1. Genetic, Psychosocial, and Cultural Influences

2. Assessing for variations in response Health perception-health management Nutritional-metabolic Elimination Activity-exercise Cognitive-perceptual Sleep-rest Self-perception Role-relationship Sexuality-reproductive Coping-stress tolerance Value-belief

3. Health perception – health management Attitudes toward health (compliance) Alcohol, drugs / tobacco Access to care, insurance Use of alternative therapies (cultural, spiritual) Explanatory models of illness / goals of treatment Nutritional – metabolic Genetic differences in metabolism Fat to muscle ratio (age, gender) Food-drug interactions Elimination Renal and hepatic function Cognitive – perceptual Ability to understand Visual acuity

4. Genetic variations INH Toxic in certain Caucasian Americans (slow metabolizers) Beta-blockers Ineffective in some African Americans Codeine Ineffective in some Asian Americans (not converted to morphine) Coumadin Toxic in certain Asian and African Americans

5. Things to watch for

6. Pharmacogenetics Individual variation in response to drug therapy. This variation is related to genetic alterations known as polymorphisms. Some pharmacogenetic differences are inherited along ethnic or racial lines. Other differences are unique to people and not inherited. Genotype testing is now available for some CYP450 enzymes.

7. Pharmacogenetics But genetics isn’t the only factor. In a United Kingdom study with DMARDs (disease-modifying anti-rheumatic drugs) in Southeast Asian immigrants, they were found to discontinue the drugs more often than Northern Europeans. Communication and cultural differences in response to chronic disease may be as important as genetic response to the drugs. Reference: http://rheumatology.oxfordjournals.org/cgi/conte nt/full/42/10/1197 http://rheumatology.oxfordjournals.org/cgi/conte nt/full/42/10/1197

8. Ethnopharmacology Another name for another way to examine differences in response to drug therapy. The difficulty lies in identifying the genetic, cultural, racial and ethnic factors behind variations in response. “Historically, most drug trials have been conducted using white men; the results have then been generalized to all patients receiving the drugs studied.” http://employment.thresholds.org/pdf/Munoz_Hilgen berg_Paper.pdf http://employment.thresholds.org/pdf/Munoz_Hilgen berg_Paper.pdf

9. In a British study, 835 women who regularly used analgesics for headache were randomly assigned to one of four groups (43). One group received aspirin labeled with a widely advertised brand name. The other groups received the same aspirin in a plain package, placebo marked with the same widely advertised brand name, or unmarked placebo. (43) Branded aspirin worked better than unbranded aspirin, which worked better than branded placebo, which worked better than unbranded placebo. http://www.annals.org/cgi/content/full/136/6/471 An example: placebo effect

10. Interesting example…. The beta-blocker propranolol is more effective in reducing blood pressure and heart rate in Chinese than in Whites. Paradoxically, the Chinese subjects metabolized propranolol much more rapidly than the White subjects Pharmacokinetic properties, therefore, do not explain the increased sensitivity of the Chinese The mechanism for the increased sensitivity is not clearly determined, but could be because of a greater suppression of renin in the Chinese population http://cobb.nmanet.org/images/uploads/Racial_and_Ethni c_Differences_in_Response_to_Medicine.pdf p.18 http://cobb.nmanet.org/images/uploads/Racial_and_Ethni c_Differences_in_Response_to_Medicine.pdf

11. Another example….. There are general differences in the pathophysiology of hypertension between Black and White populations. Black hypertensives exhibit enhanced sodium retention, a higher incidence of salt-sensitive hypertension, expanded blood volume, more frequent proteinuria, and a higher prevalence of low blood renin activity These factors may underlie some of the observed differences in the effectiveness of various antihypertensive drugs in Black populations. p.18

12. The spirit catches you and you fall down: a Hmong child, her American doctors and the collision of two cultures by Anne Fadiman (1997) http://en.wikipedia.org/wiki/The_Spirit_Catches_You _and_You_Fall_Down http://en.wikipedia.org/wiki/The_Spirit_Catches_You _and_You_Fall_Down But what about culture?

13. Another culture…. Barefoot doctors of China Their purpose was to bring health care to rural areas where urban-trained doctors would not settle. They promoted basic hygiene, preventive health care, and family planning and treated common illnesseshygienepreventive health carefamily planningillnesses Mao Zedong’s famous healthcare speech in 1965 institutionalized these rural healthcare workers. http://en.wikipedia.org/wiki/Barefoot_doctor

14. What about other cultures? America is a “melting pot” of cultures, yet… Often these cultures don’t “blend” but rather retain some elements of their differences. But what is a culture? Is there Hispanic culture? Are Africans the same as African-Americans? Are their similarities and differences the result of genetics? Or culture? Or both? Questions? Comments?