Amish Culture and Healthcare
The Amish settled in Pennsylvania and the Midwest in the early 1700s after fleeing religious persecution from Germany. The Amish are also known as the “plain people” because they tend to separate themselves from the modern world. Education ends at the eighth grade; and, at the age of fourteen, children enter the workforce, which consists of mostly farming. The Amish devote their entire lives to the service of God and believe life has no purpose apart from God. “The Amish believe that because they are given an undeserved gift of eternal life, they must live a life similar to their Savior: that of humility, forgiveness, suffering, nonviolence, and avoidance of worldliness” (Banks & Benchot, 2001, p. 192). The Amish share this culture, which is defined as “a set of beliefs, assumptions, and values widely shared by a group that serves to structure the behavior of the individuals of the group throughout the course of their life” (Julia, 1996, p. 3). It is important for nurses to recognize these beliefs and center care around them.
Amish life is significantly different from modern society in North America. For example, the Amish avoid modern conveniences such as telephones and electricity. Furthermore, their most common mode of transportation is horse and buggy. “Old Order Amish are identified by their conservative attire, straw hats, black bonnets” and hand stitched clothing (Turco, 2000, p. 139). This article will focus on the Amish culture, their beliefs about health, and their uses of the folk and modern healthcare system.
Demographic changes are forcing those who work in the helping professions to recognize that they must become not only more culturally sensitive, but also culturally competent. One of the major challenges for healthcare providers is to be culturally sensitive and to avoid stereotyping. Nurses have come to accept that “cultural values and beliefs affect the way in which people understand health practices and help them to attain and maintain healthy lives” (Wenger, 1988, p. 1).
To obtain first hand information, two healthcare professionals who work closely with the Amish were consulted. Mary Spath, an advanced practice nurse, routinely visits Amish communities and cares for those with bleeding disorders. She works closely with Dr. Amy Shapiro, a hematologist in Indianapolis. Dr. Shapiro treats the Amish from Berne and Middlebury, Indiana. Dr. David Coil runs a family practice clinic in Goshen, Indiana. He states that approximately 30% of his patients are Amish. Both Coil and Spath are very familiar with the Amish society and their expertise was greatly utilized in this research. They also agree on several factors related to the Amish and healthcare. For instance, both Spath and Coil report that trust is a major issue when working with the Amish. Without trust, the Amish would not utilize the modern healthcare system.
Spath noted that trust is gained using various methods. The most effective method is word-of-mouth from their Amish friends and neighbors. When communicating, Spath revealed that the, “acknowledgment of hierarchy and male dominance is a communication factor” (personal communication, 1 July 2002). It is important to realize that families will seek their bishop’s consent before any major medical procedures. In addition, Dr. Coil finds that most of his patients speak both English and Dutch. He also mentioned that the Amish find it offensive when non-Amish try to speak Dutch to them. Regarding Amish use of the healthcare system, Dr. Coil reports that:
“With a large portion of the Amish, we act as a second or third source. They will see the local Amish herbalist first, their Chiropractor second, and if all else fails they eventually come to us”.
Coil believes that most of the Amish do seek out regular healthcare and Spath agrees but adds that many of the Amish are hesitant with the modern system. When asked about the overall health of the Amish population both Coil and Spath were in agreement. For instance, both believe that the Amish have lower risk factors for disease than the general population because of their manual labor, consumption of fresh foods and their rare consumption of tobacco and alcohol.
When researching culture and health practices, one must first become familiar with the meanings of health and illness in that culture. This is where one of the first differences between the Amish and modern society is seen. The Amish define health as someone who has “a good appetite, looks physically well, and is able to do rigorous physical labor” (Yoder, 1997, p.49). Where as modern society focuses more internally on health. In the Amish culture, illness refers to the inability to function in the work role. Other Americans are also focused on working but they consider illness to mean more of how a person feels. Many Amish also believe that sin causes illness while most Americans have a very different outlook.
When an intervention is needed regarding the health of an Amish person, the Amish family will pray and seek advice and permission from church elders or bishops before receiving treatment. In contrast, other American cultures directly consult physicians and professionals regarding healthcare practices. The will of God plays a large role in the Amish culture; and for this reason genetic counseling does not occur, nor does birth control.
When required, “the Amish are permitted to use modern health care facilities and services including surgery, hospitalization, anesthesia, blood transfusions, and dental work. However, distance, lack of transportation, and cost can serve as barriers to accessing the health care delivery system” (Julia, 1996, p.27). In contrast with modern American culture, health promotion and disease prevention are not priorities among the Amish. Accordingly, immunizations for communicable diseases are accepted, but only about 58% of Amish children have received such immunizations (Julia, 1996, p.32). Furthermore, Amish are generally reactive, rather than proactive, regarding healthcare. However, many people in the U.S. society actively seek health related information. Also, “medical advice is sought for symptoms that interfere with daily work and activities, not for prevention of underlying causes” (Julia, 1996, p.35).
The Amish culture actively uses folk and alternative medicine, and there are a variety of folk practitioners within the Amish community. For example, the Amish use reflexologists who are thought to cure illness by manipulating the feet (Julia, 1996, p.38). They also believe that Brauche practitioners, who use words, charms, and physical manipulation to treat illness, have a special gift from God. These practitioners are favored for small children because they can sense what is wrong. This is thought to be particularly useful, because children may not be able to articulate their problems. Folk medicine may be preferred because it is less expensive than modern healthcare and more accessible in the Amish community.
The Amish people have barriers to the modern healthcare system that many Americans do not have to face. First of all, transportation problems make it difficult for the Amish to keep office hours as designated by modern health providers. Language barriers also make it difficult for the Amish to understand scientific jargon. Furthermore, the high costs of modern healthcare can deter use of the system because the Amish do not carry private insurance.
In general, the Amish have the same health problems as other Americans; however, there are some differences. First of all, “children are expected to do farm chores at a young age. Therefore, accidents resulting in severe lacerations, broken bones, or loss of digits or limbs may occur from contact with sharp tools and large animals” (Banks & Benchot, 2001, p.194). Importantly, since the Amish live in a closed community, intermarriage occurs, resulting in higher rates of genetic disorders such as cystic fibrosis, hemophilia, dwarfism, Downs syndrome, and other neurological disorders. Another contrast with mainstream America is the rate of sexually transmitted diseases. Since the Amish are strictly monogamous, their rate of STDs is dramatically lower than other cultures.
Since the Amish culture has the religious principle of separation from the world, it is hard for the rest of America not to be judgmental (Jeannet & Mercier, 1992). The Amish view wealth as a danger to becoming more modern. These sorts of beliefs have stunted the evolution of the culture, which has not changed much from its start in the 1700s, leading to both positive and negative aspects of the culture.
On a positive note, the Amish never hesitate to help each other when in need. The “Amish culture has a strong network of mutual support and assistance for its members” (Julia, 1996, p. 25). The Amish are aware that survival of the community depends upon the contributions of each member. Therefore, illness becomes a concern for the group and the Amish accept the responsibility to care for one another (Yoder, 1997).
However, the Amish culture also has drawbacks. For example, it is thought that advanced education may mainstream their culture with society. Therefore, the Amish education is limited to the eight-grade level, which severely restricts the potential of the Amish people and prohibits dreams of ideal modern careers. Also, knowledge of their body and healthcare is limited, causing problems for healthcare providers. In addition, the Amish are reserved and may not share all the needed information when visiting healthcare providers, which leads to dangerous interactions or misdiagnoses.
Overall, health is highly valued in the Amish culture and they consider their bodies to be God’s temple. Nurses and other healthcare providers must develop open and trusting relationships with their Amish patients. This can start with a focus on family-centered care. Furthermore, the nurse needs knowledge of the Amish belief system and way of life to provide culturally sensitive care.
Using empowering strategies will help to make the Amish feel more comfortable in the modern healthcare environment. It is important to ask the patient and their family for their preferences whenever possible. “By showing personal interest in an Amish person, the nurse can enhance credibility by gaining the client’s trust and confidence” (Yoder, 1997, p. 51).
Nurses and other caregivers who are outsiders to a particular culture need research-based knowledge about a culture in order to provide culturally congruent care. Culture has a major influence on what type of nursing care should be given and aids in determining a nurse’s care plan. It is crucial that nurses have an understanding of a patient’s culture in order to provide specific care to their needs. Finally, it is important that healthcare professionals do not presume they know what is best, but recognize that every patient will have valuable input as to what they need.
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Coil, David D.O. Personal communication, 10 June 2002.
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Spath, Mary. Personal communication, 1 July 2002.
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