Question 1:
1) Complete the following writing prompts concerning readings on multiple heritage individuals:
(Check readings listed under course schedule heading for multiple heritage individuals).
b) The most important learning from the 2 articles by Jeffreys and Zoucha was……………………because……………….. Prompted by this article, one action I can take to make a positive change in nursing and the workplace is…………………………
c) The sentence that most captured my attention in Root’s Bill of Rights for People of Mixed Heritage was……………………because…………………….
d) People of mixed heritage ……………………………….
e) The assigned reading that surprised me the most was…………………………….because……………..
f-1) New knowledge and insight from the assigned readings on multiple heritage individuals helped me to develop the following
CNS or NP competencies
(list up to 5). (Students enrolled in the CSI CNS or NP programs must select competencies for their intended role).
CNS or NP competencies
(List number, letter, name/area)
OR
f-2) New knowledge and insight from the assigned readings on multiple heritage individuals helped me to develop the following cultural competence guidelines (list up to 5).
Cultural Competence Guidelines
(List number and name)
Question 2: Write a brief 1-2 paragraph e-mail (5-7 sentences) to the author (Burton, et al, 2020 or Vorobyova, et al, 2022) concerning their article and its
a) timeliness to contemporary health care issues
b) contributions to your professional development
c) adaptability and/or direct application to your future APRN role or other professional practice role.
(Be sure to address the authors according to their credentials and/or titles as listed in their article. Be sure to identify your future practice role and specialty, write in a professional e-mail format, and provide your full name and credentials).
Question 3: Spend 5 minutes uninterrupted time to explore the list of HP2030 category headings. Then select 1 category (Health Conditions, Health Behaviors, Populations, Settings and Systems, and Social Determinants of Health most relevant to this week’s readings (and that you did not previously explore for this class). Spend 10 minutes uninterrupted time to explore the most relevant topic and objective (goal) from within your selected category. (Do not use a phone or other small screen device). Complete the following sentences:
A) I explored HP 2030 category heading ___________________ because _________________.
B) Within my selected HP2030 category, I then explored the __________topic and ____________ goal because___________________________________.
B) The most interesting discovery on HP 2030 relevant to this week’s readings was_____________________ Elaborate and explain what and why in 3-8 sentences.
Certification Exam Prep – (Synthesized Learning Application)
After completing all of this week’s assigned reading and website explorations, follow the recommended steps for answering exam questions.
For your discussion board post
a) Write the rationale for EACH…write why an answer is correct or incorrect beneath the response option. Begin your response with “this option is correct because…. Or this option is incorrect because…..”
b) Discuss any feelings you experienced as you worked through the process of answering the question. (See sample list of feelings).
c) Discuss any thoughts you had as you worked through the process of answering the question.
A 67-year-old alert, oriented, male patient has been diagnosed with hypertension. The APRN tells him that medications are indicated. The patient states, “I want my partner to be here when you discuss my medication plan. We have been each other’s health care proxy for the last 3 years. I rely on him to help me remember things, especially when I am anxious. My father had high blood pressure and died of a stroke. I look more like my father than my mother who is Haitian so I am worried I may die like him. My partner and I should try to follow a more healthy diet.”
Which of the following is a culturally congruent action by the APRN?
a) Explain that his full family and genetic heritage as well as lifestyle will be considered when determining the most appropriate antihypertensives.
b) Ask him if his father was overweight, black, or smoked, and then re-take his blood pressure.
c) Wait until his partner arrives and then provide them with pamphlets on low fat, low sodium foods that include traditional Haitian foods.
d) Tell him that physical features and appearance are not reliable predictors of hypertension, cardiac disease, or stroke; however, anxiety is a significant predictor.
Healthy people 2030 for question 3
https://health.gov/healthypeople/objectives-and-da…
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 marianne.jejfreys@csi.cuny.edu. 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. Children
and Society, 10, 305-316.
Campinha-Bacote, J. (1998). The process of cultural competence: A
culturally competent model of care. Wyoming, OH: Transcultural
C.A.R.E. Associates.
Cose, E. (1997). Census and the complex issue of race. Society,
6,10-13.
Dakis, P. & Rubin, L. (1998). Obstruction of valid race/ethnicity data acquisition by current data collection instruments.
Methods oflnformation in Medicine, 37,188-191.
Daniel, G.R. (1992). Beyond black and white: The new multiracial
consciousness. In M.P.P. Root (Ed.), Racially Mixed People in
America (333-341). Newbury Park, CA: Sage.
Deters, K.A. & Rowland, S. (1995). Belonging nowhere and ev
erywhere: Multiracial identity development. Bulletin of the
Menninger Clinic, 61(1), 368-384.
Fong, R.; Spickard, P.R.; & Ewalt, P.L. (1995). A multiracial reality:
Issues for social work. Social Work, 40(6), 725-728.
Fuchs, L.H. (1997). W hat we should count and why. Society, 6,
24-27.
Gaines, S. O., et al. (1999). Patterns of attachment and responses
to accommodative dilemmas among interethnic/interracial
couples. Journal of Social and Personal Relationships, 16(2),
275-285.
Giger, J. N., Davidhizar, R. E., (1995). Transcidtural nursing: Assess
ment and intervention (2nd ed.). St. Louis: Mosby.
Gordon, L.R. (1995). Specificities: Cultures of American identity
critical “mixed race”? Social Identities, 1(2), 381-395.
Hall, C.C.I. (1992). Coloring outside the lines. In M.P.P. Root
(Ed), Racially Mixed People in America (326-329). Newbury
Park, CA: Sage.
Johnson, R.C. (1992). Offspring of cross-race and cross-ethnic
marriages in Hawaii. . In M.P.P. Root (Ed.), Racially Mixed
People in America (239-249). Newbury Park, CA: Sage.
Johnson, T.P.; et al. (1997). Dim ensions of self-identification
among multiracial and multiethnic respondents in survey
interviews. Evaluation Review, 21(6), 671-687.
King, J.C. (1981). The biology of race. Berkeley, CA: University of
California Press.
Lee, S.M. & Fernandez, M. (1998). Trends in Asian American
racial/ethnic intermarriage: A comparison of 1980 and 1990
census data. Sociological Perspectives, 41(2), 323-342.
Leininger, M. (1991). Cidture Care Diversity and Universality: A the
ory of nursing. New York, NY: National League for Nursing.
Leininger, M. (1995). Transcultural nursing: Concepts, theories,
research and practices. New York, NY: McGraw-Hill.
Light, I. & Lee, C. (1997). A nd just who do you think you aren’t?
Society, 6, 28-30.
McFarland, M.R., (1997). Use of culture care theory w ith Anglo
and African American elders in a long term care setting.
Nursing Science Quarterly, 10, 4 , 186-192.
Migone, A.; Emmanuel, I.; Mueller, B.; Daling, J.; & Little, R.E.
(1991). Gestational duration and birthweight in white, black
and mixed-race babies. Pediatric and Perinatal Epidemiology,
5, 378-391.
Morrison, J.W. (1995). Developing identity formation and selfconcept in preschool-aged biracial children. Early Child
Development and Care, 111, 141-152.
Nash, G.B. (1995). The hidden history of mestizo America. Journal
of American History, 82(3), 941-962.
O’Neal, V.P.; Brown, P.M.; & Abadie, T. (1997). Treatment impli
cations for interracial couples. Cross-Cultural Practice with
Couples and Families, 2(1), 15-31.
Pascoe, P. (1996). Miscegenation law, court cases, and ideologies
of “race” in twentieth-century America. Journal of American
History, 83(1), 44-69.
Journal of Cultural Diversity • Vol. 24, No. 1
Perlmann, J. (1997). Multiracials, intermarriage, and ethnicity.
Society, 6, 20-23.
Pinderhughes, E. (1995). Biracial identity-Asset or handicap? In:
Harris, H.W.; Blue, C.; & Griffith, E.E.H., Racial and Ethnic
Identity: Psychological Development and Creative Expression.
(73-93), New York: Routledge.
Purnell, L. D., Paulanka, B. J. (1998). Transcultural health care.
Philadelphia: F.A. Davis.
Reynolds, C.L. & Leininger, M. (1993). Madeleine Leininger: Cul
tural Care Diversity and Universality Theory. Newbury Park,
CA: Sage.
Root, M.P.P. (1992). Within, between, and beyond race.. In M.P.P.
Root (Ed.), Racially Mixed People in America (3-11). Newbury
Park, CA: Sage.
Root, M.P.P. (1994). Mixed-race women. In Comas-Diaz, L. &
Greene, B. Women of Color: Integrating ethnic and gender identi
ties in psychotherapy. (455-478). New York: Guilford.
Root, M.P.P. (1997). Multiracial Asians: Models of ethnic identity.
Ameriasia Journal, 23(1), 29-41.
Root, M.P.P. (1998). Experiences and processes affecting racial
identity development: Preliminary results from the biracial
sibling project. Cultural Diversity and Mental Health, 4(3),
237-247.
Ropp, S.M. (1997). Do multiracial subjects really challenge race?:
Mixed-race Asians in the United States and the Caribbean.
Ameriasia Journal, 23(1), 1-16.
Sato, A. (1999, July 7). Buzzword on mainland is hapa go lucky.
The Honolulu Adviser, p. C l.
Small, S. (1994). Racial group boundaries and identities: People
of ‘mixed-race’ in slavery across the Americas. Slavery and
Abolition, 15(3), 17-37.
Spickard, P.R. (1997). W hat m ust I be? Asian Americans and the
question of m ultiethnic identity. Ameriasia Journal, 23(1),
43-60.
Spickard, P.R. & Fong, R. (1995). Pacific Islander Americans and
multiethnicity: A vision of America’s future? Social Forces,
73(4), 1365-1383.
St. Jean, Y. (1998). Let people speak for themselves: Interracial
unions and the general social survey. Journal of Black Studies,
28(3), 398-414.
St. Jean, Y. & Parker, R.E. (1995). Disapproval of interracial unions:
The case of black females. In: Jacobson, C.K., American Fami
lies: Issues in Race and Ethnicity (341-351). New York: Garland.
Taylor, C.; Lillis, C.; & LeMone,P. (1997). Fundamentals of Nursing:
The Art and Science of Nursing Care, New York, NY: Lippincott.
Vivero, V.N. & Jenkins, S.R. (1999). Existential hazards of the
multicultural individual: Defining and understanding “cul
tural homelessness”. Cultural Diversity and Ethnic Minority
Psychology, 5(1), 6-26.
Westphal, D. (1999, September 15). U.S. minority population tops
75 million. Pittsburgh Post-Gazette, p. A10.
Williams, D.R. (1996). Race/ethnicity and socioeconomic status:
measurement and methodological issues.International Journal
of Health Services, 26(3), 483-505.
Wilson, D.S. & Jacobson, C.K. (1995). White attitudes towards
black and white interracial marriage (353-367). In: Jacobson,
C.K., American Families: Issues in Race and Ethnicity, New
York: Garland.
Zoucha, R. D., (1998). The experiences of Mexican-Americans
receiving professional nursing care: An ethnonursing study.
The Journal of Transcultural Nursing, 9, 2, 34-44.
Zoucha, R. D., (2000). The keys to culturally sensitive care: Un
derstanding the significance of culture in nursing. American
Journal of Nursing, 100, 2, 24GG-26.
Spring 2017
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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: dwoods@apu.edu
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.
The American Geriatrics Society. (2012). American Geriatrics
Society Updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American
Geriatrics Society, 60, 616-631.
Beckie, T. M. (2012). A systematic review of allostatic load, health
and health disparities. Biological Research for Nursing, 14,
311-346.
Branch, R. A., Salih, S. Y., & Homeida, M. (1978). Racial differences in drug metabolizing ability: A study with antipyrine
in the Sudan. Clinical Pharmacology & Therapeutics, 24,
283-286.
Burroughs, V. J., Maxey, R. W., & Levy, R. A. (2002). Racial and
ethnic differences in response to medicines: Towards individualized pharmaceutical treatment. Journal of the National
Medical Association, 94(10 Suppl.), 1-26.
Clarke, A. J., Cooper, D. N., Krawczak, M., Tyler-Smith, C.,
Wallace, H. M., Wilkie, A. O., . . . Chiano, M. (2012). “Sifting
the significance from the data”: The impact of high-throughput genomic technologies on human genetics and health care.
Human Genomics, 6, 11. doi:10.1186/1479-7364-6-11
Cooper, R. S., Kaufman, J. S., & Ward, R. (2003). Race and genomics. New England Journal of Medicine, 348, 1166-1170.
Exner, D. V., Dries, D. L., Domanski, M. J., & Cohn, J. N. (2001).
Lesser response to angiotensin-converting-enzyme inhibitor
therapy in black as compared with white patients with left ventricular dysfunction. New England Journal of Medicine, 344,
1351-1357.
Fialová, D., Topinková, E., Gambassi, G., Finne-Soveri, H., Jónsson,
P. V., Carpenter, I., . . . Bernabei, R. (2005). Potentially inappropriate medication use among elderly home care patients in
62
Europe. Journal of the American Medical Association, 293,
1348-1358.
Fick, D. M., Mion, L. C., Beers, M. H., & Waller, J. (2008). Health
outcomes associated with potentially inappropriate medication
use in older adults. Research in Nursing & Health, 31, 42-51.
Garwood, C. L., Clemente, J. L., Ibe, G. N., Kandula, V. A., Curtis,
K. D., & Whittaker, P. (2010). Warfarin maintenance dose in
older patients: Higher average dose and wider dose frequency
distribution in patients of African ancestry than those of
European ancestry. Blood Cells, Molecules, & Diseases, 45,
93-97. doi:10.1016/j.bcmd.2010.03.006
Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006).
“Weathering” and age patterns of allostatic load scores among
Blacks and Whites in the United States. American Journal of
Public Health, 96, 826-833.
Gonzalez, J. M., Bowden, C. L., Berman, N., Frank, E., Bauer, M.
S., Kogan, J. N., . . . Miklowitz, D. J. (2010). One-year treatment outcomes of African-American and Hispanic patients
with bipolar I or II disorder in STEP-BD. Psychiatric Services,
61, 164-72. doi:10.1176/appi.ps.61.2.164
Haas, S. A., Krueger, P. M., & Rohlfsen, L. (2012). Race/ethnic
and nativity disparities in later life physical performance: The
role of health and socioeconomic status over the life course.
Journal of Gerontology Series B: Psychological Sciences &
Social Sciences, 67, 238-248. doi:10.1093/geronb/gbr155
Institute of Medicine (US) Committee on Pharmacokinetics and
Drug Interactions in the Elderly. (1997). Pharmacokinetics and
drug interactions in the elderly and special issues in elderly
African-American populations. Washington, DC: National
Academies Press.
Jurima, M., Inaba, T., Kadar, D., & Kalow, W. (1985). Genetic polymorphism of mephenytoin p(4’)-hydroxylation: Difference
between Orientals and Caucasians. British Journal of Clinical
Pharmacology, 19, 483-487.
Keltner, N. L., & Folks, D. G. (2001). Psychotropic drugs (3rd ed.).
St. Louis, MO: Mosby.
Kudzma, E. C., & Carey, E. T. (2009). Pharmacogenomics:
Personalizing drug therapy. American Journal of Nursing, 109,
50-57.
Laffer, C. L., & Elijovich, F. (2002). Essential hypertension of
Caribbean Hispanics: Sodium, renin, and response to therapy.
Journal of Clinical Hypertension (Greenwich), 4, 266-273.
Lin, K. M., Poland, R. E., & Nakasaki, G. (Eds.). (1993).
Psychopharmacology and psychobiology of ethnicity.
Washington, DC: American Psychiatric Press.
Lin, K. M., & Smith, M. W. (2000). Psychopharmacotherapy in the
context of culture and ethnicity. In P. Ruiz (Ed.), Ethnicity and
psychopharmacology (pp. 1-36). Washington, DC: American
Psychiatric Press.
Luo, H. R., Aloumanis, V., Lin, K. M., Gurwitz, D., & Wan, Y. J.
(2004). Polymorphisms of CYP 2C19 and CYP 2D6 in Israeli
ethnic groups. American Journal of Pharmacogenomics, 4,
395-401.
Manton, K. G., Poss, S. S., & Wing, S. (1979). The black/white
mortality crossover investigation from the perspective of the
components of aging. The Gerontologist, 19, 291-300.
McDowell, S. E., Coleman, J. J., & Ferner, R. E. (2006). Systematic
review and meta-analysis of ethnic differences in risks of
adverse reactions to drugs used in cardiovascular medicine.
British Medical Journal, 332(7551), 1177-1181.
Journal of Transcultural Nursing 28(1)
Murphy, E. I., & McMahon, F. J. (2013). Pharmacogenetics of antidepressants, mood stabilizers, and antipsychotics in diverse
human populations. Discovery Medicine, 16, 113-122.
National Council on Patient Information and Education. (n.d.).
Retrieved from http://www.talkaboutrx.org
Norris, J. M., & Rich, S. S. (2012). Genetics of glucose homeostasis: Implications for insulin resistance and metabolic syndrome. Arteriosclerosis, Thrombosis, and Vascular Biology,
32, 2091-2096. doi:10.1161/ATVBAHA.112.255463
Porth, C. (2014). Essentials of pathophysiology concepts of altered
health states (4th ed.). Philadelphia, PA: Wolters Kluwer/
Lippincott Williams & Wilkins.
Qato, D. M., Alexander, G. C., Conti, R. M., Johnson, M., Schumm,
P., & Lindau, S. T. (2008). Use of prescription and over-thecounter medications and dietary supplements among older
adults in the United States. Journal of the American Medical
Association, 300, 2867-2878.
Richardson, S. I., Freedman, B. I., Ellison, D. H., & Rodriguez, C.
J. (2013). Salt sensitivity: A review with a focus on non-Hispanic blacks and Hispanics. Journal of the American Society of
Hypertension, 7, 170-179. doi:10.1016/j.jash.2013.01.003
Serretti, A., Kato, M., De Ronchi, D., & Kionshita, T. (2007). Metaanalysis of serotonin transporter gene promoter polymorphism
(5-HTTLPR) association with selective serotonin reuptake
inhibitor efficacy in depressed patients. Molecular Psychiatry,
12, 247-257.
Shah, R. (2007). Pharmacogenetics, ethnic differences in drug
response and drug regulation. In G. Suarez-Kurtz (Ed.),
Pharmacogenomics in admixed populations (pp. 180-197).
Austin, TX: Landes Bioscience.
Shu, Y., Leabman, K. M., Feng, B., Mangravite, L. M., Huang, C.
C., Stryke, D., . . . Giacomini, K. M. (2003). Evolutionary conservation predicts function of variants of the human organic cation transporter, OCT1. Proceedings of the National Academy
of Sciences of the United States of America, 100, 5902-5907.
Solus, J. F., Arietta, B. J., Harris, J. R., Sexton, D. P., Steward, J. Q.,
McMunn, C., . . . Dawson, E. P. (2004). Genetic variation in
eleven phase I drug metabolism genes in an ethnically diverse
population. Pharmacogenomics, 5, 895-931.
Takane, H., Shikata, E., Otsubo, K., Higuchi, S., & Ieiri, I. (2008).
Polymorphism in human organic cation transporters and metformin action. Pharmacogenomics, 9, 415-422.
Wadelius, M., Chen, L. Y., Eriksson, N., Bumpstead, S., Ghori, J.,
Wadelius, J., . . . Deloukas, P. (2007). Association of warfarin
dose with genes involved in its action and metabolism. Human
Genetics, 121, 23-34.
Weng, M. C., Tsai, C. F., Sheu, K. L., Lee, Y. T., Lee, H. C., Tzeng,
S. L., . . . Chen, S. C. (2013). The impact of number of drugs
prescribed on the risk of potentially inappropriate medication
among outpatient older adults with chronic diseases. Quarterly
Journal of Medicine, 106, 1009-1015.
Wright, J. T., Jr., Dunn, J. K., Cutler, J. A., Davis, B. R., Cushman,
W. C., Ford, C. E., . . . Habib, G. B. (2005). Outcomes in
hypertensive black and nonblack patients treated with chlorthalidone, amlodipine, and lisinopril. Journal of the American
Medical Association, 293, 1595-1608.
Yuen, E., Gueorguieva, I., Wise, S., Soon, D., & Aarons, L. (2010).
Ethnic differences in the population pharmacokinetics and pharmacodynamics of warfarin. Journal of Pharmacokinetics &
Pharmacodynamics, 37, 3-24. doi:10.1007/s10928-009-9138-4
895099
research-article2019
TCNXXX10.1177/1043659619895099Journal of Transcultural NursingBurton et al.
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: lgibbs@uci.edu
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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
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Journal of Transcultural Nursing 31(5)
Table 1. Sample Interview Questions.
Question
Do you agree or disagree with the
following statement…