% had no health insurance coverage in 2010.  Health Status and Other Biological Variables o Health disparities are prevalent in this minority group as demonstrated by the high rates of alcoholism (552% higher), diabetes (182% higher), unintentional injuries (138% higher), homicide (83% higher), and suicide (74% higher), when compared to the Caucasian population. o Among young males age 15–34, suicide is the second leading cause of death, which is 2.5 times higher than the national average for the same age group (CDC, 2012b). The infant mortality rate is 65% higher than that of whites, and the rate of sudden infant death syndrome is 2.4 times that of whites. Additionally, AI/AN infants have 2.3 times the rate of death from accidental injuries (MacDorman & Matthews, 2011). o Life expectancy is 73.6 years, 4.1 less than the overall life expectancy for all races in the US. o 5 top causes of mortality are heart disease, cancer, injury, diabetes, and chronic live disease/cirrhosis. o The higher the heritage of AI/AN, the more likely to develop DM II. o Navajo Neuropathy is a fatal autosomal recessive genetic disorder present in the Navajo population. Those with the illness display weakness, metabolic acidosis, neuropathy, and liver failure (Hodgins & Hodgins, 2013). Karadimas and colleagues (2006) examined incidences of Navajo Neuropathy and found that a mutation on the MPV17 gene is associated with disease development. The authors suggest that this finding can be used in genetic testing. o Lactose intolerance is very common among American Indians, with between 79% and 100% of the population affected. o found the rate of alcoholism among Mission Indians to be 60%, with men being more affected than women.  Those with 50% < heritage of AI/AN more likely to be alcoholic than AI/ANs with less than 50%. o 31.5 AI/AN smoke compared to 20.6% of whites. Health Beliefs and Practices o Practitioners must understand that the AI/AN population is characterized by a wide variance in cultural values, beliefs, and practices; the environments that they live in; and their socioeconomic circumstances. o The AI/AN population’s high-risk behaviors, such as alcoholism and higher smoking rates, may be due to alcohol metabolism issues and long-held sacred cultural traditions involving tobacco, which include the use of tobacco products for prayer, protection, respect, and healing. o For these populations, health is harmony with nature and oneself. Illness is disharmony and may be caused by a supernatural force or by violation of a restriction or prohibition. The illness is seen as an imbalance of mind, body, and spirit. Because the cause of the illness is external, illness-prevention practices that relate the cause of illness to the behavior of the patient are questioned. This is an interesting conflict, because self-control is considered to be a central attribute to maintaining harmony, and each person is accountable for his or her own health. o Western medicine is accepted but not seen as able to heal except when used in conjunction with native healing practices. Because the hospital is considered the place to die, the patient may resist hospitalization. Pain is supposed to be borne, so AI/AN may not request pain medication when needed. Practitioners should be mindful about educating the AI/AN community on the positive aspects of healing in regard to adequate pain control. o Providers need to determine which herbal remedies a patient is using before prescribing modern medicines. Racial Differences in Drug Pharmacokinetics and Response  More recently, Gizer, Edenberg, Gilder, Wilhelmsen, and Ehlers (2011) investigated traits related to chromosome 4q near a cluster of alcohol dehydrogenase (ADH) genes. These genes encode enzymes of alcohol metabolism and may be responsible for variants in the ADH1B and ADH4 genes, which may protect against the development of commonly seen symptoms associated with alcohol dependence in other ethnic/racial groups.  Native Indians were more susceptible to morphine depression of the ventilatory response than Whites.  Providers should use caution when medicating this group to avoid an exaggerated response in the respiratory system. Asian Americans Cultural Factors  Demographics o 50 distinct racial/ethnic subgroupings with over 30 different languages. o Asians have many countries of origin (spanning East Asia, Southeast Asia, and South Asia), religious/spiritual affiliations, cultural backgrounds, health-care beliefs and practices, and immigration experiences. o The top six Asian subgroups in the United States are Chinese, Filipino, Asian Indian, Vietnamese, Korean, and Japanese. o 5.6% of the population identified themselves as Asian, either alone or in combo with other groups.o In the 2011 census study the median household income for those identifying as Asian American alone was $67,885, which is the highest of all minority groups in the United States, and the percentage of the population living in poverty was 12.8%, the lowest of all minority groups. o A high percentage (76.9%) of this population, age 5 and older, does not speak English at home, and large percentages are not fluent in English: 55% of Vietnamese, 46% of Chinese, 22% of Filipino, and 22% of Asian Indian.  Family Relationships o Family relationships are strong, with extended (often multigenerational) families and an expectation of family loyalty from all members. Families are a source of strength. In Japanese families, the father is away from the home on business a great deal of the time, so the mother–eldest son relationship is very strong. o In all Asian American groups, males are more “valued” than females, females are submissive to males, and respect for elders is taught at an early age. o Spector (2004) says that adherence to Buddhism, Confucianism, and Taoism leads these Asian American families to avoid admitting physical or mental illness. Conflicts are handled within the family, and there is kinship solidarity in which the individual is expected to seek the input of elders in the family and from kin.  Health-Care Utilization o Recent immigrants less likely to have health-care coverage, which may result in less frequent visit to health care providers. o Overall, Asians are well insured.  Health Status and Other Biological Variables o Health status overall is excellent as a whole. o Have a longer life expectancy and lower death rates from all causes than does the general population. o Illnesses experienced more than the general population: TB, stomach/colorectal CA (esp. Japanese), and suicide (among Chinese women). o Southeast Asian refugees have a higher incidence of intestinal parasites, TB, and hep. B antigen and more anemia than other Asian Americans or the general population. o Leading causes of death: cancer, heart disease, stroke, accidents, and diabetes. o Have the highest rate of TB and twice the rate of hep B. o SIDS is the fourth leading cause of infant mortality. o High rate of COPD. o Korean and Vietnamese have the highest smoking rates. o Also, important to note is that pneumonia/influenza is the fourth leading cause of death among Asians aged 65 and over and that case rates for tuberculosis (TB) (25.8 cases per 100,000) are the highest among any other ethnic/minority group, with Asians having the highest percentage of new TB cases among foreign-born persons living in the United States.  Health Beliefs and Practices o Chinese and Vietnamese people have a fatalistic attitude and believe that health is a result of forces that rule the world: yin (cold) and yang (hot). Illness results when there is an imbalance in these forces. Illness is diagnosed by pulses (there are seven different ones), color and texture of the tongue, and other means not commonly used by allopathic medicine. Treatment is provided with the opposing force to achieve balance.o “Chi” is innate energy, and lack of it results in fatigue and long illnesses. Asians may call on their ancestors for help, and the Vietnamese may use cupping with a heated cup or glass jar that is placed on the skin to create a vacuum. This practice leaves bruising and may be misinterpreted in children as child abuse. o Asian populations may believe that mental illness and physical disabilities should be hidden. Women usually seek care from female providers. Older clients may appear willing to comply with prescribed therapies but then don’t follow them; their respect for the provider prohibits them from discussing their unwillingness to follow the regimen. o Japanese beliefs are influenced by Shinto, a religious orientation. They believe that humans are inherently good and that evil is caused by outside spirits. Both Japanese and Vietnamese people believe that pleasing good spirits and avoiding evil ones help to maintain harmony and health. Evil is removed by purification rituals. Mental illness is taboo and often translates into acceptable somatic symptoms, and addictions are shameful. o Filipinos also subscribe to the concept of yin and yang but believe that God’s will and supernatural forces govern the universe and determine health and illness. Illness is punishment for violations of God’s will. Amulets and religious medals may be worn as a shield from witchcraft or as a good-luck charm. The “evil eye” may be considered the reason for illness in infants and children. Racial Differences in Drug Pharmacokinetics and Response  The CYP 2D6 isoenzyme system is responsible for metabolism of antiarrhythmics, antidepressants, and neuroleptics, among others. The mean activity of CYP 2D6 extensive metabolizers is lower in Asians and is the molecular genetic basis for slower metabolism of antidepressants and neuroleptics in Asians. This difference in metabolism requires lower doses of these drugs.  The CYP 2C19 system is involved in the metabolism of acids (e.g., mephenytoin), bases (e.g., imipramine and omeprazole), and neutral drugs (e.g., diazepam). Diazepam (Valium) is partially demethylated by CYP 2C19, and the high frequency of mutated alleles in Asians is probably the reason that such populations have slower metabolism and are treated with lower doses of diazepam than are whites. Although other drugs in this same class have not been studied, it is likely that they have similar metabolic fates as diazepam. Omeprazole (Prilosec) is hydroxylated to a major extent by CYP 2C19, and there is an approximately 4-fold difference in oral clearance between Asians and whites. Hence, a lower dose for this drug is required for Asians.  Those of East Asian descent (Japanese, Chinese, and Korean) have a propensity toward an aldehyde dehydrogenase-2 (ALDH2) deficiency, causing a “flush” to occur after drinking alcohol. This may occur despite the amount of alcohol ingested being minimal. o Can also increase the incidence of esophageal cancer.  Asians are called “fast acetylators” meaning that they metabolize many drugs faster, such as cardiac and psychotropic drugs. This faster metabolism may require a more frequent or higher dose of drugs metabolized by acetylation to achieve efficacy. 78% to 93% of Asians are “fast acetylators”.  Warfarin should be dosed lower in Asian patients.  Atypical antipsychotics and SSRIs need to be dosed lower in Asian Patients. Filipinos require lower doses of dopaminergics (levodopa) than do whites, and they develop dyskinesia more readily at comparable doses. This difference appears to be related to racial differences in erythrocyte catechol-o-methyltransferase.  Hypertensive patients may need lower doses than whites. Native Hawaiian and Pacific Islanders Cultural Factors  Demographics o More than half of the NH/PI population declared a mixed combination with other racial groups, making up 0.4% of the total US population. o Relatively young: 30% are under 18. o The NH/PI population describes a wide array of people and customs whose origins may be Native Hawaiian, Guamanian or Chamorro, Samoan, or other Pacific Islander; Polynesian, such as Tahitian, Tongan, and Tokelauan; Micronesian, such as Marshallese, Palauan, and Chuukese; and Melanesian, such as Fijian, Guinean, and Solomon Islander. o The NH/PI poverty rate was 21.5% and the median income was $49,378, versus 13% and $55,305, respectively, for the non-Hispanic white population.  Education and Employment o High school degree is similar to those of whites. o Only half continue to college or complete a bachelor’s degree or a graduate degree. o Increased poverty rate.  Family Relationships o The average family size for NH/PI is four and its organization is matriarchal with a belief in placing children in a position of prominence within the family. o The family interdependence is of utmost importance when forming a caring relationship with a patient from this group.  Interdependence is based on collectivism, relational orientation, familism, and family obligation.  Collectivism is described as a predisposition to place group goals above those of the individual; relational orientation is defining the self as interdependent with others in the family unit; familism describes a family hierarchical system that includes extended family members as the basic social unit; and family obligation includes attitudes and behaviors expected from children.  Children are expected to show respect and affection for older family members; seek their advice on important matters and accept their decisions; and maintain physical proximity, kinship, psychological and financial assistance, and emotional ties with parents, native Hawaiian elders, and the extended family across the life span.  Health-Care Utilization o Native Hawaiians have one of the lowest life expectancy rates – 68.3 years. o The native Hawaiian population continues to have the highest rates of morbidity and mortality and chronic health conditions such as hypertension, diabetes, and asthma than other ethnic groups and have higher rates of smoking and drinking and more risk factors, such as overweight and obesity.o Native Hawaiian children and adolescents also face significant health disparities: exposure to prenatal alcohol and tobacco use, late or no prenatal care, macrosomia as well as low birth rates, low rates of exclusive breastfeeding at 6 months, high rates of infant mortality, and high rates of obesity and physical, mental and sexual abuse.  Health Status and Other Biological Variations o Second highest rate of TB. o Also has a high infant mortality.  Health Beliefs and Practices o In the Polynesian cultures, a Hawaiian philosophy called Huna is an important concept. One of the tenets of Huna is the seeking of harmony, love, and positive energy flow. o The energy flow is believed to tap into the Universal Power that the Hawaiians call mana. The secret for attaining true health, happiness, prosperity, and success is the loving use of the power of mana. o One of the ways that this can be achieved is through a Hawaiian massage, lomi lomi, that is delivered by a trained traditional healer. Lomi lomi is performed in a rhythmic and fluid motion that uses the practitioner’s forearms as well as the hands to change the energy toward a positive flow. Lomi lomi is sometimes described as feeling like gentle waves moving over the body and is meant to relieve stress, stimulate blood and lymph flow, and assist in the elimination of wastes in the body. o The cause of illness may be attributed to the stress of anger, guilt, recriminations, and lack of forgiveness. Families and individuals are encouraged to participate in Ho′oponopono, an ancient Hawaiian practice that leads to forgiveness and reconciliation. In other Polynesian cultures, illness may be attributed to a person’s mistakes or errors, which may anger the gods. Ho′oponopono are family conferences in which interpersonal family relationships can be corrected through prayer, discussion, confession, repentance, and mutual restitution and forgiveness. o The Native Hawaiian family, ‘ohana, is the core social unit within which the individual lives and interacts. It should be taken into account during the health-care transaction in order to aid NH/PI patients to meet their health-care goals. Racial Differences in Drug Pharmacokinetics and Response  Warfarin dosage in Chinese patients separately from Pacific Islanders that Chinese patients required lower doses of warfarin to achieve optimal results when compared to New Zealand Europeans and that Pacific Islanders had very few variants along the CYP2C9 gene, requiring higher doses of warfarin. Hispanic Americans Cultural Factors  Demographics o Largest minority group. o Are not homogeneous group and anyone can be of any race and self-identify as Hispanic. o The majority are born in the US (62.9%). o Include Mexican descent (63%), Puerto Ricans (9.2%), Cubans (3.5%), and people from Central and South America. o Population is young with 37.1% under 20 years old. o Over 50% live in CA, FL, TX. Education and Employment o Hispanics of Mexican origin have a drastically lower college attainment rate (8%) than Hispanics from Cuba and South America (30% and 28%, respectively). o Hispanics as a whole have lower socioeconomic status than that of the predominant white population. o 61% of Hispanic adults compared to 89% of the total population had a high school education, 12.5% of Hispanic adults compared to 30.5% of the total population had at least a bachelor’s degree, and 3.8% had advanced degrees. o The unemployment rate for Hispanics in 2011 was 11.5%, the second-highest unemployment rate after African Americans.  Family Relationships o Needs of the family are more important than the needs of the individual family member. o Kinship bonds often extend outside blood and marriage lines and including godparents. o The family roles and titles of brother, sister, aunt, and uncle may not be a true blood relative. o Higher household size is due to higher fertility rates, continued migration, and the presence of other family members living in the home. o Respect for parents and elders is taught early. o The father is the main decision maker in the family, but women, who are considered the primary healers in the group, decide health-related issues and provide health advice and remedies.  Health-Care Utilization o Highest percentage without health insurance and lacks preventive care and health promotion. o Public health clinics and EDs are often used as the sites for primary care.  Health Status and Other Biological Variations o 9.5% of Hispanics/Latinos were reported to be in fair or poor health. o Obesity is a major problem for this population. o 11.8% of Hispanics reported having diabetes. o 13.4 Mexicans reported having diabetes. o Hispanic patients were found to have higher insulin resistance and lower insulin sensitivity than whites. And they were found to demonstrate less insulin secretion yet be more insulin sensitive when compared with AAs. o Leading cause of mortality is cardiovascular disease, cancer, CVA, accidents, and DM. o Hispanics experience pain differently than whites, having a lower pain threshold for health and cold pain; however, there is no difference in ischemic pain. o Choose to use contraception, but methods that are often less reliable, such as rhythm method and condoms. o Other health disparities include an increase in HIV/AIDS and the highest rate of diabetes among Puerto Ricans; a low rate of individuals who receive the flu vaccine; and more than twice the death rate from asthma than is seen in whites. o Many pregnant Hispanic women do not seek prenatal care until late in their pregnancy; however, the rate of low birth weight is lower than that of whites except for a high rate among Puerto Ricans. o Puerto Ricans also have low rates of prostate and breast cancer but a high rate of stomach and liver cancer.o In the area of asthma prevention education, the data demonstrate that Hispanics of Mexican origin are least likely to have been given an asthma management plan, taught how to recognize early signs and symptoms of an asthma episode, advised on environmental controls, and taught how to properly respond to an asthma exacerbation.  Health Beliefs and Practices o The continued use of traditional medicine/folk medicine and traditional folk practitioners (curanderos/curanderas) is one of the most important variables leading to underutilization of Western medical care by many groups, including Hispanics (Ericksen, 2006). Patients may choose these traditional practices because they are often more accessible and affordable and have been used for many generations; patients also believe that traditional medicine and treatments are somehow gentler on the body. o Hispanics are also more likely to engage in prayer as a form of TC/CAM, especially when feeling frustrated by lack of information regarding their disease processes and treatment options. o TM/CAM practices sometimes used are medicinal berbs/teas, spiritual healing, religion, and prayer modalities and other traditional remedies, and visits to nutritionists and chiropractors. o Spanish medicine was grounded in the humoral beliefs, that is, that the body was made up of four fluids: blood, phlegm, yellow bile, and black bile. These humors were further subdivided into the dualities of “wet and dry” and “hot and cold,” which are classifications still used by many Hispanics to describe illness and wellness. Diseases and illnesses, which can result from an imbalance of these forces, are either hot or cold and need to be treated with these concepts in mind. o Illness may also be caused by several cultural ideas, such as envidia (jealousy), mal ojo (evil eye), mal aire (bad air), nervios (restlessness/anxiety), caida de mollera (fallen fontanel), and susto (magical freight), that can affect patients with physiological and/or psychological symptoms that vary in intensity and can be severe and life-threatening. o Health beliefs often have a strong religious association, with health being a gift from God as a reward for good behavior. Eating proper foods, working the proper amount of time, wearing religious medals, and sleeping with relics in the home are thought to prevent illness. Hispanics typically consult both traditional healers and allopathic providers and may or may not follow the modern medicine prescribed. o When prescribing other drugs, understanding that curanderas/curanderos (traditional folk healers) treat illness with a variety of herbs and teas as well as recommend visits to shrines, medals, the use of candles, and promises to God to change behavior will reduce the risk for drug interactions. Racial Differences in Drug Pharmacotherapeutics and Response  Asthma is the most common chronic illness among all children, with around 10% of all children afflicted. But Puerto Ricans have a much higher rate of asthma, with more than 20% afflicted compared with non-Hispanic whites. Conversely, only approximately 8% of Mexican American children are reported to have asthma. Non-Hispanic Whites  Whites of various ethnic backgrounds may hold beliefs in the “evil eye” and the curative powers of folk medicine. German, Polish, and Italian Americans also see stress and environmental changes as sources of illness.  Along with Irish Americans, they have strong family ties, with the male as the dominant force and decision maker.  Polish and Italian Americans may use folk remedies and native healers. All four groups have strong religious ties, with Polish, Irish, and Italian Americans being mainly Roman Catholics.  Religious medals and rituals are often used to promote health, prevent illness, and heal.