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Cultural Diversity in Health and Illness (7th Edition) ReviewThis review updated by author on March 21, 2006:I recently (Spring 2005) used this text in an undergraduate health professions course titled "Diversity in Health and Illness". The author addresses a broad scope of cultures, issues and responses to cultural needs in health care. Although the book contains much that is useful, my students found it to be, on balance, confusing and disorganized.
I believe much of this response can be attributed to poor editing. We identified numerous spelling and grammar errors throughout. Poorly edited content is also evident in several chapters. Example: "...this chapter has introduced the dominant culture's perception of health and illness through countless lenses" (pp. 67). Similarly, "...countless letters are displayed attesting to the healing powers of this statue" (pp. 106). Isn't there a more accurate word to use in place of `countless'? More importantly, ethnic and race labels are not used consistently. "Hispanic" and "Latino" are used as though they are strictly interchangeable; ditto for "Black" and "African American." Term consistency would enhance clarity.
My concerns with the text are more fundamental and numerous but I will limit myself to a few examples:
USE OF SOURCE DATA AND REFERENCE MATERIALS
Although the text is heavily laden with descriptive statistics, comparative data is often not included, thus limiting interpretations. For example, the discussion of rising expenditures for unconventional therapies in the U.S. (pp. 96) includes expenditure estimates for 1990 and 1997. Without companion statistics for conventional therapy expenditures, readers are unable to asses the magnitude of the trend. Similarly, the description of the African American population as young (54.4% are under 18 - pp. 233) is not very enlightening in the absence of corresponding percentages for the white population and the overall American population. Figure 10-3 adds little additional information.
References for culture group descriptions are often either very old (1950's - 1970's), not the definitive works, or are not sufficiently academic (encyclopedias and web pages), and should be replaced with citations for newer research reported in more rigorous formats. Several important sections contain insufficient or no reference citations. The "Health/HEALTH Care Choices" section (pp. 85) contains numerous historical claims but only a single reference to the American Heritage Dictionary.
OUT OF DATE THEORIES
Some of the sociological and anthropological concepts presented do not represent current theoretical stances. I was especially interested in exploring citations for the "Cycle of Poverty" discussion in Chapter 2, as this blame-the-victim concept has fallen out of favor in sociological circles because it ignores structural realities that are beyond the control of individuals. This conflation of structural problems with cultural phenomena inadvertently creates a situation where the subtle racist beliefs we all learn through our socialization is reinforced in the classroom. Sadly, the only citation provided in this section, (Spector 1979, pp. 148-152), refers to an earlier edition of this book. Original references should be provided.
The Chapter 3 discussion of the sick role is limited to functionalist models presented by Talcott Parsons (1966) and Edward Suchman (1965). As our society ages we are experiencing increasing levels of chronic illness and more patients cannot expect to fully recover. More recent examinations of the illness experience would be appropriate.
CULTURAL MISUNDERSTANDINGS
The discussion of historical background for Native American cultures (pp. 186-188) is particularly dismal. While somewhat correct in broad outlines, the text reads like a less-than-distinguished freshman research paper, and includes various repeats. The discussion of traditional health beliefs and practices is limited to those of the Navajo and Hopi - important southwestern groups - but not representative of all Native Americans. Sources cited are limited to a few 1960's and 1970's references. Strains of the Noble Savage are also evident, particularly with reference to the discussion of "True Indian love" and domestic violence (pp. 200).
The role of voodoo in African American traditions is somewhat overstated (Chapter 10), and is presented as an explanation for present-day underutilization of the allopathic system (pp. 239). At the same time, more realistic explanations are omitted. Chief among those are the disproportionate poverty experienced by the community as well as recent and historical sources of distrust between the African Americans and the largely white medical establishment (e.g., antebellum forced medical experimentation, Tuskegee Experiment, Holmesburg Prison Experiments).
INTERPRETATIONS
My graduate degree is in anthropology, and although I expected some level of disconnect between my training and the nursing orientation of Spector, I found myself admonishing my students several times over to ignore specific passages and sections in this text as irrelevant or just plain wrong.
For example, in the section titled "Cultural Phenomena Affecting Health", in Chapter 1, subheadings include "Biological Variations" and "Social Organization". Confusion between biology and culture appears in other places as well, and was especially troublesome for my students with their limited previous exposure to the concept of culture.
The "Social Organization" subheading precedes a disjointed (but brief) discussion of childhood socialization, family organization, and barriers to health care access. Perhaps the first two could be combined in a section "Socialization". Regarding the barriers to health care access (e.g., unemployment, poverty and lack of health insurance), these could be better characterized as economic barriers rather than social barriers. Diminished economic resources are correlated to large extent with particular demographic groups, but one should avoid essentializing the availability of resources as a series of ethnic or cultural traits. Conceptualizing these issues as cultural phenomena obscures the contributions of racism, xenophobia, and unequal distribution of wealth to the problems of unequal access. Spector draws these categories from a previously published article, and the uncritical use of other people's published materials is apparent throughout the book.
Spector's background is nursing, and on balance, I am not sure that this provides one with the appropriate skills necessary to summarize the fundamentals of culture and cultural diversity. Theorising culture and society is (and should remain) the domain of anthropologists and sociologists (and perhaps psychologists). Like nursing and most other applied and academic fields of inquiry, understanding culture requires a great deal of specialized education.
On my initial reading I suspected a functionalist interpretation of the intersection between health care and culture, but on further examination this book is more like an online encyclopedia where everything (including the kitchen sink) is thrown in. What is missing is a critical evaluation of the usefulness and theoretical implications of others' data and interpretations. The result is conflicting content and a great deal of confusion.
A final example: Spector rejects the WHO health definition but does not suggest a better alternative. Instead she seems to think that health is indefinable: "I would define health as an undefined term" (pp. 50). I agree that students should maintain an open mind, but perhaps a series of limited definitions addressing a variety of situations would be more useful in the classroom. Social science practitioners and researchers struggle with variability in human behavior as a matter of course, but that struggle is mitigated through a realization that definitions are often necessary heuristic devices rather than complete summaries. Put simply, if we can't know a thing, aren't we just wasting our time?
I have reviewed a number of alternate texts over the past year and have found the problems discussed here to be present in several other texts. Perhaps the academic pursuit of cultural care is still in its nascent stage.
In any case, I have found "Culture in Rehabilitation: from Competency to Proficiency" edited by Royeen and Crabtree (Pearson 2006) to be a much better text for my class. The authors represent a variety of health professions and the text was reviewed by a similarly diverse panel of ten. Most of the contributions present robust bibliographies, rely on up-to-date social science research, and avoid the culture-as-checklist approach. I will review the text in detail sometime in May 2006.Cultural Diversity in Health and Illness (7th Edition) Overview
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