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Marianne R. Jeffreys, EdD, RN and Rick Zoucha, PhD, PMHCNS-BC, CTN-A, FAAN Abstract: Past and present policies, politics, myths, stereotypes, and societal at titudes influence the lived experience of multiple heritage individuals, often resulting in marginalization, disparities, invisibility, cultural pain, and/or unmet needs. This article offers commentary about the past and present with thought-provoking questions for future direction regarding “The Invisible Culture of the Multiracial, Multiethnic Individual: A Transcultural Imperative.” The commentary revisits and reminds readers about the 2001 article on the same topic, quickly brings them to the reality of the present, and challenges nurses and other professionals to dismantle disparities through cultural congruent care that focuses on making the invisible culture visible. Key Words: Multiracial, multiethnic, culture, cultural competence, interprofessional R evisiting “T he I nvisible C ulture of the M ultiracial, M ultiethnic I ndividual : A T ranscultural I mperative” com m entary n 2001, the Journal of Cultural Diversity published our article entitled “The Invisible Culture of the Multiracial, M ultiethnic Individual: A Transcul tural Imperative” (Jeffreys & Zoucha, 2001). At that time, the nursing literature lacked visibility to this topic and we were pleased to have our work published as a landm ark article on this topic. One purpose of our article was to evoke professional awareness, spark in terest, stimulate thought, and disseminate information concerning multiracial, multiethnic (multiple heritage) individuals w ithin the United States. We provided general background information, terms, definitions, ethno-historical influences, and practice implications. We urged all nurses and other health care profession als to become active participants in the new cultural evolution of a different, broader w orldview that u n covers the “invisible” culture of m ultiple heritage I Marianne R. Jeffreys, EdD, RN, is Professor of Nurs ing at The City University of New York (CUNY) Gradu ate College & C U N Y College of Staten Island. Dr. Jeffreys may be reached at: http://wwzv mariannejejfreys.com; or at firstname.lastname@example.org. Rick Zoucha, PhD, PMHCNS-BC, CTN-A, FAAN, is Professor and Joseph A. Lauritis, C.S.Sp. Endowed Chair for Teaching and Technology Chair of Advanced Role and PhD Programs at Duquesne University Schoo. of Nursing. Dr. Zoucha may be reached at: Zoucha@duq.edu. Journal of Cultural Diversity • Vol. 24, No. 1 individuals. This new vision challenged nurses and other health care professionals to embark upon a new journey in the quest for cultural congruent care for all individuals through ongoing assessment, education, research, and practice initiatives. Unfortunately, 15 years later, despite changes in demographics, the election of a multiracial president of the United States, the US Census change perm it ting multiple heritage individuals to select multiple options, and the prediction that 1 in 5 Americans will claim multiracial heritage by 2050 (Farley, 2001; Jackson & Samuels, 2011), the visibility of multiracial, m ul tiethnic (multiple heritage) individuals in the nursing literature remains virtually invisible and non-existent (Ahmann, 2005; Byrd & Garwick, 2004; 2006; Jeffreys, 2016; Jeffreys, 2005). Within related disciplines, sub stantial gaps and under-representation in research, literature, education, and clinical practice applica tions has also been acknowledged (Charmaraman, Woo, Quach, & Erkut, 2014). Deficits in literature and disparities impact academic settings, the multicultural workplace, diverse client populations, and all places that involve people, cultural competence, and cultural safety. This inexcusable gap, combined w ith the sig nificant political, economic, and health care changes occurring in the US and w orldw ide today, prompts the need for prioritized publicity, re-dissemination, and new publications. Historically, multiple heritage couples and individ uals have been the subject of controversy and scrutiny (Kenney & Kenney, 2012). Policies, politics, myths, Spring 2017 stereotypes, and societal attitudes have influenced the lived experience of multiple heritage individuals, often resulting in marginalization, disparities, invisibility, an d /or unmet needs. Unfortunately, “current politics and policies have not kept pace with changing demo graphics and raise questions about attitudes toward multiracial people, prevalence of anti-discrimination policies directed at individuals who identify with a single race, and other disparities that keep multiracial and multiple heritage individuals ‘invisible’ (Campbell & Herman, 2010; Giamo, Schmitt, & Outten, 2012; Nazish & O’Brien, 2011; Nadal, et al, 2013; and Smith & Maton, 2015 cited in Jeffreys, 2016, p. 6). Consequently, social justice demands dismantling disparities and making the invisible visible; this requires courage, com mitment, and change. Provoking change in attitudes, thought, education, politics, policy, and health care amidst individual and societal apathy, complacency, or unintentional obliviousness often necessitates (or benefits from) an intellectual jolt. A newly coined term, phrase, or metaphor can become the intellectual jolt that sparks attentiveness, change and action. Recently, in the field of education, Tutwiler (2016) refers to mixed-race children as the “‘fifth minority.” The phrase challenges old ways of thinking, prompts new questions, and arouses emotions. The phrase instantly exposes the invisibility and vulnerability of mixedrace individuals. She raises an awareness that the life experiences, worldview, attributes, and developmental and learning needs of mixed-race children are uniquely different from whites and the four major US minority groups, yet they have not been adequately assessed or addressed in schools, the professional literature, or teacher preparation. The concept of the “fifth minority” is presented to create visibility and is not meant to construct another boxed-in category or label; diversity within this group is recognized. The intent is to expose an invisible issue (population), encourage (and expect) individualized assessment, and develop diagnosticprescriptive culturally congruent actions to enhance learning, development, equality, and quality of life. Quality of life is adversely affected by cultural imposition and cultural pain. For the multiracial or multiple-heritage individual, cultural imposition occurs whenever self-identification of ethnicity, race, religion, etc. is challenged, not permitted, or ignored and can result in cultural pain. Leininger (1997) defined cultural pain as the “hurtful, offensive, and inappropriate acts or words to axi individual or group that are experienced as insulting, discomforting, or stressful due largely to the lack of awarness, sensitivity, and understanding by the offender of differences in the cultural values, beliefs, and meanings of the offended persons” (p. 32). Whether cultural imposition is intentional or not, cultural pain is real and is experienced whenever a person says so (or perceives it). Unfortunately, current multidisciplinary literature concerning multiracial or multiple heritage individuals continues to document disparities in past and present day life experiences that fit with Leininger’s definition of “cultural pain” (Ahmann, 2005; Blount & Young, 2015; Byrd & Garwick, 2006; Ecklund, & Johnson, 2007; Tran, Miyake, Csizmadia, & Martinez-Morales, 2016; Remedios & Chasteen, 2013). Lack of visibility and lack of professionals’ preparation to accurately assess, address, Journal of Cuhural Diversity • Vol. 24, No. 1 and meet the needs of multiple heritage individuals con tinues to be a dominant theme. So why is cultural pain and the potential for cultural pain prevalent, especially among multiracial and multiple heritage individuals? Tlais question prompts several others: How can cultural pain be prevented or alleviated? What new ideas can be generated through brainstorming? What analogies or resources can be found in the professional literature? About twenty years ago, the American Pain Society introduced the concept of pain assessment as the “fifth vital sign” in order to prevent or reduce pain and pain disparities. Brainstorming resulted in several questions shared here for further pondering and more brainstorm ing in relation to broadening the view of pain to include cultural pain: • • • • • • • Can (or should) cultural pain considerations be part of routine patient assessment? Could a blended concept of “the fifth vital sign for the fifth minority” expose the need (and expecta tion) to conduct culturally-sensitive assessments of multiracial and multiple-heritage individuals? (and all individuals)? Does coining such a phrase or concept as “fifth mi nority” spark more focused attention on accurately assessing cultural identity or is it just another label? Will it spark an awareness of the “diversity of di versity” that recognizes that culture is more than just a few “labels” and necessitates individualized appraisal? Will more focused and accurate cultural identity, heritage, and background assessments prevent cultural pain, avoid cultural imposition, and lead to culturally congruent care and improved health outcomes and quality of life? Will such expanded diversity awareness in educa tional settings and the workplace enhance multicul tural harmony, prevent multicultural conflicts, foster a culturally safe environment, enhance retention, and reduce attrition? How can nurses, other health professionals, and educators actively engage in the process of develop ing optimal cultural competence in self and in others that includes a prioritized attention on multiple heritage individuals”? Answers to these questions must begin by openly acknowledging the uniqueness of multiple heritage individuals and seeking to learn about their lived experi ence. Giving voice to this population will provide a place to be heard and known. Understanding the influences of the past is a necessary first step. Frequently, land mark articles are reprinted in order to share historical information that remains relevant to enhance under standing within the present day and future. Therefore, our 2001 landmark article is reprinted and follows our commentary. Readers are invited to actively engage in concentrated reflection that includes emotional aware ness, reflection-on-action (or inaction), and reflectionfor-action. It is the intentions of the authors to continue this discussion through this commentaiy and reprint of the 2001 manuscript. In the absence of literature regarding this topic, it seems appropriate in the near future to bring the discussion of Tutwiler’s (2016) “fifth minority” to Spring 2017 the forefront by engaging nurses and other healthcare professionals in this dialogue. The authors have writ ten a book review of her work including implications for healthcare, practice and research. The commentary, reprint and book review in this issue of JCD will serve to inform the readers about the next step which includes a manuscript dedicated to a theory and evidenced based approach to innovative ideas and actions. This work will include an interprofessional and collaborative ap proach to practice, education and research in a variety of health care settings and will appear in a future issue of the Journal of Cultural Diversity. REFERENCES Ahmann, E. (2005.1. Tiger Woods is not the only “Cablinasian:” M ulti-ethnicity and health care. Pediatric Nursing, 31(2), 125-129. Blount, A.J. & Young, M.E. (2015). Application: Theory to cul turally competent practice – Counseling multiple-heritage couples .Journal of Multicultural Counseling and Development, 4 3 ,137-152. Byrd, M.M. & Garwick, A.W. (2004). A feminist critique of research on interracial family identity: Implications for family health. Journal of Family Nursing, 20(3), 302-322. Byrd, M.M. & Garwick, A.W. (2006). Family identity: Black-white interracial family health experience. Journal of Family Nurs ing, 22(1), 22-37. Campbell, M.E. & Herman, M.R. (2010). Politics and policies: Attitudes tow ard multiracial Americans. Ethnic and Racial Studies, 33(9), 1511-1536. Charmaraman, L., Woo, M., Quach, A., & Erkut, S. (2014). How have researchers studied multiracial populations? A content and methodological review of 20 years of research. Cultural Diversity and Ethnic Minority Psychology, 20(3), 336-352. Ecklund, K. & Johnson, W.B. (2007). The im pact of a culturesensitive intake assessment on the treatm ent of a depressed biracial child. Clinical Case Studies, 6(6), 468-482. Giamo, L.S., Schmitt, M.T., & Outten, R. (2012). Perceived dis crimination, group identification, and life satisfaction among m ultiracial people: A test of the rejection-identification model. Cultural Diversity and Ethnic Minority Psychology, 28(4), 319-328. Farley, R. (2001). Identifying with multiple races. Report 01-491. Ann Arbor, MI: University of Michigan, Population Studies Center, (as cited in Shih, M. & Sanchez, D. T. (2009). W hen race becomes even more complex: Toward understanding the landscape of multiracial identity and experiences. Journal of Social Issues, 65(1), page 2. Jackson, K.F. & Samuels, G.M. (2011). Multiracial competence in social work: Recommendations for culturally attuned work with multiracial people. Social work, 56(3), 235-245. Jeffreys, M.R. (2005). Clinical nurse specialists as cultural brokers, change agents, and partners in meeting the needs of cultur ally diverse populations. Journal of Multicultural Nursing and Health, 11 (2), 41-48. Jeffreys, M.R. (2015). Teaching cultural competence in nursing and health care: Inquiry, action, and innovation (3rd Edition), New York: Springer. Jeffreys, M.R. & Zoucha, R. (2001). The invisible culture of the multiracial, multiethnic individual: A transcultural im pera tive. Journal of Cultural Diversity, 8(3), 79-84. Kenney, K.R. & Kenney, M.E. (2012). Contemporary US multiple heritage couples, individuals, and families: Issues, concerns, and counseling implications. Counseling Psychology Quarterly, 25(2), 99-112. Leininger, M.M. (1997). Understanding cultural pain for improved health care. Journal of Transcultural Nursing, 9, 32-35. Journal of Cultural Diversity • Vol. 24, No. 1 Nadal, K.L., Sriken, ]., Davidoff, K.C., Wong, Y., & McLean, K. (2013). Microaggressions w ithin families: Experiences of multiracial people. Family Relations, 6 2 ,190-201. Nazish, S.M. & O’Brien, K.M. (2011). Challenges and resilience in the lives of urban, multiracial adults: An instrument develop ment study. Journal of Counseling Psychology, 58 (4), 494-507. Remedios, J.D. & Chasteen, A.L. (2013). Finally, someone who “gets” me! Multiracial people value others’ accuracy about their race. Cultural Diversity and Ethnic Minority Psychology, 29(4), 453-460. Smith, T.D. & Maton, K.I. (2015). Perceptions and experiences in higher education: A national study of multiracial Asian American and L atin o /a students in psychology. Cultural Diversity and Ethnic Minority Psychology, 22(1), 97-104. Tran, A.G.T.T., Miyake, E.R., Csizmadia, A., & Martinez-Morales, V. (2016). “What are you?” Multiracial individuals’ responses to racial identification inquiries. Cultural Diversity and Ethnic Minority Psychology, 22(1), 26-37. Tutwiler, S.W. (2016). Mixed-race youth and schooling: The fifth minority. New York: Routledge. Spring 2017 Copyright of Journal of Cultural Diversity is the property of Tucker Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Marianne R. Jeffreys, EdD, RN and Rick Zoucha, APRN, BC, DNSc, CTNN Abstract: The main purpose of this introductory article is to evoke professional awareness, spark interest, stimulate thought, and disseminate information concerning multiracial, multiethnic (multiple heritage) individuals within the United States. General background information, terms, definitions, ethno-historical influences, practice implications, and current issues will be highlighted. Areas for further exploration will be proposed. Transcultural imperatives urge all nurses and other health care professionals to become active participants in the new cultural evolution of a different, broader worldview that uncovers the “invisible ” culture of multiple heritage individuals. The new vision challenges nurse and other health care professionals to embark upon a new journey in the quest for cultural congruent care for all individuals. K ey Words: Multiethnic, Multi-Racial Individual, Transcultural T he I nvisible C ulture of the M ultiracial, M ultiethnic I ndividual : A T ranscultural I mperative (R eprint from 2001) ith the projected increase of multiracial and multiethnic individuals in the United States (Johnson, 1997; Lee, & Fernandez, 1998; Perlmann, 1997; Spickard & Fong, 1995) and throughout the world, it is increasingly imperative that nurses and other health care professionals are adequately prepared to provide culturally congruent care for this growing population (Boushel, 1996). Prior to the 2000 census, people in the United States were given limited choice in responding to questions regarding one’s ethnic background (Fuchs, 1997; Light & Lee,1997). In 1990, for example, people had the choice of selecting one category: Black (African-American), Hispanic, White, Native American, Asian, Pacific Islanders and other. If an individual’s ancestry includes African American, German, and Cherokee, w hat do they choose? Al though we have entered a new millenium w ith great technological advances, the U nited States Census Bureau is still “unequipped” to allow multiracial per sons to claim their entire heritage (Cose, 1997; Fong, Spickard, & Ewalt,1995; Fuchs, 1997; Light & Lee, 1997). The forced choice of one category, two categories, or the “other” category makes the unique culture of the multiracial person “invisible”. The impact of this invis ibility is twofold: one, it hides the existence of mestizo W Marianne R. Jeffreys, EdD, RN is an Associate Pro fessor at The C ity U niversity o f N ew York, College of Staten Island, N ursing Department, Staten Island, New York. Rick Zoucha, APRN, BC, DNSc, CTN is an Associate Professor at Duquesne University, School of N ursing, Pittsburgh, PA 15282. Journal of Cultural Diversity • Vol. 24, No. 1 (mixing) in the United States (Nash, 1995); and two, it denies that being multiracial constitutes a “cultural experience” (Root, 1997). Culturally congruent nursing and health care can only occur when culture care values, expressions, or patterns are know n and used appropriately (Leininger, 1993). Unfortunately, the topic of multiracial and multiethnic people has not received attention in the nursing literature (Boushel, 1996); in other disci plines, “racially mixed” people have been addressed minimally in contrast to individually distinct racial or ethnic groups (Boushel, 1996; Deters & Rowland, 1995; Fong, Spickard, & Rowland, 1995; Gaines, 1999; Johnson, 1997; O’Neal, Brown, & Abadie,1997; Spick ard & Fong, 1995; Root, 1992; Root, 1997; Root, 1998). Nash (1995) traces the hidden Jiistory of mestizo (ra cial intermixture) in America and reveals that about three-quarters of African Americans are multiracial w ith an estimated one-third w ith Native American ancestry; Latino Americans, Filipino Americans, Na tive Americans, and millions of whites have multiracial roots (Nash, 1995; Root, 1992). Furthermore, scholars document that being multiracial constitutes a unique “reality” and “cultural experience” (Gordon, 1995; Johnson, 1997; Root, 1994; Root, 1997; Spickard & Fong, 1995; Vivero & Jenkins, 1999). Consequently, nursing and health care professionals have an ethical obligation to uncover the yet “invisible” culture of the multiple heritage individual. A comprehensive investigation is urgently needed to disseminate knowledge, research, and the skills needed to provide culturally congruent care for multiracial individuals. Spring 2017 An updated, computerized search of the nursing literature resulted in no references on this topic; a com puterized literature search in the medical, anthropology, sociology, and psychology disciplines also revealed a paucity of literature concerning multiracial and/or multiethnic individuals. The main purpose of this intro ductory article is to evoke prolessional awareness, spark interest, stimulate thought, and disseminate information concerning multiracial, multiethnic (multiple heritage) individuals. The scope of this article will be limited to multiracial, multiethhic (mulliple heritage) individuals within the United States. General background informa tion, terms, definitions, and ethnohistorical influences, practice implications, and current issues will be high lighted. Areas for further exploration will be proposed. Background Despite the scarcity of citations in the professional literature, various terms and definitions were used to describe individuals of mixed heritage. To develop a common knowledge base, several frequently used terms, definitions, and background information will be presented. The “orientational” definitions are not precise definitions but are intended to give a broad contextual meaning to each term. The reader is urged to critically appraise each meaning in terms of its social implications. Race is a way of categorizing humans into separate and distinct groups based on physical characteristics, geographical origins of one’s ancestors, and/or social status. Essentially, the purpose of classifying humans into distinct groups was to create a hierarchical tier, maintain boundaries between groups, and prevent op pressed groups from gaining power (Root, 1992). The term “biracial” often refers to an individual with two distinct racial heritages, usually one from each par ent. In a broader sense, the term biracial has been used to describe a prior history cf racial blending in past generations (Root, 1992). Ultimately, the term biracial may be too linear and limiting in understanding the multidimensionality of multiple heritage individuals. Since many individuals in the United States are unsure of their multigenerational heritage, the term multiracial is considered to be more accurate. Multiracial refers to an individual with two or more distinct racial heritages (Root, 1992). The definition of “race” and the recognition of ra cial differences, however, are culturally determined (King, 1981). Culture refers to “the learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guides their thinking, decisions, and actions in patterned ways” (Reynolds & Leininger, 1993, p. 19). Therefore, the cecision of racial identity by two individuals of common racial background to regard themselves as of the same or of different races is influenced by similarities ir. history, tradition, values, beliefs, norms, personal experiences, and lifeways rather than degree of similarity in genetic material (King, 1981). Ethnicity has been defined as “the sense of identifica tion of a collective cultural group based on the group’s common heritage” (Taylor, Lillis, & LeMone, 1997). It has been suggested that membership in a specific ethnic group can occur either through birth or through the adoption of group characteristics. Such characteristics include the sharing of common values, beliefs, norms, language, literature, food preferences, music, and art. At Journal of Cultural Diversity • Vol. 24, No. 1 times, the term ethnicity has been used interchangeably with race (Root, 1992). The term “biethnic” often refers to an individual with two distinct ethnic heritages, usually one from each par ent. For example, an individual with an Italian-American arent and an Irish-American parent could be labeled iethnic. In a broader sense, the term biethnic has been used to describe a prior history of ethnic assimilation in ast generations. Similar to the limitation with the term iracial, the term biethnic is often considered too linear and limiting in understanding the multidimensionality of multiple heritage individuals (Root, 1992). Since many individuals in the United States are un sure of their multigenerational heritage, the term mul tiethnic is considered to be more accurate. Multiethnic refers to an individual with two or more distinct ethnic heritages. At times, the term multiethnic has been used interchangeably with the term multiracial (Root, 1992). The term “multiple heritage individual” is proposed to encompass the terms biracial, multiracial, biethnic, and multiethnic individual. People who are multiethnic and multiracial are often pressured to make choices about “what they are.” Race is often assumed to be synonymous with ethnicity and culture, thus complicating the identity process and group belonging (Root, 1997). Within a heterogeneous society, racial and ethnic identity is an important com ponent in understanding the person holistically. Identity refers to the group or groups to whom an individual identifies, despite heritage or background. The process by which multiple heritage individuals develop identi ties is complex and multidimensional. Various factors (background, social, legal, political, historical, economic, and environmental) interact and influence identity de velopment. ). It may be impossible for an individual who is multiethnic an d /o r multiracial, if forced, to choose one ethnic racial identity and own it without giving up the other (Hall, 1992; Pinderhughes, 1995). Multiple heritage identity can include simultaneous membership with two or more distinct groups, membership within one select group, synthesis of cultures, an d /o r fluid identities with different groups that changes with time, circumstances, and setting (Daniel, 1992; Root, 1992; Spickard & Fong, 1995). Additionally, multiple heritage individuals often acknowledge being “multiracial” or “multiethnic” as a separate and unique culture (Root, 1997; Spickard, 1997). Although it is beyond the scope of this first article to elaborate on the concept of identity, it is important to acknowledge that many individuals experience a unique multiracial and multiethnic culture; this demands a new, evolutionary cultural awareness in thinking about this issue. This awareness should incorporate the conscious choice of a neutral, non-denigrating term to describe “mixed” individuals and value their uniqueness (Root, 1997; Spickard, 1997). For example, in the Hawaiian culture, the acceptance of multiethnic and multiracial individuals is evidenced by the existence of a term to describe such individuals. Hapa (literally translated as meaning “half”) has been used for generations to describe the uniqueness of individuals with multiple heritages. In the Hawaiian context, the word carries no stigma or baggage and signifies acceptance of people who are multiethic and multiracial (Sato, 1999). There is an acceptance of difference that regardless of hapa all Spring 2017 are viewed as one culture (C. Ruiz, personal communica tion, July 10,1999). The significance of this is that hapa individuals are not alienated or marginalized, as would be the case in most other parts of the United States. The term hapa is now gaining broader use beyond the Hawaiian islands. Other self-descriptive terms used by persons of mixed ancestry in Hawaii are cosmopolitan or local (Johnson, 1992). Within Hawaii, mixed ancestry predominates and personal attributes are more important than race or ethnicity in mate selection. It is predicted that in a few generations the mixed ancestry individual (hapa, cosmopolitan, and local) will be viewed as the one culture within Hawaii (Johnson, 1992). Ethnohistory Ethnohistory refers to those past facts, events, instanc es, and experiences of individuals, groups, cultures, and institutions that are primarily people-centered (ethno) and that describe, explain, and interpret human lifeways within particular cultural contexts and spacetime referents (Leininger, 1991). When exploring the “invisibility” of multiracial people in the United States from an ethnohistorical approach, numerous attempts to suppress multiple heritage identification are revealed. These attempts, made by the white dominant society, sought to oppress nonwhites and benefit whites. The first documented interracial marriage in America, be tween John Rolfe and Pocahontas, provides one such example. The English accepted this marriage since such a union would prevent attacks from the Indians and allow for further undisturbed colonization. When visiting England in 1617, however, Pocahontas was iven the name “Rebecca” in an attempt to anglicize er, thus making her heritage “invisible” (Nash, 1995). Most historical accounts of interracial unions between whites and Indians in the 1600s through the 1800s oc curred with white men (settlers, colonists, fur traders) and Indian women. Such unions benefited whites by enhancing trade and settlement opportunities. The term “half-breed” was a denigrating term created by whites to describe the offspring of such unions and limit op portunities only afforded whites. The dichotomous classification system of “white versus non-white” is another such example. Interracial marriages and unions were illegal in most states until 1967 (Pascoe, 1996). As a result, multiracial individu als were labeled as “illegitimate” or “out of wedlock” and often suffered the subsequent social and economic stigmas of illegitimacy associated with the era. Birth certificates usually only acknowledged one race. Until recently, multiracial newborns were recorded as non white, thereby resulting in a forced identity while ignor ing the other(s). In other words, birth records followed the hypodescent rule that one could only identify with one group. Furthermore, the multiracial individual was assigned to the racial group with lower social status. For example, the “one-drop rule” labeled anyone with any known African ancestry as an African-American (Root, 1992). Such a practice marginalizes the many United States citizens who have multigenerational multiracial roots. Even today, cancer statistics have focused primarily on white versus black groups. Death records account for only one racial heritage. The importance of acknowledg g Journal of Cultural Diversity • Vol. 24, No. 1 ing multiple heritage identification in genetically-linked diseases should be obvious. Since the development of appropriate illness prevention protocols, treatment interventions, and genetic counseling is usually based upon racial identification, multiple heritage identifica tion should be actively encouraged (Dakis & Rubin, 1997). Likewise, birth records usually account for only one racial heritage. Although blacks are reported to have higher rates of low birthweight infants, the statistical sig nificance of this finding varied when multiracial (blackwhite) infants were listed as white as opposed to black (Migone, Emmanuel, Mueller, Daling, & Little,1991). Perhaps socioeconomic status an d /o r prenatal care are variables that transcend race and warrant further evalu ation and have greater significance. The multiracial baby boom in the United States can be traced to the repeal of the last laws against misce genation (race mixing). From the 1660s through the 1960s, miscegenation laws imposed racial restrictions and reflected the racial ideologies of white Americans (Pascoe, 1996). Such laws existed in 41 American colo nies or states at one time or another and prevented mar riage between whites and one or more of the following groups: African Americans, American Indians, Chinese, Japanese, Koreans, Malays, Filipinos, Mongolians, and Hindus. Additionally, 22 colonies or states prohibited interracial sex. One state (New York) prohibited inter racial sex but not interracial marriage. Between 1850 and 1970, 227 appeals court cases involving miscegenation were recorded. Ninety-five of these cases were listed as criminal cases (Pascoe, 1996). Although there are many other events, laws, and experiences that have contributed to the development of lifeways within a multiracial perspective, it is beyond the scope of this article to explore all ethnohistorical dimensions. It is recommended that future literature reviews explore the ethnohistory of specific subgroups of multiple heritage individuals (for example: American Mexican-European or Cherokee-African-American). The overwhelming “invisibility” of multiple heritage individuals within the professional literature demands the visibility of new, innovative transcultural health care imperatives. Transcultural Imperatives in Nursing and Health Care Past and current teachings in transcultural nursing have focused upon the cultural care needs of the per son, family, and community (Leininger, 1995). Many transcultural nursing researchers and scholars (Leini nger, 1995; McFarland, 1997; Purnell & Paulanka, 1998) have focused research on seeking to understand the worldview and cultural care needs of individuals and families of one particular culture. Historically, trans cultural nursing theories and models (Leininger, 1995; Campinha-Bacote, 1998; Purnell & Paulanka, 1998, Giger & Davidhizar, 1995) have the capability of viewing the individual, family and group within the context of their particular culture and may have the flexible capacity of viewing the multiethnic, multiracial individual with their unique cultural background. However, most trans cultural nursing and health care research has focused on the individual in the context of one particular culture. The concept of cultural care and its definitions must now go beyond the worldview of the select cultures Spring 2017 studied in the past. It has been appropriate to under stand the cultural care needs of African, Mexican, Pol ish, Italian, German, Spanish, Arab, Japanese, Filipino, Greek and Irish American, to name a few. However, the time has come to understand that in the evolution of cultures in the United States, a changing demographic view is emerging. People of minority status (according to the U.S. Census) have surpassed 75 million, with one in every four people living in the United States being of racial or ethnic minority. In addition, the United States is rapidly moving towards a multiracial, multiethnic society with an addition of over 1,000,000 immigrants entering and living in the United States every year. (Westpnal, 1999). Many people in the United States can no longer claim a unicultural background, therefore, viewing and acceptance of the specific cultural needs of multiethnic, multiracial individual and their families is imperative to the health and well being of all involved. This dramatic change in the ethnic, cultural make up of people will affect the cultural care needs of people from very different cultural backgrounds of the past. Understanding multiracial and multiethnic indi viduals can be considered the new phase of discovery in transcultural nursing and health care. Nurses and other health care professionals must see the world and the people in it as different than what they have come to understand. The challenge of transcultural health care is to demonstrate a richer understanding of mul tiracial, multiethnic individuals and families in order to promote culturally congruent care. In addition to acknowledging the cultural evolution occurring in the United States, it is imperative that transcultural nurs ing and health care understand the impending cultural revolution. The term presented here is not meant to describe the revolution of the military or of a particular generation, but a revolution of thinking. The cultural evolution and revolution occurring in the United States has the potential to bring about a different worldview regarding cultural care and caring. What is the impact of large groups of people who do not claim identity with a particular ethnic and or racial group, but have shared identities? Transcultural nurses and other health care professionals will be presented with an entirely new set of cultural care values that may be a blending of many cultural values possibly resulting in the Hawaiian view of hapa or cosmopolitan. Thinking differently about the culture care needs of multiple heritage individuals is complex because there may be a tendency for nurses to treat people according to a past belief without fully understanding the indi vidual cultural care needs. For example, nurses may make assumptions about culture care needs based on an individual’s physical appearance. If a person looks Euro-American but actually represents the multiethnic ity of Mexican American, Euro-American and African American heritage, then the assumptions may not be correct. Stereotyping based on physical appearance may be promoting culturally imposed care based on wrong assumptions. The key to promoting culturally congruent care is based on the ability of transcultural nurses being self reflective about their own culture, and being open, honest and real in relating with multiethnic, multiracial individuals (Zoucha, 2000). Journal of Cultural Diversity • Vol. 24, No. 1 Issues of Concern In contemporary society in the United States, grave issues such as prejudice, discrimination, racism, and stereotyping occur for people of color and multiethnic, multiracial people everyday. No longer can the issues, thoughts, and actions of people (and especially nurses and other health care professionals) be dismissed as “just merely a lack of understanding”. Views and actions of racism, prejudice, discrimination, and stereotyping can and does effect the nurse patient / family relationship (Zoucha, 1998). With increasing numbers of people who are multiethnic, multiracial there are increased opportu nities to be targets of prejudice, discrimination, racism, and stereotyping. The actions of racist people affect not only the individual but also may have a negative impact on the families of multiethnic, multiracial individuals (Morrison, 1995; Nash, 1997; Ropp, 1997; Small, 1994; St. Jean, 1998; St. Jean & Parker, 1995; Williams, 1996). The issues of racism, prejudice, discrimination, and stereotyping cannot be addressed lightly, but rather head on in a direct and honest manner. Transcultural nurses have the opportunity to be leaders in the promo tion of culturally congruent nursing care for multieth nic, multiracial individuals and families. In the future, transcultural nursing research studies must address and fervently seek to understand the cultural care needs of multiethnic, multiracial individuals and families. Multi ethnic, multiracial individuals present unique concerns and challenges for transcultural nurses because of the lack of research and published studies addressing their unique needs. Transcultural nursing theories and models (Leininger, 1995; Campinha-Bacote, 1998; Purnell & Paulanka, 1998, Giger & Davidhizar, 1995) have the potential to address the specific cultural care needs of multiethnic, multiracial individuals and their families. This paper offers the challenge to nurse theorists, researchers, practitioners, educators and other health care profes sionals to embrace the impending cultural evolution and revolution and understand the potential cultural care concerns of the growing number of multietlmic, multiracial individuals in the United States. In the spirit of transcultural nursing and health care, embracing a different worldview will promote culturally congruent care, health, and well-being to people of many cultures — including people who are multiethnic and multiracial. Acknowledging the uniqueness of multiple heritage individuals, w ithout attaching pity, stigmatization, alienation, marginalization, or lowered social status, is an important first step in making this “culture” truly visible and fully appreciated. In this new millenium, all nurses and other health care professionals must become active participants in the new cultural revolution that seeks to embrace the evolution of a different, broader worldview. This new vision challenges nurses and other health care professionals to embark upon a new journey in the quest for cultural congruent care for all individu als. Spring 2017 REFERENCES Boushel, M. (1996). Vulnerable multiracial families and early years services: Concerns, challenges and opportunities. 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Spring 2017 Copyright of Journal of Cultural Diversity is the property of Tucker Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. 606202 research-article2015 TCNXXX10.1177/1043659615606202Journal of Transcultural NursingWoods et al. Research Department Aging, Genetic Variations, and Ethnopharmacology: Building Cultural Competence Through Awareness of Drug Responses in Ethnic Minority Elders Journal of Transcultural Nursing 2017, Vol. 28(1) 56–62 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659615606202 tcn.sagepub.com Diana Lynn Woods, PhD, RN, APRN-BC, FAAN, FGSA1, Janet C. Mentes, PhD, APRN-BC, FGSA1, Mary Cadogan, DrPH, RN, GNP-BC, FAAN, FGSA1, and Linda R. Phillips, PhD, RN, FAAN, FGSA1 Abstract Unique drug responses that may result in adverse events are among the ethnocultural differences described by the Agency for Healthcare Research and Quality. These differences, often attributed to a lack of adherence on the part of the older adult, may be linked to genetic variations that influence drug responses in different ethnic groups. The paucity of research coupled with a lack of knowledge among health care providers compound the problem, contributing to further disparities, especially in this era of personalized medicine and pharmacogenomics. This article examines how age-related changes and genetic differences influence variations in drug responses among older adults in unique ethnocultural groups. The article starts with an overview of age-related changes and ethnopharmacology, moves to describing genetic differences that affect drug responses, with a focus on medications commonly prescribed for older adults, and ends with application of these issues to culturally congruent health care. Keywords gerontology, nursing practice, transcultural health Introduction Unique drug responses that may result in adverse events are among the ethnocultural differences described by the Agency for Healthcare Research and Quality (2012). For example, adverse events associated with low-molecular weight heparin and warfarin are significantly higher among Black versus White elders (Agency for Healthcare Research and Quality, 2012). While these differences may be attributed to a lack of adherence on the part of the older adult, another plausible explanation is that they are produced by interacting factors that influence the response to drug therapy in different ethnic older adults. In addition, the paucity of research and the concomitant lack of knowledge among health care providers may compound the problems, contributing to further disparities, especially in this era of personalized medicine and pharmacogenomics. To be truly culturally competent, nurses need to be proficient with information about age-related changes and genetic differences, whether they are prescribing medications or monitoring medication responses. The purpose of this article is to explain how age-related changes and genetic differences influence variations in drug responses among older adults in unique ethnocultural groups. The discussion starts with an overview of age-related changes and ethnopharmacology, moves to describing genetic differences among ethnocultural groups that affect drug responses, and finally uses examples of specific medications commonly prescribed for older adults to highlight unique drug responses among ethnocultural groups. The application of these issues to culturally congruent health care will also be discussed. Aging-Related Changes and Ethnopharmacology Despite the great heterogeneity in health status and functional levels within the elderly population, aging generally increases an individual’s risk of illness and, subsequently, increases use of medications. Although persons more than age 1 University of California, Los Angeles, CA, USA Corresponding Author: Diana Lynn Woods, PhD, RN, APRN-BC, FAAN, FGSA, Azusa Pacific University, 701 East Foothill Blvd, Azusa, CA 91702-7000, USA. Email: email@example.com Woods et al. 65 represent merely 13% of the total U.S. population, they consume an estimated 34% of all prescription medications and 30% of all over-the-counter drugs, with four types of medications (warfarin, insulin, oral antiplatelet agents, and oral hypoglycemics) accounting for 67% of all adverse drug responses resulting in emergency hospitalization across all ethnic groups (National Council on Patient Information and Education, n.d.). The cost of medication-related problems in older adults is upward of $76.6 billion for clinic care, $20 billion for hospitals, and $4 billion for nursing home care (Fick, Mion, Beers, & Waller, 2008). Of community-dwelling older adults more than age 64, two out of five take 5 or more medications, whereas older persons (>80 years), older hospitalized patients, and older adults in residential care take 7 to 11 medications (National Council on Patient Information and Education, n.d.). The dearth of knowledge about the interactions of drugs and physiological changes in aging can lead to polypharmacy (the use of five or more medications). Polypharmacy, recognized as a geriatric syndrome, increases the risk of drug–drug interactions, including interactions with over-thecounters such as herbal supplements (Qato et al., 2008), the risk of use of potentially inappropriate medications in older adults (Weng et al., 2013), and the risk of hip fractures (Qato et al., 2008). Further complicating the picture is that few drug studies include adults >80 years with several comorbidities, thus missing potential drug–drug interactions related to age and comorbidities. The prescribing cascade is frequently seen in older adults. This phenomenon occurs when a drug-induced adverse response is misinterpreted as a new disease or condition with additional drugs prescribed to treat the “new problem,” leading to additional complications. Polypharmacy accounts for up to 30% of all hospitalizations for all older adults (Fick et al., 2008). Ethnic minority elders are even more vulnerable to polypharmacy and hospitalization for several reasons including those related to the social determinants of health such as socioeconomic status, and access to resources (Haas, Krueger, & Rohlfsen, 2012), and increased allostatic load, the cumulative wear and tear on biological systems over time (see Beckie, 2012, for a review). These life course factors can alter responses to life stresses and increase physiological vulnerability resulting in more coexisting chronic disease at earlier ages, 45 to 50 years instead of 65 to 70 years (Geronimus, Hicken, Keene, & Bound, 2006). Moreover, genetic variations, about which little is currently understood, play a major role in pharmacokinetics (absorption, metabolism, distribution, and elimination) and pharmacodynamics (mechanism of action and effects at the target site). Researchers still do not fully understand the physiological mechanisms of aging or the interaction of age-related changes with often multiple drug responses, especially in the context of biological variations related to ethnicity. Aging and Altered Drug Responses Aging changes make all older adults vulnerable to altered responses to medications. Some of these changes include a 57 reduction in lean body mass, a reduction in bone mass, a decrease in total body water, altered renal function, altered hepatic metabolism, decreased serum albumin, increased stomach pH, and decreased absorptive surface. Important age-related changes in body composition and functioning are relevant to drug disposition and, in turn, affect drug concentration. These changes have significant implications for elders in general and are even more pertinent to ethnic minority elders (Institute of Medicine (US) Committee on Pharmacokinetics and Drug Interactions in the Elderly, 1997). The absorption of drugs (which affects the duration and intensity of drug action) does not generally appear to be significantly altered in the elderly; however, the distribution of drugs may be affected. Certain physiological and physiochemical properties including cardiac output and regional blood flow determine how a drug is distributed through the body. The drug is distributed to the heart, liver, kidney, brain, and other highly perfused organs during the first few minutes after absorption. Delivery to muscle, viscera, skin, and fat occurs later and at lower levels (Porth, 2014). In addition, distribution may be limited to the vascular compartment by the drug binding to plasma proteins, particularly albumin and alpha1-acid glycoprotein. As the production of albumin by the liver generally declines with age, there is an age-related rise in the free fraction (that which is available and has a biologic effect) of any highly albumin-bound drug such as psychotropic medications (Keltner & Folks, 2001). In addition, as lean body mass and total body water fall, both in absolute terms and as a percentage of body weight, the volume of distribution of highly lipid soluble drugs, such as most psychotropic medication, are affected. In light of the aging-related changes associated with altered drug metabolism and adverse drug responses seen in older adults, the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (The American Geriatrics Society [AGS], 2012) was created in 1991 as a prescribing guide for clinicians. Drugs on the Beers list are categorized according to level of risk for adverse outcomes with ratings including drugs that should be avoided, drugs that should be avoided with certain other medical conditions, and drugs that should be used cautiously. Potentially inappropriate medications were still being widely prescribed for elders in the United States, Canada, and Europe as recently as 2005 (Fialová et al., 2005). One limitation of the Beers Criteria is its lack of focus on multiple drug interactions and comorbidities. Another limitation, most important to this discussion, is that the Beers Criteria does not include consideration of genetic differences that characterize ethnically diverse older adults. Nevertheless, the list is an extremely important tool for understanding the complexity of prescribing for older adults and monitoring drug responses. These aging changes coupled with the genetic differences present in elder ethnic minority populations serve to further increase older adults’ vulnerability to unexpected drug responses. 58 Ethnopharmacology, Genetic Differences, and Drug Responses The field of ethnopharmacology, which deals with ethnocultural differences and the concomitant genetic differences that affect a person’s response to a specific drug, is relatively new. Genetic differences influence both pharmacokinetics and pharmacodynamics. The aspect of pharmacokinetics most studied is metabolism—enzymes and transport receptor protein binding, while the aspect of pharmacodynamics most studied is the intensity of therapeutic and adverse effects. The majority of the studies discuss the metabolism aspect of pharmacokinetics. Most medications act by binding to receptors at the cell surface, while others require transport between cells through passive diffusion (i.e., carriermediated transport in which there is no input of energy) or facilitated diffusion (i.e., active transport through carriermediated membrane transport). Few studies examine the effects of age, gender, or ethnicity on transport mechanisms. Drug concentration also depends on pharmacokinetics. There is mounting evidence from pharmacogenetic studies that ethnic populations vary significantly in the genetic variants of enzymes that determine drug disposition, metabolism, variants of drug receptors, or protein binding (Lin & Smith, 2000; Solus et al., 2004; Takane, Shikata, Otsubo, Higuchi, & Ieiri, 2008). Moreover, factors such as diet and tobacco use can influence a gene’s expression, which can in turn alter a drug’s effect (Burroughs, Maxey, & Levy, 2002; Lin & Smith, 2000). However, whether ethnicity is an important contributor to the variable outcomes of drug treatment remains a matter of some debate (Shah, 2007). Also, how age-related biological changes influence these mechanisms requires research. With the advent of genomics some believe that for the first time drug candidates may be available for “race-specific” therapy. “Race-specific” therapy draws rationale from the presumption that the frequencies of genetic variants influencing drug efficacy are substantially different among races. This perspective has limitations since race is embedded in both culture and ethnicity. The use of the word race to describe differences is fraught with a long history of prejudice and discrimination (Cooper, Kaufman, & Ward, 2003). However, currently the terms “personalized medicine and pharmacogenomics” may in fact be replacements for “racespecific therapy.” Regardless of the terms used, this perspective provides a false sense of distinctiveness among different “racial” groups and does not account for gene flow, a term that describes the lack of real boundaries and concomitant sharing of genes among the races through intermarriage over generations. Genetic Differences Among Ethnocultural Groups In general, genetic differences exist between individuals in different ethnic groups; however, they remain poorly understood. Moreover, the lack of homogeneity within ethnic groups means that biological differences are even less well Journal of Transcultural Nursing 28(1) understood. However, several population-based studies indicate that drugs are metabolized differently in different groups. For example, genetic differences in ethnocultural groups are evident in antihypertensives and drugs for cardiovascular disease (McDowell, Coleman, & Ferner, 2006), anticoagulants (Garwood et al., 2010; Wadelius et al., 2007; Yuen, Gueorguieva, Wise, Soon, & Aarons, 2010), hypoglycemic agents (Shu et al., 2003), and psychotropics (Murphy & McMahon, 2013). Studying ethnic differences is challenging in part because of the variations that exist within each ethnic group based on gene flow. However, ethnic differences could still account for interactions between genetics, environment, society, and other factors (Haas et al., 2012). Genetic differences in enzyme action affect drug metabolism and consequently therapeutic and adverse responses. Many of the described genetic differences that affect drug metabolism are due to polymorphisms, natural variations in a gene, DNA sequence, or chromosome that have no adverse effects on the individual and occur with fairly high frequency in the general population. One of the most common sites for the metabolism of drugs is the liver. Interindividual and intraindividual variability in the metabolism of many drugs is largely determined by genetic differences in enzyme content that influence variations in hepatic drug clearance and may be altered by aging changes in the liver. A general discussion of hepatic metabolism follows including a discussion of anticoagulant and antihypertensive medications, hypoglycemic agents, and psychotropic medications as exemplars of how genetic differences affect responses to these medications. Hepatic Metabolism Drugs are metabolized in the liver in an oxidation phase (Phase 1) and a conjugation phase (Phase 2). Recent research has focused on the oxidative phase, specifically Cytochrome P-450 (CYP450) enzymes and the enzyme subgroups since these enzymes are responsible for the metabolism of many widely prescribed drugs, including those for type 2 diabetes (metformin), anticoagulants such as warfarin, and psychotropics such as antipsychotics and antidepressants. Many studies have indicated that genetic differences in the CYP enzymes are not only extremely common but have profound implications for drug metabolism (Lin & Smith, 2000; Solus et al., 2004). Keltner and Folks (2001) noted that the genetic ability to produce these enzymes varies by ethnicity. For example, genetic changes in specific CYP alleles affect the rate of drug metabolism, which in turn affects the plasma level of the drug and the bioavailability of the drug. Those with two functional copies of CYP2D6 metabolize drugs more rapidly (rapid metabolizers [RMs]), while those with fewer functional copies metabolize some drugs more slowly (slow or poor metabolizers [PMs]), resulting in higher serum levels of the drugs. These genetic differences affecting drug metabolism also differ significantly within ethnic groups. For example, Luo, Aloumanis, Lin, Gurwitz, and Wan (2004) 59 Woods et al. found that 18% of Ethiopian Jews and 13% of Sephardic Jews had more than two functional CYP2D6 genes and metabolized some drugs rapidly compared with 6% of Yemenite Jews and 4% of Bedouin Arabs. In addition, since increased age is associated with a decline in the ability of the liver to detoxify drugs, older adults in general are at higher risk for being PMs. Specific Medications Commonly Prescribed for Older Adults Anticoagulant Medications Use of anticoagulants among older adults presents problems. One problem relates to genetics. For example, the CYP2C enzyme, a subfamily of the CYP enzyme, accounts for approximately 20% of total hepatic CYP450 enzymes. Specifically, CYP2C9 is responsible for 80% to 85% of the metabolism of warfarin. Persons with one variant of CYP2C9 allele (*2 or *3) have an increased sensitivity to warfarin, with an increased risk of bleeding, necessitating a decreased dose. Genetic differences in CYP2C9 alleles *2 or *3 occur in 87% of ethnic Chinese, and are associated with lower warfarin doses, while another variant, occurring in 9% of Chinese is associated with higher warfarin doses (Yuen et al., 2010). Thus, the picture remains complex. An example of the interaction between aging changes and ethnocultural genetic differences is found in the difference between the therapeutic doses of warfarin required by older adults of European ancestry compared with those of African American ancestry. African Americans require higher doses of warfarin to decrease thromboembolic risk than their European counterparts, while the amount of warfarin required by both groups decreases with age (Garwood et al., 2010). In addition, warfarin dosing is affected by comorbidities and the numerous drugs (five-seven) used to treat common comorbid illnesses experienced by older adults with oftentimes complex drug regimes. The net result can be problems with bleeding and emergency room utilization. Antihypertensive Drugs Ethnic differences are also evident for those medications used to control hypertension. Given the high prevalence of hypertension in ethnic minority elders combined with the fact that many of these drugs are on the Beers list, health professionals need to be well informed about drugs prescribed for hypertension. Research over the past 20 years has found that African Americans respond differently to angiotensin-converting enzyme (ACE) inhibitors, which are less effective in African Americans than in Whites (Exner, Dries, Domanski, & Cohn, 2001). However, African Americans respond well to hydrochlorthiazide and calcium channel blockers compared with Whites (Wright et al., 2005). A recent review by Richardson, Freedman, Ellison, and Rodriguez (2013) sheds light on the genetic differences that are likely responsible for these differing responses. African Americans have a greater frequency of low plasma rennin activity (52%) than their White counterparts (31%). Interestingly, ACE levels are positively associated with higher blood pressure in Whites, while the rennin angiotension-aldosterone system does not play a significant role in hypertension frequently seen in African Americans and other Blacks such as those of Caribbean Hispanic origin (Laffer & Elijovich, 2002). This difference accounts for the efficacy of ACE inhibiters for the treatment of hypertension in Whites. Overactivity of the rennin angiotension-aldosterone system is believed to play a significant role in hypertension in Whites. In non-Hispanic Blacks high salt intake, salt retention, and/or volume overload is the main culprit in hypertension. Salt sensitivity, defined, as blood pressure that responds acutely to changes in salt intake, is likely related to salt retention (Richardson et al., 2013). Further exploration of the mechanisms and potential therapies for salt sensitivity will likely shed light on the origin of hypertension seen more commonly in non-Hispanic Blacks. Several mediators of salt sensitivity are genetically determined. These include nitric oxide, a potent vasodilator, increased levels of aldosterone linked to fluid retention and potassium (Richardson et al., 2013). Moreover, salt sensitivity is positively correlated to age in general, and especially affects vulnerable ethnic minority older adults, potentially resulting in adverse drug responses and/or overtreatment or undertreatment for elevated blood pressure. Further complicating this picture is a phenomenon known as the aging paradox, where a higher percentage of Black men than Black women have hypertension (HBP) until 45 years of age, then from 45 to 64 years, the percentages of men and women with HBP are similar, after which a much higher percentage of women have HBP than men (Manton, Poss, & Wing, 1979). These are only some of the differences seen in drug response to antihypertensive drugs between non-Hispanic Blacks and Whites. Hypoglycemic Agents Diabetes occurs in about 40% of White older adults more than 80 years of age, while ethnic minority older adults have an even higher prevalence. Ethnic differences in the prevalence of type 2 diabetes mellitus (T2DM) are evident, with non-White populations such as American Indians and African Americans having the greatest risk (Norris & Rich, 2012). One example of genetic differences that influence the drug response is found in the organic cation transporter (OCT) family of transporter genes that occurs in three forms, OCT1, OCT2, and OCT3. These genes occur abundantly in the liver, play a major role in the hepatic uptake and renal transport of metformin, an oral hypoglycemic agent, widely used for treating T2DM as first-line monotherapy (Takane et al., 2008). Although they are three forms of OCT, in a number of ethnocultural groups, polymorphisms occurring in OCT1 are associated with decreased transporter activity. For example, 60 polymorphisms occur in 80% of Southern Indians of Tamilian origin, Koreans (74%), Japanese (81%), Asians residing in the United States (76.2%), and African Americans (73.5%; Shu et al., 2003), which is significantly higher than found in European Caucasians from the United States (59.8%), Germany (57.4%), and the Netherlands (60.3%; Takane et al., 2008). These differences significantly alter the renal clearance of metformin, such that Caucasians tend to clear metformin more quickly requiring more of the drug, while those with decreased transporter ability require less medication or perhaps a medication that is not dependent on this specific transporter to obtain the optimal hypoglycemic effect. There continues to be significant gaps in our knowledge regarding ethnocultural differences and T2DM. Understanding the genetic basis of glucose homeostasis and insulin resistance should provide insight on known and novel metabolic pathways that inform potential therapeutic and intervention targets. To avoid problems with oral hypoglycemic agents, providers may change from an oral agent to an insulin regimen including a sliding scale based on glucose levels. However, the Beers Criteria advises clinicians specifically to avoid prescribing insulin on a sliding scale for any older adult (AGS, 2012). Psychotropic Drugs Psychotropic drugs, such as antidepressants and antipsychotics, are commonly prescribed for older adults for depression and for new onset behavioral disturbances associated with dementia, agitation, and sleep problems with suboptimal results. For ethnically diverse older adults, the results are even less optimal. African Americans show poorer outcomes on multiple measures (Gonsalez et al., 2010) as do other nonWhite groups. Although these outcomes are complicated by psychosocial adversity and comorbidities, genetic differences play a role and poorer outcomes are not inevitable (Murphy & McMahon, 2013). The Beers Criteria recommend that psychotropics such as antipsychotics be used with caution and not be prescribed for behavior disturbances associated with dementia unless nonpharmacological measures have been tried and have failed. The Beers Criteria recommend avoiding use of all benzodiazepines (e.g., Lorazepam [Ativan] in all older adults; AGS, 2012). These issues are multiplied in ethnic minority older adults given genetic differences and lack of research supporting therapeutic effects. Most psychotropic drugs such as antipsychotics and antidepressants are metabolized in the liver. The differential speed of metabolism (RMs or PMs) of psychotropic medication, is dependent on genetic polymorphisms in CYP450 that influence liver metabolism. Examples of drugs that are affected by these polymorphisms are antidepressants, antipsychotics, benzodiazepines, and anticonvulsants. Thus, PMs will likely require less of the medication than the recommended dose, while RMs might require more than the recommended dose. These genetic differences are implicated Journal of Transcultural Nursing 28(1) in side effect profiles as well (Murphy & McMahon, 2013). Serretti, Kato, De Ronchi, and Kionshita (2007) found that Whites metabolized selective serotonin reuptake inhibitors antidepressants more efficiently than Asians due to genetic differences. In general, several Asian subgroups are PMs of phenytoin, an anticonvulsant, with approximately 20% of Japanese classified as PMs compared with about 4% of Caucasians (Jurima, Inaba, Kadar, & Kalow, 1985). Interestingly, Asians living in Canada exhibit drug metabolism similar to Caucasians (Jurima et al., 1985), suggesting a gene–environment interaction affecting these specific enzymes. A more complete discussion of these complex and interesting differences can be found in the classic text, The Psychopharmacology and Psychobiology of Ethnicity (Lin, Poland, & Nakasaki, 1993). Plasma protein binding must also be considered with psychotropics. These medications are largely lipophilic, meaning that they are soluble in fat and depend on plasma proteins for their transport. The plasma proteins generally regarded as most important to solubility are the glycoproteins and albumin, which are genetically determined and vary across ethnic groups. Normal aging changes such as an alteration in the muscle/fat ratio, with an increase in fatty tissue, mean that more of the psychotropic drugs are in solution. This coupled with changes in albumin can result in unintended drug responses frequently assessed as adverse medication events. Since psychotropics mainly work directly or indirectly by affecting brain receptors, any ethnic variation in the structure and function of brain receptors can alter the effect of the drug. Such alterations can lead to a malfunctioning of the receptor and thus an alteration in drug response. To date, little research has examined ethnic differences in the structure and function of receptors and the potential clinical relevance. Herein lies another fruitful area of exploration to improve the precision and appropriateness of prescribing and monitoring drug responses. Implications for Culturally Congruent Health Care For nurses, cultural competence includes knowledge about prescribing and monitoring drugs for elders in unique groups as well as advocacy for ethnically diverse elders related to adherence to prescribed medication regimens. Specifically, to become culturally competent, they must begin to appreciate the interplay of genetic, cultural, and social factors that may create differential drug responses. Nurses must understand that the differences in drug responses that are frequently attributed to a lack of adherence to a medication regime on the part of the older adult, may in fact be related to the complex interactions among genetic differences, gene flow, gene–environment interactions, and aging-related changes. In addition, drug responses may be influenced by cultural-based food preferences, food availability, or socioeconomics. Early work by Branch, Salih, and Homeida (1978) found differences in drug metabolism among Sudanese living in their home villages compared with those 61 Woods et al. living in Britain and Whites in Britain. Other researchers (Allen, Rack, & Vaddadi, 1977) studying selective serotonin reuptake inhibitors antidepressants and Clozapine, an antipsychotic, found that drug responses were similar to those in the country of origin if immigrants retained their cultural dietary habits. All of these findings suggest an influence of diet on drug responses which underscores the importance of nurses obtaining a complete diet history for individuals in unique ethnic groups and advocating for other health professionals to consider diet as a source for unexpected drug responses. From a clinical perspective in prescribing or monitoring a drug regimen in ethnically diverse older adults, these differential drug responses must be given consideration to guide practice. Given aging changes, genetic differences, the presence of coexisting illness (comorbidities), and multiple medications, the potential for drug interactions and harmful side effects such as delirium, hospitalization, and falls increases exponentially in older adults. Typically, older adults are overmedicated for health problems, however, some of the polypharmacy seen in older adults may be related to genetic differences related to drug metabolism making a prescribed drug less effective, precipitating a clinician to add another medication in attempt to treat the health problem. Some of the problems can be avoided by consulting resources about appropriate prescribing practices for older adults such as the Beers criteria. Even though the Beers list does not address ethnic differences, it is currently the best source of information available. This deficit emphasizes an urgent need for research in this area. To fill in the information about ethnic differences, nurses need to regularly consult the ethnopharmacology literature to be up-to-date about the latest research. Suffice it to say that the phenomenon of drug response in ethnic minority elders is complex and requires extraordinary knowledge and sensitivity to adequately assess responses to drugs and to formulate appropriate regimens. Therefore, nurses and other health care professionals must be slow to assume that drug nonresponse is a result of nonadherence in ethnic elders. Instead, all health care professionals have a responsibility to advocate for further assessment of drug nonresponse and for drug regimens that are simple and with the fewest drugs to adequately treat the older adults’ health problems. In an era of pharmacogenomics and personalized medicine, it is critical that nurses increase their knowledge about genetic differences that affect drug responses in the care of older adults from differing ethnocultural groups. This knowledge is essential for nurses to attain proficiency in prescribing and monitoring drug responses and to be culturally competent in a new and rapidly expanding field. While we are advocating for increased genetic knowledge, there also is a word of caution. As Clarke et al. (2012, p. 12) asserted, that while “New knowledge of the human genome is transforming . . . our understanding of evolution and human disease,” our new challenge lies in interpretation and application. The statement applies equally to the complexity of drug responses and to ethno-gero-pharmacology. One size does not fit all. Nursing’s strength lies in a biopsychosocial perspective of health, which uniquely positions nurses to be aware of the interplay of genetics, culture, society, and individual differences that have the potential to influence drug responses in ethnic elders. This balanced perspective gives nurses the advantage to consider all factors influencing the health of ethnic older adults, by promoting appropriate medication prescription and preventing adverse drug events, thus averting costly hospitalizations, treatments, and decreased quality of life for all older adults (Kudzma & Carey, 2009). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References Agency for Healthcare Research and Quality. (2012). Measuring healthcare quality. Retrieved from http://www.ahrq.gov/qual/ measurix.htm Allen, J. J., Rack, P. H., & Vaddadi, K. S. (1977). Differences in the effects of clomipramine on English and Asian volunteers: Preliminary report on a pilot study. Postgraduate Medical Journal, 53(Suppl. 4), 79-86. 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Research “Things Are Different Now But”: Older LGBT Adults’ Experiences and Unmet Needs in Health Care Journal of Transcultural Nursing 2020, Vol. 31(5) 492–501 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions https://doi.org/10.1177/1043659619895099 DOI: 10.1177/1043659619895099 journals.sagepub.com/home/tcn Candace W. Burton, PhD, RN, AFN-BC, AGN-BC1 , Jung-Ah Lee, PhD, RN1 , Anders Waalen, BA2, and Lisa M. Gibbs, MD2,3,4 Abstract Background: Approximately 2.7 million U.S. older adults self-identify as lesbian, gay, bisexual, and transgender (LGBT). Many felt unsafe revealing their sexual orientation until relatively recently, and may still not be “out” to medical providers. The aim of this study was to increase understanding of the experiences and needs of older LGBT adults when accessing care. Method: Individual semistructured interviews were conducted with 10 individuals aged 65 years or older from a local LGBT community. Interviews were audio taped and transcribed verbatim. Transcripts were analyzed via thematic analysis. Results: Major themes were “Outness,” “Things are Different Now,” and “Additional Resources.” These describe participant comfort with being “out”; how treatment they received changed over time, and needed services or other options from the community. Conclusion: While many older LGBT adults are accustomed to navigating social mores to avoid negative experiences, nurses as well as other health care providers must be prepared to create trusting relationships with these individuals to provide truly comprehensive care. Keywords LGBT, older adults, health care, perception, unmet needs Introduction Background and Significance Although there are no official U.S. census data, studies suggest that the number of adults older than age 60 who self-identify as lesbian, gay, bisexual, and transgender (LGBT) may range from 1.75 million to as high as four million (Choi & Meyer, 2016). Older LGBT adults may have specific health needs, and are especially at risk for health issues related to tobacco use, mental health, substance abuse, and sexually transmitted infections (Choi & Meyer, 2016). This means that older LGBT individuals may require not only care that accounts for geriatric health needs, but care that attends to their needs as members of the LGBT community. This is critical in view of models such as the cultural distress model, which suggests that there is a pernicious health effect of receiving care that does not accord with or attend to all facets of an individual’s life and sociocultural environs (DeWilde & Burton, 2016). It is thus vital that older LGBT adults feel sufficiently comfortable and safe to disclose and discuss their sexual orientation in the course of health care interactions. This article reports on a qualitative effort to understand what influenced a regional population of older LGBT adults when deciding whether to disclose sexual orientation to a provider, how this population viewed the social status of older LGBT adults, and what health-related or other needs existed in the community. The LGBT community has a decade-long history of coming together to resist stigmatizing and marginalizing influences, and older adults in this population may remain cautious about disclosing their sexual orientation. Many have witnessed or experienced discriminatory behaviors, and many have fewer social supports than do their younger or heterosexual counterparts (Brennan-Ing, Seidel, Larson, & Karpiak, 2014). This may be due in part to concerns about acceptance among other populations of older adults as well as to loss of family and friends in the “coming out” process (Czaja et al., 2016; 1 Sue and Bill Gross School of Nursing, University of California Irvine, Irvine, CA, USA 2 School of Medicine, University of California Irvine, Irvine, CA, USA 3 Division of Geriatrics and Gerontology, Department of Family Medicine, School of Medicine, University of California Irvine, Irvine, CA, USA 4 University of California Irvine Health, Senior Health Center, Orange, CA, USA Corresponding Author: Lisa M. Gibbs, MD, Division of Geriatrics and Gerontology, Department of Family Medicine, School of Medicine, University of California Irvine, Irvine, CA 92697, USA. Email: firstname.lastname@example.org 493 Burton et al. Gardner, de Vries, & Mockus, 2014). When accessing health care services, many older LGBT adults may thus anticipate discriminatory or even condemnatory treatment from nurses, other staff, or other people in the environment. It is therefore important that older LGBT adults be considered a specific cultural group and appropriate attention paid by providers to the needs thereof. Fear of Discrimination Although significant social progress has been made toward LGBT equality, less than half of U.S. state governments prohibit discrimination on the basis of sexual orientation and there is as yet no federal law that specifically prohibits such discrimination (Hebl, Barron, Cox, & Corrington, 2016). Due to fear of discrimination, many LGBT adults may not disclose their sexual orientation to nurses or other kinds of providers. Studies suggest that as many as 36% of older LGBT adults’ primary health care providers are unaware of their patients’ sexual orientation; and that 20% of older adults identifying as lesbian, gay or bisexual and 44% of those identifying as transgender felt that their relationships with other providers (i.e., hospital or nursing home staff) would be negatively affected if their sexual orientation/gender identity were known (Espinoza, 2014; Movement Advancement Project & SAGE, 2017). This may stem from the fact that same-sex attraction was labeled a mental illness until relatively recently (Martos, Wilson, & Meyer, 2017). In addition, environments that do not clearly indicate an organizational culture of inclusivity and affirmation with regard to LGBT populations may be seen as potentially threatening to older LGBT adults. Participants in one study noted that older LGBT adults preferred to know that they would be around others from the LGBT community in care settings so that there was no need to “skirt around issues” (Gardner et al., 2014, p. 137). Another study found that the absence of inclusive language on forms or presumption of heterosexuality in interactions with personnel caused stress for older LGBT adults (Orel, 2014). Foregoing care due to fear of discrimination may have especially pernicious effects on older LGBT adults, who have demonstrably more propensity for chronic health conditions including weakened immunity, chronic back or neck pain, cancer, and cardiovascular disease than do younger adults or non-LGBT-identified individuals (Fredriksen-Goldsen, Kim, Shiu, & Bryan, 2017). Trauma, Stigma, and Betrayal in Health Care Trauma is defined as an experience so overwhelming that the individual anticipates significant injury or even death (Hunt & Evans, 2004). Among LGBT populations, trauma can come from sources ranging from physical victimization to the psychological trauma of existing in a heterosexist and binary gendered social paradigm (Alessi & Martin, 2017). For older LGBT adults, the trauma of discrimination may be magnified in the health care setting via the dual impacts of stigmatization and betrayal. Stigmatization is the received sense of being in some way inferior or powerless due to some aspect of identity that may or may not be under the individual’s control (Whitehead, Shaver, & Stephenson, 2016). Stigmatization also particularly implies the reduction of social capital—access to opportunities, resources, and social systems (Weber, 2010). This can have pernicious effects in the health care setting, because the threatened access is to a system on which the individual may be extremely dependent. If the stigmatizing influence comes from within the needed system, there may also be betrayal trauma. Betrayal trauma theory explores the implications of betrayal and its traumatic impact on the individual. Betrayal is a specific trauma that happens when there is a mismatch between expected and actual outcomes, especially when the affected individual is dependent on the betraying agent in some way (Smith & Freyd, 2017). When interacting with health care providers, individuals are necessarily seeking a particular type of support that cannot be accessed any other way. If a provider responds negatively, in a discriminatory or judgmental manner, the individual may feel that access to this care is at risk. If more than one provider in an organization responds in such a way, the sense of betrayal can extend to the entire organization—otherwise known as organizational betrayal (Smith & Freyd, 2017). This may be particularly injurious if it occurs during the patient’s initial encounter with the clinical setting: for example, if a nurse behaves negatively toward an LGBT patient, it may seem to the patient that the nurse is a kind of gatekeeper for other services and access to those services is threatened. Vicarious Trauma. In addition to their own histories of discrimination, rejection, or other negative responses to their LGBT status, some older adults also experience anxiety, elevated sense of danger or vulnerability, anger, or sadness in response to reports of such experiences from others (Balsam, Beadnell, & Molina, 2013). Called vicarious trauma, this is an indirect encounter with traumatic events—usually through shared stories among a social group—that influences how individuals believe their identities are constructed in the broader social context. Vicarious trauma factors into the broader construct of LGBT minority stress, which also involves internalized homophobia, concealment stress, and expected rejection based on sexual orientation (Balsam et al., 2013). Vicarious trauma and minority stress overall can intensify perceptions of danger and need for vigilance among LGBT-identified older adults. Method The goal of the present work was to explore the local population of older adults’ perception of experiences with providers including physicians, nurses, and other caregivers in order to develop more culturally competent services. The work reported in this article was part of larger parent project titled the “Geriatric Workforce Enhancement Project” supported 494 Journal of Transcultural Nursing 31(5) Table 1. Sample Interview Questions. Question Do you agree or disagree with the following statement…
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