From the September 4, 2003 issue

US Census reports show that 1 in 4 Americans are of a race other than white; 1 in 3 children are African American, Hispanic, or Asian; and 1 in 10 people are foreign-born.1 This cultural diversity can have implications for medication safety. Ethnic culture affects our beliefs about health, illness, and medications, as well as how we interact with healthcare providers, comply with prescribed medications, and respond physiologically to medications. While our ethnic differences are endless, a few common themes found in the literature are provided below as examples.2-4 However, it’s unwise, even false and prejudicial, to assume that everyone from a certain culture will respond the same way.

Beliefs about health, illness, and medications. When illness or injury strikes, white patients are typically intolerant to pain, unlike many other cultures, where pain is seen as part of life. White patients also have a high expectation that their disease will be cured, or at least well managed, through technology and powerful drugs. In fact, most white Americans expect to leave the doctor’s office with a prescription, and often believe that the management of microbes is more important than bolstering resistance to them. Thus, American medicine tends to be aggressive, with primary focus on the effectiveness of treatment, and a fairly high tolerance of side effects. In Japan, a drug’s safety profile is stressed more than its effectiveness, which explains the general use of lower doses and fewer reported side effects. European medicine reflects a mid-position between American and Japanese medical cultures. Immigrants from different cultures may, therefore, have different expectations regarding the type of drug prescribed, dosages, and tolerance of side effects.2-4
For example, while Hispanics, Chinese, and Asians often expect quick relief from symptoms, they are cautious about American medicines and often initiate downward dosage adjustments to avoid even minor side effects. The Chinese also consider American medicine to be quick and effective in removing symptoms, but not a permanent cure. Since they believe that traditional Chinese medicine can remove the cause of the illness, they often use American medicine for acute illness, surgery, and severe disease, and rely on Chinese medicine for long-term treatment.2-4

Interaction with healthcare providers. When dealing with white providers, minority patients often find eye contact, body posture, and other forms of nonverbal communication significant, especially if a language barrier is present. For Asian patients, who may be accustomed to a formal relationship with their healthcare providers, a casual appearance, attire, or attitude may damage the development of a trusting relationship. Even when comfortable with healthcare providers, some Asian or Hispanic patients may be reluctant to speak up about their illness. Out of misplaced deference for doctors and a reluctance to share deeply personal information, they may minimize or conceal adverse events, or stop taking medications because of the side effects without telling their providers. Family involvement may be important, too. In Hispanic families, the mother or grandmother (of the husband especially) usually makes the healthcare decisions, and the opinions of Asian family members and elders are greatly respected during illness.2-4

Adherence with prescribed medications. Ethnic beliefs may play a role in the early discontinuation of a prescribed medication. For example, African Americans and Native Americans often doubt the need for medications when symptoms ease, and may discontinue drugs like antibiotics and antidepressants. In some developing countries, medications are customarily prescribed for just a few days. This knowledge may thwart the acceptance of drugs with a delayed onset of action, such as antidepressants. Hispanics also tend to believe that the lack of symptoms means they are cured. This could be especially problematic in treating diabetes, a prevalent illness in the Hispanic community. When symptoms abate, patients often stop taking their medication. Diabetes is a challenge for Asian Americans, too. The disease is uncommon in Asia, so it’s difficult for patients to grasp the relationship between blood sugar and diet. Dietary requirements also do not fit well with the Asian way of thinking about food.2-4

Cultural preferences, rituals, or fears may also affect adherence with medications. Women from Islamic and African cultures who have vaginal yeast infections may prefer oral drugs to vaginally inserted medications. Latin Americans expect injections, so they may believe that oral medications are less effective. Some cultures practice religious fasting, which can affect medication schedules or interfere with drug absorption. Mexican and Puerto Rican patients’ concern about the addictive effects of medications can lead to reluctance to take long-term medications. Vietnamese patients have taken only half of their prescribed medication, believing it’s too strong.2-4

Physiologic response to medications. A patient’s race or ethnic background influences how medications are metabolized. Common genetic polymorphisms (multiple forms of enzymes used for drug metabolism) affect the metabolism of many important medications. For some polymorphisms, the proportion of rapid metabolizers and slow metabolizers varies based on ethnicity. For example, only 3% to 5% of whites are poor metabolizers of drugs affected by mephenytoin polymorphism (e.g., diazepam, imipramine), but 15% to 20% of Chinese and Japanese are poor metabolizes of mephenytoin and related drugs. Clinically, there may be an increase or decrease in the expected drug effect, so dosage adjustments may be necessary. 2-4

For example, Asians and Eskimos need lower doses of anxiolytics than white patients. Asians, Indians, and Pakistanis require lower doses of lithium and antipsychotic drugs. African Americans’ symptoms generally improve faster after taking neuroleptics and anxiolytics. Hispanics may require lower doses of antidepressants than whites. Since various drugs within the same class are often cleared by different metabolic pathways, ethnic differences in the metabolism of specific drugs may differ within a class.2-4

Pointing out ethnic differences can be a touchy subject because of fear of offending people. However, these examples of ethnic diversity serve only to point out that we are all members of an ethnic group, each with cultural values that influence our behavior and physiologic response to medications. That knowledge should help us avoid a “we/they” attitude when caring for patients from a different culture than our own. The large number of ethnic cultures in America makes it hard to be culturally competent. But we can approach patients with respect while assessing their likelihood of acting on cultural beliefs that could adversely affect treatment outcomes. Individuals who are recent immigrants; live in ethnic enclaves; prefer using their native tongue; travel frequently to that country; and have frequent contact with others within their ethnic group are more likely to follow strongly held cultural beliefs. While misinformation or lack of information should be addressed, we should strive to bring effective healthcare to patients within a psychosocial context that is appropriate for their culture.2-4

References: (1) US Census Bureau Website. United States Census 2000. Available at: www.census.gov/main/www/cen2000.html. Accessed August 2003. (2) Levy R, Hawks J. Cultural Diversity and Pharmaceutical Care. Reston, VA: National Pharmaceutical Council; May 1999. [Monograph] Available online at: www.npcnow.org/issues_productlist/PDF/culturaldiversity.pdf. (3) Burroughs VJ, Maxey RW, Levy RA. Racial and ethnic differences in response to medicines: towards individualized pharmaceutical treatment. J Natl Med Assoc. 2002;94:1-26. (4) Pavlovich-Danis S. Ethnicity and culture vary medicinal effects. Nurs Spectr(Phila/TriState). 1999 Oct 4:18-19.