Journal of Nursing and Researchers

Larry PurnellProfessor Emeritus, University of Delaware, Adjunct Professor, Excelsior Col-lege, PhD Program, University of Panama, Transcultural Nursing Scholar

Review Article

*Corresponding authorLarry Purnell, Professor Emeritus, University of DelawareAdjunct Professor, Excelsior College PhD Program, Univer-sity of Panama. Transcultural Nursing Scholar

Submitted: 29 July 2021Accepted: 31 July 2021Published: 04 Aug 2021

Copyright© 2021 Larry PurnellOPEN ACCESS

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Volume 2 | Issue 5 | 66

Amish Literature Review

Journal of Nur & Res 2021

AbstractAs with most, if not all cultural groups, much diversity exists among the Amish, a variant stream of the Anabaptist movement that originated in Swit-zerland in 1525. The name Amish is derived from the surname of Jacob Ammann that emerged in 1693 from this group. They started emigrating to the United States from Europe in 1737. Currently, no Amish live in Europe. Most Amish live in the United States followed by Canada. However, there are Amish populations living in other countries. In general, the Amish can be roughly divided into four groups: The Swartzentruber Amish, the most conservative and smallest subgroup, Old Order Amish the largest subgroup, the New Order Amish, and the Beachy Amish who are the most liberal. This literature review concentrates on the Old Order Amish, although other Amish subgroups groups are also addressed. The increasing growth of the Amish population necessitates that healthcare providers enhance their cultural competence skills and become familiar with Amish customs, beliefs, val-ues, health-care needs, and communication practices. Twelve domains from the Purnell Model for cultural competence guides the development of the content in this literature review. The 12 domains are overview/heritage, cultural communication patterns, family roles and organization, workforce is-sues, biocultural ecology, high-risk health behaviors, nutrition, pregnancy, death rituals, spirituality, health-care practices, and health-care practitioners.

Keywords: Overview/heritage, cultural communication patterns, family roles and organization, workforce issues, biocultural ecology, high-risk health behaviors, nutrition, pregnancy, death rituals, spirituality, health-care practices, health-care practitioners, Old Order Amish, Swartzentruber Amish, Beachy Amish.

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IntroductionThis review of the literature is organized around the 12 domains of the Purnell Model for Cultural Competence. This model has classified as ho-lographic complexity grand theory and is applicable to all health profes-sionals. The model has an extensive assessment guide. The 12 domains are overview/heritage, cultural communication patterns, family roles and or-ganization, workforce issues, biocultural ecology, high-risk health behav-iors, nutrition, pregnancy, death rituals, spirituality, health-care practices, and health-care practitioners.

Overview Heritage and ResidenceThe Amish are a loosely connected network of conservative Anabaptist communities that originated in Switzerland. They broke from the Men-nonites between 1693 and 1697 and are followers of Jakob Ammann who spearheaded the schism because he favored harsher excommunication practices and more conservative modes of dress. Currently, the more pro-gressive conservative Mennonite population are expanding women’s dress (Mong & Clifton). The Mennonites and Amish still share basic Anabaptist values such as opposition to war and infant baptism. Amish communities

have disappeared from Europe. The formal separation of this new group occurred on January 21, 1525, when believers re-baptized themselves and took on the new name of Anabaptist, meaning to be re-baptized [1]. The group later separated again and led to the formation of the Mennonites. In 1693 Jacob Ammann led another separation from the Mennonites of a more conservative group to be known as the Amish [2].

The Amish settled in the United States in 1737 [1]. Today, the greatest numbers of Amish settlements are in Pennsylvania but Ohio has the larg-est population. Accurate statistics about the Amish are difficult to find because of a lack of detailed record keeping, although following are some statistics for the Amish population in the United States [3]. The Ohio population is estimated at 56,430. The next two most populated states are Pennsylvania and Indiana with 51,435 and 39,960, respectively [4]. These statistics include both Old- and New-Order Amish groups, but excludes some less conservative groups including the Amish Mennonites [5].

The Amish are not a homogeneous population. Diversity occurs among and within each group. Theoretically, the Amish are divided into four groups. Swartzentruber Amish, a subset of the Old Order, see themselves

as the truest heirs to the Anabaptist Amish tradition. They are stricter than most Old Order Amish and have a lower standard of living. They are quicker to excommunicate and are usually more isolated from non-Amish people. Their standards of dress are harsher; members may not even ride in cars owned by non-Amish people, except in some emergencies [6]. An off shoot of the Swartzentruber Amish is the Andy Weaver group who only exists in Holmes County, Ohio. This “subgroup” was formed in 1952 over the issue of shunning. They are less conservative than the Swartzentruber Amish but more conservative than the Old Order Amish [7]. They have a stricter approach to shunning but are more liberal with tobacco and al-cohol use. Their parochial schools are less rigorous than the usual eighth grade education provided in Old Order Amish schoolhouses [8].

The Old Order Amish constitute the largest group of rural Amish settlements descended from the Amish Mennonites. Their stricter rules involving dress often prohibit the use of buttons and zippers. They wear dark colors, mostly black. The communities regulate hair length -- men grow beards at an acceptable length. Women are not allowed to get haircuts [9]. They oppose church buildings, preferring to meet in individ-ual homes. This reflects their wariness of organized religion; in general, they think of their house meetings as more organic and unregulated. They also eschew modern technologies like cars, electricity, and tractors [10].The New Order Amish, sometimes called the Amish Brotherhood, have settlements that grew out of the Old Order Amish communities in the mid-20th century. They are similar to the Old Order Amish with slightly relaxed rules governing dress and technology. Colorful clothing is per-mitted and men are allowed to trim beards. The communities allow some modern technologies such as telephones, tractors, and even airplane trav-el. Telephones, however, are usually not permitted in the house and may be in the barn or a separate shed. Telephones and even cell phone are now used by some who have businesses but the phone must not be allowed to ring in the main house [11,12]. In a study by Rivka, female research participants reported that the distance from English/secular media not only raises their status in their communities but also gives them multiple opportunities to invest time and considerable power in face-to-face—not digital—social capital and strong social network connectedness, collective activities, and in formal social engagement.

The Beachy Amish broke from the Old Order Amish at the turn of the 20th century, largely because of disputes over evangelicalism in the Unit-ed States. They admired the revivalism of many churches in the country, like the Baptists and Methodists, and were convinced by their messages of individual salvation. The Beachy Amish began holding their own tent revivals, a practice firmly opposed by the larger Old Order Amish settle-ments. The group is more relaxed when it comes to technology and dress than other Amish communities based on the grounds that they do not find biblical references that prohibit the use of buttons and some other basic innovations. They also allow cars, home electricity, and send missionaries to proselytize throughout the world [13].

Clothing, dress, and appearance are based solely on Amish basic beliefs and their faith. They believe that their appearance and clothing is a very simple way to express their faith to the world. They choose fabrics that rep-resent humility and being separate from the rest of the world. They make their own clothing, mainly from dark simple fabrics. On occasion some groups will use light fabrics for children’s clothing or for summer apparel. Women wear dresses without any patterns, usually with long sleeves and a large skirt. Adult women and girls are not allowed to wear any jewelry because it might take away from the simplicity and humility. Women do not cut their hair, wearing it in a bun or a braid of some kind that is cov-ered with a small white cap [9]. Plain dress is to reject worldliness, vanity, and materialism.

Amish education is unique to their lifestyle and based on homemaking vo-cational skills. Children receive traditional education through the eighth grade and are then sent out into the workforce. The education includes

instruction in reading, writing, spelling, history, and arithmetic, but the primary goal is to obtain real life skills they can contribute to Amish so-ciety. These skills include homemaking, farming, and carpentry which are necessary to thrive in the Amish community. The curriculum focuses on the important Amish values of cooperation, respect, and the natural world instead of independent thinking and critical analysis which are em-phasized more in public education. The teachers themselves have only an eighth-grade education, but they receive further training from other expe-rienced educators [14]. A local board of fathers are responsible for hiring teachers and approving the curriculum. Despite their seemingly substan-dard level of education, students have proved to achieve high scores on standardized tests given by the U.S. Office of Education. In some cases, the average scores surpassed those of the public-school students in the region [15,16], reported that some Amish wanted their children to attend public schools for the following reasons: (a) the desire to have students relate to English children and the wider world, (b) the desire to gain life skills, (c) the desire to have quality teachers, and (d) the desire to take advantage of the draw of public schools.

Before 1950, most Amish children attended public schools. These were small rural public schools organized by parents. As the public schools be-gan to grow, parents were slowly losing control over the education of their children. The community began to favor private Amish Schools. These schools allowed a method of passing their traditions to younger genera-tions in order to preserve their way of life. The separate schooling limited their exposure to the non-Amish world and prevented children from be-ing exposed to the technology used in public schools. Their children were no longer exposed to the influences of peer pressure. Another benefit of private Amish schools is the ability to incorporate Bible study and wor-ship. A larger population of Amish students are in public schools in areas dominated by traditional Mennonites. Some parents choose to place their children in the public school system to better prepare them for contact with the “English.” They are required to pay taxes that go towards public education; there are no further costs for entering the public school sys-tem. A third option that some parents choose is homeschooling, but this is much less common [4].

The lack of certification of the teachers and the decision of the Amish to remove children from school at a young age became controversial but in 1972 the Supreme Court ruled in the case Wisconsin vs. Yoder that it was lawful for Amish families to discontinue their children’s formal education at age fourteen years. This decision was made based on the issues of “Pa-rental rights and Religious freedom”. It is not an Amish practice to defend themselves in a court of law, so the National Committee for Amish Reli-gious Freedom took action and defended the issue in court [17]. Although the Amish are permitted to vote in state and federal elections, most refrain from involvement in politics unless it directly involves their communi-ty. They do, however, cooperate with local elected officials. There have been numerous conflicts between the Amish community and the Federal government. Conflicts have centered around social security, child labor, education, and military service. The Amish separate themselves from the Federal government, but they are required to pay state and federal income taxes, sales tax, real estate tax, and public-school tax. The only tax that they are exempt from is social security if they are self-employed since they do not receive its benefit. Close-knit Amish communities ensure that each member is taken care of throughout their life; thus, federal assistance is unnecessary [18], (Do Amish Pay Taxes?).

CommunicationLike most people, the Amish vary their language usage depending on the situation and the individuals being addressed. American English is only one of three language varieties in their repertoire. For the Amish, English is the language of school, written and printed communications, and, above all, the language used in contacts with most non-Amish outsiders, espe-cially business contacts. Because English serves a useful function as the

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contact language with the outside world, Amish schools use English as the language of instruction with the strong support of parents because elementary schooling offers the best opportunity for Amish children to master the language. Within Amish homes and communities, English is discouraged in favor of the vernacular Deitsch, or Pennsylvania German. Because all Amish except preschool children are literate in their second language; American English helps to define their cultural space [19].

The first language of most Amish is Deitsch, an amalgamation of several upland German dialects that emerged from the interaction of immigrants from the Palatinate and Upper Rhine areas of modern France, Germa-ny, and Switzerland. Their regional linguistic differences were resolved in an immigrant language better known in English as “Pennsylvania Ger-man” (also known as “Pennsylvania Dutch”). Amish immigrants who lat-er moved more directly from the Swiss Jura and environs to midwestern states (with minimal mixing in transit with Deitsch-speakers) call their home language Düütsch, a related variety with marked Upper Alemannic features. Today, Deitsch and Düütsch both show a strong admixture of vocabulary borrowed from English. The basic structure remains nonstan-dard German. Both dialects have practically the same functional distribu-tion [20].

Deitsch is spoken in the home and in conversation with fellow Amish and relatives, especially during visiting, a popular social activity by which news is disseminated orally. It is important to note that Deitsch is primarily a spoken language. Some written material has been printed in Pennsylvania German, but Amish seldom encounter it in this form. Even Amish publi-cations urging the use of Deitsch in the family circle are printed in English (What is in a language? 1986).

The third language used by Amish deserves mention in this cultural pro-file to complete the scope of their linguistic repertoire. Amish proficien-cy in English varies according to the type and frequency of contact with non-Amish, but it is increasing. The use of Pennsylvania German is in decline outside the Old Order Amish community. Its retention, despite the inroads of English, has been related to religious communities’ persistent recourse to Hochdeitsch, or Amish High German, their so-called third language [21].

Amish do not use Standard Modern High German, but an approximation, which gives access to texts printed in an archaic German with some re-gional variations [22]. Rote memorization and recitation for certain cere-monial and devotional functions, for selected printed texts from the Bible, from the venerable Ausbund hymnbook, and from devotional literature are a part of public and private prayer and worship. Such restricted and non-productive use of a third language hardly justifies the term “trilin-gual” because it does not encompass a fully developed range of discourse. However, Amish High German does provide a situational-functional com-plement to their other two languages [22]. Its retention is one more sym-bol of a consciously separated way of life.

Within a highly contextual subculture, the base of shared information and experience is proportionately larger. Thus, less overt verbal communica-tion is required than in the relatively low-contextual American culture and more reliance is placed on implicit, unspoken understandings. Children and youth may learn adult roles more through modeling than through explicit teaching. The many and diverse kinds of multigenerational social activities on the family farm provide an optimal framework for encultura-tion. Although this may facilitate the transmission of traditional accepted knowledge and values within a high-context culture, this same informa-tion network may impede new information imparted from the outside, which entails some behavior changes. Wenger [14,23,24], suggested that health-care providers should consider role modeling as a teaching strategy when working with Amish patients.

Much of the nonverbal behavior of Amish is also symbolic. Many of the details of Amish dress and customs were once general characteristics with-out any particular religious significance in Europe. However, in the Amer-ican setting, they are closely regulated and serve to distinguish the Amish as a self-consciously separate ethnoreligious group [25].

In the domain of ideas held to be normative for the religious aspects of Amish life that they find their English vocabulary lacking. The key source texts in Hochdeitsch and the oral interpretation of them in Deitsch are crucial to an understanding of two German values that have an impact on Amish nonverbal behavior. Demut, German for “humility,” is a priority value, the effects of which may be seen in the height of the crown of a man’s hat, as well as in very general features such as the modest and unassuming bearing and demeanour usually shown in public. This behavior is rein-forced by frequent verbal warnings against hochmut, which means “pride” or “arrogance,” and should be avoided [26].

A second term, gelassenheit, is embodied in behavior more than it is ver-balized. Gelassenheit is treasured for its earlier religious meanings denot-ing quiet acceptance and reassurance encapsulated in the biblical formula “godliness with contentment” (1 Tim. 6:5). The Amish paradigm for the good life flows from the calm assurance found through inner yielding and forgoing one’s ego for the good of others:

1. One’s life rests secure in the hands of a higher power.2. A life so divinely ordained is therefore a good gift.3. A godly life of obedience and submission will be rewarded in the life

hereafter [25].

These inner qualities, an unpretentious quiet manner, and modest outward dress in plain colors lacking any ornament, jewelry, or cosmetics presents a striking contrast to contemporary fashions both in clothing styles and in personal self-actualization. Public behavior is seen as deliberate rath-er than rash, deferring to others instead of being assertive or aggressive, avoiding confrontational speech styles and public displays of emotion in general.

Amish should be greeted with a handshake and a smile. Amish use the same greeting among themselves and with outsiders, but little touching follows the handshake. Younger children are touched and held with affec-tion, but adults seldom touch socially in public [27]. However, therapeutic touch appeals to many Amish and is practiced informally by some who find communal affirmation for their gift of warm hands (see the section on health-care practices). In public, the avoidance of eye contact with non-Amish may be seen as an extension of the general reserve and measured larger body movements related to a modest and humble being.

After generations of rural life guided by the rhythms of daylight and seasons, the Amish manage the demands of clock time in the dominant culture. They are generally punctual and conscientious about keeping ap-pointments, although they may seem somewhat inconvenienced by not owning a telephone or car. These communication conveniences, deemed essential by the dominant American culture, are viewed by the most con-servative Amish as technological advances that could erode the deeply held value of community in which face-to-face contacts are easily made. Therefore, telephones (cell phones are now being used by a few) and auto-mobiles are generally owned by nearby non-Amish neighbors and used by Amish only when it is deemed essential, such as for reaching health-care facilities [28], or visiting family and friends in distant location.

Using first names are appropriate, particularly because generations of in-termarriage have resulted in a limited number of surnames. It is preferable to use first names during personal contacts rather than titles such as Mr. or Mrs. Miller. With so many Millers, Lapps, Yoders, Bylers, and Zooks, given names like Mary, Sarah, Rebecca, John, Amos, and Samuel are overused so

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some might be identified by nicknames, residence, a spouse’s given name, or a patronymic, which may reflect three or more generations of patrilin-eal descent. For example, a particular John Byler may be known as “Blond John,” or “Tall John,” or “Ruth’s John,” or “Sam’s Eli’s Lap’s John.”

Family Roles and OrganizationAmish families are large. Six to 10 children are common [29], (ohio-samishcountry.com). If parents are unable to have children, adoption is available either within the Amish community or from outside the Amish community [30]. The defining aspect of the Amish social structure is each person’s commitment to his or her family and the other members of the community. This is evident when the people come together to support those in need, regardless of the situation. The Amish hold “frolics” when a neighbor requires help raising a house, barn or other large project. A frolic is a work party of men from several neighboring families with the women preparing food for the entire gathering.

Large extended families maintain contact by sending letters through the mail or sending them to “The Budget,” an Amish publication. Families usually adhere to traditional gender roles, although this varies from family to family. The men maintain the role of the head of household and are re-sponsible for supporting the family financially [31]. Women maintain the house and the children, although many sell quilts, fruits, jam, honey, pas-tries, pies and cakes, and flowers. However, these roles are not concrete as men offer support in the home and women may assist with physical labor that is consistent with the general trend in modernization of the Amish culture [29].

Men are the primary spiritual leaders, but men and women share the de-cision making within the household. As gender roles have become less defined, changes in the traditional Amish courtship are apparent. The Old Order Amish adhered to the custom of bedroom courtship, but in modern times Amish youth spend more time engaging in social activities that may be associated with courtship. However, bedroom courtship continues for some ultra-conservative groups (Purnell, personal communication, 2017). The Amish demonstrate humility and modesty. They avoid personal praise, manifestations of individualism and attention seeking activities because these behaviors lead to pride and self-sufficiency that does not come from the Lord. Their only traces of pride can be seen in their home exteriors, yards, and fancy buggy trimmings and harnesses [32].

The Ordnung dictates what is and what is not appropriate within the Amish culture. For example, you will not find electricity or telephones in very traditional Amish households. In order to avoid electricity, they use kerosene, gasoline, and batteries to power lights and generators. These generators can power washing machines, water pumps, and agricultural equipment. Windmills are also sometimes used to power machinery. Most Amish, especially Old Order Amish, rely on horse drawn buggies for trans-portation. They also rely on horses to pull farm machinery. Some technol-ogies that they use that are not prohibited by the Ordnung include inline skates, disposable diapers, and gas grills. The technologies that Amish use greatly depend on the order of which they are a part. The Swartzentruber order is very conservative and does not allow battery powered lights to be used. Some of the Swartzentruber communities do not allow bicycles but scooters without rubber tires are acceptable. The Old Order Amish don’t use modern technology, but they are allowed to ride in motorized vehicles, as long as they do not own them. New Order Amish are more lenient, al-lowing automobiles, modern farming machines and electricity [31].

The Amish believe in living separately with an emphasis on humility. Their education avoids subjects associated with self-exaltation, pride, and en-joyment of power. They believe that God is pleased when people work in harmony with nature; therefore, they put great value into manual labor and hard work. This is another reason why the Amish always live-in rural

communities. They view the city as a place of evil and wickedness. Com-munity is of utmost importance. They often socialize through helping each other through building projects or helping on each other’s farms. Because the Amish do not have life or property insurance, the church will assist in cases of significant loss. The elderly is cared for by the community, and often retire to the dawdyhaus, which is a smaller house that is built next to the main farmhouse [31,33,34].

From the time of marriage, the man’s role as husband is defined by the re-ligious community to which he belongs. Titular patriarchy is derived from the Bible: Man is the head of the woman as Christ is the head of the church (I Cor. 3). This patriarchal role in Amish society is balanced or tempered by realities within the family; the wife is accorded high status and respect for her vital contributions to the success of the family. Practically speak-ing, husband and wife may share equally in decisions regarding the family business. In public, the wife may assume a retiring role, deferring to her husband, but in private, they are typically partners. However, it is best to listen to the voices of Amish women themselves as they reflect on their values and roles within the Amish family and their shared ethnoreligious cultural community [35].

The highest priority is child rearing, an ethnoreligious expectation in the Amish culture. With a family averaging at least 5 (and frequently more) children, the mother contributes physically and emotionally to the bur-geoning growth in the Amish population [36]. She also has an important role in providing food and clothing needs, as well as a major share in child nurturing. Amish society expects the husband and father to contribute guidance, serve as a role model, and discipline the children. This shared task of parenting takes precedence over other needs, including economic or financial success in the family business. On the family farm, all must help as needed, but in general field, barn work, and animal husbandry are primarily the work of men and boys. Food production and preserva-tion, clothing production and care, and management of the household are mainly the province of women.

Children and youth represent a key to the vitality of the Amish culture. Babies are welcomed as a gift from God; the high birth rate is one factor in their population growth. Another is the surprisingly high retention of youth; an estimated 75 percent or more choose as adults to remain in the Amish way [37].

Young people over 16 years of age may work away from home to gain experience or because of insufficient work at home or on the family farm. Their wages are still usually sent home to the parental household because of the cultural value that the whole family contributes to the welfare of the family.

Some experimentation with non-Amish dress and behavior among teen-agers is tolerated during Rumspringa [38]. Rumspringa, also spelled Rum-schpringe or Rumshpringa, is a rite of passage during adolescence, trans-lated in English as “jumping or hopping around,” used in some Amish communities. For Amish youth, the Rumspringa normally begins around the ages of 14–16 and ends when the youth choose to be baptized in the Amish church or to leave the community. This is a period of relative leni-ency, but the expectation is that an adult decision to be baptized before marriage will call young people back to the discipline of the church as they assume adult roles [39]. Some children do not return to the Amish com-munity; however, research according to Cory (2021) reports that wealth-ier Amish retain more of their children in the order than do less wealthy. Perhaps this is because more amenities help them have contact with the outside world.

In recent years, the media have been fascinated with this period of Amish teenage life as Americans in general have learned more about the Amish

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as a distinctive culture. Meyers and Nolt (2005) contended that although some Amish teenagers do experiment with behaviors that are incongru-ent with Amish beliefs and values, they do so in a distinctive Amish way. Amish teenagers are aware of the dominant American culture. When they choose to participate in behaviors, some of which may involve the legal system, they do so in ways that are not common to American teenagers in general. For example, Amish youth will usually experiment with other Amish youth, rather than with non-Amish teenagers. However, children of richer Amish parents are less likely to leave the community [40].

The Amish family pattern is referred to as the freindschaft, the dialectical term used for the three-generational family structure. This kinship net-work includes consanguine relatives consisting of the parental unit and the households of married children and their offspring. All members of the family personally know their grandparents, aunts, uncles, and cousins, with many knowing their second and third cousins as well [29].

Individuals are identified by their family affiliation. Children and young adults may introduce themselves by giving their father’s first name or both parents’ names so they can be placed geographically and genealogically. Families are the units that make up church districts; the size of a church district is measured by the number of families rather than by the number of church members (see the section on Spirituality). This extended family pattern has many functions. Families visit together frequently, thus learn-ing to anticipate caring needs and preferences. Health-care information often circulates through the family network, even though families may be geographically dispersed. [41], found that informants referred to freind-schaft when discussing the factors influencing the selection of health-care options. “The functions of family care include maintaining freindschaft ties, bonding family members together intergenerationally, and living according to God’s will by fulfilling the parental mandate to prepare the family for eternal life” [41].

As grandparents turn over the primary responsibility for the family farm or business to their children, they continue to enjoy respected status as elders, providing valuable advice and sometimes material support and services to the younger generation. Many nuclear families live on a farm with an adjacent grandparent’s cottage, or a smaller apartment attached to the main farmhouse promoting frequent interactions across generations. Grandparents provide childcare and help in rearing grandchildren and, in return, enjoy the respect generally paid by the next generations. This emo-tional and physical proximity to older adults facilitates elder care within the family setting. In an ethnonursing study on care in an Amish commu-nity Wenger (1988) reported that an informant discussed the reciprocal benefits of having her grandparents living in the attached daedihaus and her own parents living in a house across the road. Her 3-year-old daughter could go across the hall to spend time with her great-grandfather, which the mother reported was good for him in that he was needed. The child benefited from knowing her great-grandfather; the young mother gained some time to do chores. There is no set retirement age among the Amish. Grandmothers continue in active roles as advisers and assistants to young-er mothers.

Assuming full adult membership and responsibility means the willingness to put group harmony ahead of personal desire. In financial terms, it is an obligation to help others in the brotherhood. This mutual aid commitment provides a safety net, allowing Amish to rely on others for help in emer-gencies. Consequently, the Amish do not seek federal pension or retire-ment support. They have their own informal “social security” plan. Amish of varying degrees of affluence enjoy approximately the same social status; extremes of poverty and wealth are uncommon. Property damage or loss and unusual health-care expenses are also covered to a large extent by an informal brotherhood alternative to commercial insurance coverage [42]. The costs of high-technology medical care present a new and severe test of

the principle of mutual aid or “helping out,” which is almost synonymous with the Amish way of life.

There is little variation from the culturally sanctioned expectations for parents and their unmarried children to live together in the same house-hold while maintaining frequent contact with the extended family. Un-married children live in the parents’ home until marriage, which usually takes place between the ages of 20 and 30 years of age. Some young adults may move to a different community to work and live as a boarder with another Amish family. Being single is not stigmatized, although almost Amish do marry. Single adults are included in the social fabric of the com-munity with the expectation that they will want to be involved in family- oriented social events [43].

Individuals of the same gender do not live together except in situations in which their work may make it more convenient. For example, two female schoolteachers may live together in an apartment or home close to the Amish school where they teach. There are no available statistics on the incidence of homosexuality in Amish culture. Isolated incidents of ho-mosexual practice may come to the attention of health providers, but ho-mosexual lifestyles do not fit with the deeply held values of Amish family life and procreation (Purnell personal communication 2019). However, alternative lifestyles do occur as with any population. The website LGBTA-mish.com [44], offers support, education, networking opportunities, and friendship to those who are interested in and practice alternative lifestyle. This is a safe place to share stories and struggles, a place to find under-standing, support, and community.

Workforce Issues In every generation except the present one, the Amish have worked almost exclusively in agriculture and farm-related tasks. Their large families were ideally suited to labor intensive work on the family farm. As the number of family farms has been drastically reduced because of competition from agribusinesses that use mechanized and electronically controlled produc-tion methods, few options are available for Amish youth; therefore, many have relocated to other states, Honduras, Belize, Bolivia, and Mexico. They are not always well-accepted in these environments. For example, in Be-lize, they are not well accepted because they are farmers and considered lower-class (Purnell - Person communication in Belize).

Traditionally, the Amish have placed a high value on hard work with little time off for leisure or recreation. Productive employment for all is the ide-al and the intergenerational family provides work roles appropriate to the age and abilities of each person. However, prospects have begun to narrow with the increased concentration of family farms in densely settled Amish communities as their population increased [4]5. Amish are more physi-cally active than many other cultural groups because of their lifestyle [46].Several cultural factors combine to limit the opportunities for young Amish to adapt to new work patterns. Children attending school through only eight grades have a limited basis for vocational training in many work areas other than agriculture. Avoiding compromising associations with “worldly” organizations such as labor unions, restricts them to non-union work that often pays lower hourly rates. Work off the family farm, at one time a good option for unmarried youth, has become an economic neces-sity for some, although it is considered less acceptable for social reasons. Fathers who “work away,” sometimes called “lunch pail daddies,” have less contact with children during the workday which has impacted the tradi-tional father’s modeling role and places more of the responsibility for child rearing on stay-at-home mothers. This shift in traditional parental roles is a source of some concern, although the effects are not yet clear [25].

Another concern in relation to the workplace is the use of technologies that may be of concern. Hurst and McConnell (2001) describe survey re-sults of Amish in Holmes County, Ohio where 9 out of 10 persons “believe

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there are some technologies that are harmful to the stability and integrity of Amish culture, regardless of how they are used” (p. 210). Computers, Internet, and TV were mentioned the most. These technologies are perva-sive in non-Amish lifestyles and workplaces. Their concern is the difficul-ty in using these technologies in healthy ways that uphold Amish beliefs and values. External and internal factors have converged and cause doubt about the continued viability of Amish farming communities. Exorbitant land prices triggered group movement and resettlement in states to the west and south. The declining availability of affordable prime farmland in and around the centers of highest Amish population density is due in part to their non-Amish neighbors’ land-use practices, especially in areas of suburban sprawl. A powerful internal force is at work as well in the population growth rate among the Amish, now well above the national av-erage. So, contrary to popular notions that such a “backward” subculture is bound to die out, the Amish today are thriving.

Population growth continues even without a steady influx of new immi-grants from the European homeland or significant numbers of new con-verts to their religion or way of life [25]. The Young Center for Anabaptist and Pietist Studies at Elizabethtown College (2019) reports that the esti-mated population of the Amish of North America (adults and children) as of June 2018 is 330,270. This is an increase of approximately 11,880 since 2017, a growth rate of 3.73 percent. In the 20-year period from 1991 to 2018, the Amish in North America (adults and children) increased from 123,500 in 1991 to 330,270 in 2017, an overall growth of 260 percent. This population growth has been attributed largely to the size of families and the retention rate of young adults [5,47].

The pressures to control the changes in their way of life while maintaining its religious basis, particularly the high value placed on in-group harmony, have challenged the Amish to develop adaptive strategies. One outcome is an increasingly diversified employment base with a trend toward cottage industries and related retail sales, as well as wage labor to generate cash for higher taxes and increasing medical costs. Another recent development includes a shift from traditional multigenerational farmsteads as some re-tirees and crafts workers employed off the farm have begun to relocate to the edges of country towns. Thus, pressures to secure a livelihood with-in the Amish tradition have heightened awareness of the tension within which the Amish coexist with the surrounding majority American culture [5]. Because English is the language of instruction in schools and is used with business contacts in the outside world, there is generally no language bar-rier for the Amish in the workplace. English vocabulary that is lacking in their normative ideas for religious aspects of Amish life is rarely a concern. The shift from agriculture as the primary income for Amish families is partially due to the increasing cost and scarcity of land. There have been increasing numbers of Amish owned small businesses popping up around the country and perhaps the most well-known being Amish furniture stores. Other successful business ventures include quilt shops, greenhous-es, and bakeries. Amish men also work in construction. They form con-struction crews within a settlement and travel between rural towns con-tracting work from non-Amish people. In some settlements the majority of the people work at non-Amish owned factories or restaurants. Those who choose to make their primary income away from agriculture still of-ten continue farming as a hobby. Despite the new diversity in the Amish work habits, the primary goal remains finding work that supports an indi-vidual family and also serve the community as a whole [48].

Biocultural Ecology Since 1962, several hereditary diseases have been identified among the Amish. The earliest findings of the genetic studies have been published by Dr. Victor McKusick of the Johns Hopkins University. The Clinic for Spe-cial Children in Strasburg, PA was started in 1989 by Dr. Holmes Morton and continues to provide medical care for Amish and Mennonite children

with genetic disorders [49]. Because Amish tend to live in settlements with relatively little domiciliary mobility, and because they keep extensive ge-nealogical and family records, genetic studies are more easily done than with more mobile cultural groups [50]. Many years of collaboration be-tween the Amish and geneticists from the Johns Hopkins Hospital and the Clinic for Special Children have resulted in mutually beneficial projects. The Amish received printed community directories. Geneticists compiled computerized genealogies for the study of genetic diseases that continue to benefit society in general [51].

Essentially the Amish are a closed population with exogamy very rare-ly occurring. However, they are not a singular genetically closed popu-lation. The larger and older communities are consanguineous, meaning that within the community the people are related through bloodlines with common ancestors. Several consanguine groups have been identified in which relatively little intermarriage occurs between the groups. The sep-arateness of these groups is supported by the history of the immigration into each area, by the uniqueness of the family names in each community, by the distribution of blood groups, and by the different hereditary dis-eases that occur in each of these groups [19]. These diseases are one of the indicators of distinctiveness among the groups.

Hostetler [19] cautioned that although “inbreeding” is more prevalent in Amish communities than in the general population, it does not inevita-bly result in hereditary defects. In some societies, marriages between first and second cousins were relatively common without major adverse effects. However, in the Amish gene pool there are several recessive tendencies that in some cases are limited to specific Amish communities in which the consanguinity coefficient (degree of relatedness) is high for the specific genes of at least 12 recessive diseases, 4 should be noted here [19,52].

Dwarfism has long been recognized in several Amish communities. El-lis–van Creveld syndrome, known in Europe and named for Scottish and Dutch physicians, is especially prevalent among the Lancaster County, Pennsylvania, Amish. This syndrome is characterized by short stature and an extra digit on each hand with some individuals having a congen-ital heart defect and nervous system involvement resulting in a degree of mental deficiency. The Lancaster County Amish community, the second largest Amish settlement in the United States, is the only one in which Ellis–van Creveld syndrome is found [53]. The lineage of all affected peo-ple has been traced to a single ancestor, Samuel King who immigrated in 1744 [52].

Cartilage hair hypoplasia, also a dwarfism syndrome, has been found in nearly all Amish communities in the US and Canada, although it is not unique to the Amish [54]. This syndrome is characterized by short stat-ure and fine, silky hair. There is no central nervous system involvement; therefore, no mental deficiency. Most affected individuals have deficient cell-mediated immunity increasing their susceptibility to viral infections [52].

A rare blood cell disorder, pyruvate kinase anemia, was described by Bow-man and Procopio in 1963. The lineage of all affected individuals can be traced to Jacob Yoder (known as “Strong Jacob”) who immigrated to Mif-flin County, Pennsylvania, in 1792 [19,52]. This same genetic occurs in the Geauga County, Ohio Amish community. Notably, the families of all those who were affected were from the “Strong Jacob” lineage. Symptoms with jaundice and anemia usually appear soon after birth. Transfusions during the first few years of life and eventual removal of the spleen are considered cures.

Hemophilia B, another blood disorder, is disproportionately high, espe-cially in Ohio. [55], reported on an Amish man who was treated for a rup-tured spleen. It was discovered that he had grandparents and 10 cousins

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who were hemophiliacs; five of the cousins had died from hemophilia. Re-search on causative mutations indicated a strong probability that a specific mutation may account for much of the mild hemophilia B in the Amish population [56].

Through the vigilant and astute observations of some public-health nurs-es, a major health-care problem was noted in a northern Indiana Amish community. A high prevalence of phenylketonuria (PKU) was found in the Elkhart-Lagrange Amish settlement [50,57]. Those affected are unable to metabolize the amino acid phenylalanine, resulting in high blood lev-els of the substance and eventually severe brain damage if the disorder is untreated. Through epidemiological studies, the health department found that 1 in 62 Amish were affected, whereas the ratio in the general popu-lation is 1 in 25,000. Through the leadership of these nurses, the county and the state improved case funding for PKU and health-care services for affected families throughout Indiana, which was followed by improved health services in Amish communities in other states as well.

In recent years, a biochemical disorder called glutaric aciduria has been studied by Dr. Holmes Morton, a Harvard-educated physician who has chosen to live and work among the Amish in Lancaster County, Penn-sylvania. Morton made house calls, conducted research at his own ex-pense because funding was not forthcoming, and established a clinic in the Amish community to screen, diagnose, and educate people to care for individuals afflicted with the disease [58]. By observing the natural histo-ry of glutaric aciduria type I, the researchers postulated that the onset or progression of neurological disease in Amish patients can be prevented by screening individuals at risk; restricting dietary protein; thus, limiting protein catabolism, dehydration, and acidosis during illness episodes.

Dr. Morton was well received in the Amish community. Many people re-ferred friends and relatives to him. When he noted the rapid onset of the symptoms and the high incidence among the Amish, he did not wait for them to come to his office. He went to their homes and spent evenings and weekends driving from farm to farm, talking with families, running tests, and compiling genealogical information [59]. In 1991, he built a clinic with the help of donations, in part the result of an article in the Wall Street Journal about the need for this non-profit clinic. Hewlett-Packard donat-ed the needed spectrometer, local companies provided building materi-als, and an Amish couple donated the building site. Although volunteers helped to build the clinic, a local hospital provided temporary clinic space lease-free because the community recognized the very important contri-bution Morton was making, not only to the Amish and the advancement of medical science but also to the public health of the community.

A countywide screening program is now in place. Health-care providers are able to recognize the onset of symptoms. Research continues on this metabolic disorder, its relationship to cerebral palsy in the Amish pop-ulation, and the biochemical causes and methods of preventing spastic paralysis in the general population. However, education remains a highly significant feature of any community health program. Nurses and phy-sicians need to plan for family and community education about genetic counseling, screening newborns and recognizing of symptoms during ac-iduric crises in affected children In The New York Times Magazine [58], Dr. Morton was called “a doctor for the future”’ because he practices what is now referred to as genetic medicine, which recognizes genetics as part of all medicine. To the Amish, he is their friend who cares about their children, knows their families by name, and comes to their homes to see how they are able to cope with the manifestations of these genetic diseases. Similar to the views of non-Amish parents, there is great variability in pa-rental willingness to obtain genetic counselling [60]. As in most health care decisions, obtaining genetic counselling remains with the individual. Family members, friends, and religious leaders may give advice. Genetic counselling may or may not be done before pregnancy and may be re-

quested prior to delivery. This information may be helpful in childbirth decisions made in collaboration with health-care providers.

Extensive studies of manic-depressive illnesses have been conducted in the Amish population. Comparative studies have been done on both Amish [62] and non-English families [62] to determine the genetic basis of men-tal disorders. While new information on the genome has been obtained, the specific locus for bipolar disorders had not yet been found. Attempts have been made to gain knowledge about the affective response the Amish have to their ethnoreligious cultural identity and experience [62,63], stud-ied the protective factors of the Amish lifestyle in mental health disorders. The incidence of alcohol and drug abuse, which can complicate psychiat-ric diagnoses, is much lower among the Amish than in the general Unit-ed States population, thus contributing to the importance of the Amish sample. Although the incidence of bipolar affective disorder is not found to be higher in the Amish, some large families with several affected mem-bers continue to contribute to medical science by being subjects in the genetic studies. Because the Old Order Amish descend from 30 pioneer couples whose descendants have remained genetically isolated in the Unit-ed States, have relatively large kindred groups with multiple living gener-ations, and generally live in close geographic proximity, they are an ideal population for genetic studies [61].

No drug studies specifically related to the Amish were found in the liter-ature. Given the genetic disorders common among selected populations, astute clinicians are tailoring interventions to provide the safest medical care of Amish [51]. The impact of genetic variance in pharmacogenetics is one area in which more research needs to be conducted.

High-Risk BehaviorAmish, traditionally agrarian, prefer a lifestyle that provides intergener-ational and community support systems to promote health and mitigate the prevalence of high-risk behaviors. Genetic studies using Amish popu-lations are seldom confounded by the use of alcohol and other substances. However, health providers should be alert to potential alcohol and recre-ational drug use in some Amish communities, especially among young, unmarried men. When young adult men exhibit such behavior as straying from the Amish way of life and “sowing their wild oats” before becoming baptized church members and before marriage, it is tacitly tolerated. Al-though this may be considered a high-risk behavior, it is not prevalent in all communities, nor is it promoted in any. Parents confide in each other and sometimes in trusted outsiders that this behavior causes many heart-aches. At the same time, they try to be patient and keep contact with the youth so they may choose to espouse the Amish lifeways.

Another lifestyle pattern that poses potential health risks is nutrition. Amish tend to eat high-carbohydrate and high-fat foods with a relatively high intake of refined sugar. Wenger (1994) reported that in an ethnonurs-ing study on health and health-care perceptions, informants talked about their diet being too high in “sweets and starches” and knowing they should eat more vegetables. Obesity was found to be greater among Amish women than for women in the general population [64]. In this major health-risk survey of 400 Amish adults and 773 non-Amish adults, the authors found that the pattern of obesity in Amish women begins in the 25-year-old and older cohort with the concentration occurring between the ages of 45 and 64. An explanation for the propensity for weight gain among the Amish may be related to the central place assigned to the consumption of food in their culture and the higher rates of pregnancy throughout their child-bearing years (Wenger, 1994). However, in recent studies related to eating behaviors, obesity, and diabetes, the Old Order Amish cohorts showed some significant differences from other Whites in the majority culture.

The Old Order Amish sample evidenced diabetes approximately half as

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frequently as did other Whites. There has been additional research done on linkage of familial hypercholesterolemia and diabetes among related Amish families (Xu et al., 2017). An important difference was the level of daily physical activity which was reported to be higher among both Amish men and women than among other White cohorts [46].

Health-Care PracticesMuch of what passes for “general knowledge” in an information-rich pop-ular culture is screened, or filtered, out of Amish awareness. The Amish have restricted their access to print media, permitting only a few news-papers and periodicals. Most have also rejected the electronic media, be-ginning with radio and television, but also including entertainment and information applications of films, computers, and cell phones. However, the Amish are openly curious about the world beyond their own cultur-al horizons, particularly regarding literature that deals with health and quality-of-life issues. They especially value the oral and written personal testimonial as a mark of the efficacy of a particular treatment or health-en-hancing product or process. [23]. identified testimonials from Amish friends and relatives as a key source of information in making choices about health-care providers and products [65].

Fondness and love for family members are held deeply but privately. Some health-care providers have observed the cool, almost aloof behavior of Amish husbands who accompany their wives to maternity centres, but it would be presumptuous to think that it reflects a lack of concern. Joy and suffering are not entirely subdued by dour or stoic silence but are clearly not outwardly demonstrative or exuberant [66,67]. Most are physically active, largely due to their agrarian lifestyle and farming as a preferred occupation. Physical labor is valued. Men, women, and children help with farm work. Household chores and gardening, generally considered to be women’s work, require physical exertion, particularly because the Amish choose not to use electrically operated appliances in the home or machin-ery that conserve human energy. The impact of increased physical activity is found in comparison studies of Amish and non-Amish children [68]. Nevertheless, many women do contend with a tendency to be overweight. It is not uncommon to find Amish women seeking help for weight control.Physical contact should be kept to a minimum: it is inappropriate for con-tact between members of the opposite sex. Thus, nursing care should be performed by members of the same sex if at all possible. Health educators who venture into the Amish community should adhere to modesty prac-tices depending on their gender in order to facilitate the best quality of communication.

Farm and traffic accidents continue to be an increasing health concern in communities with a dense Amish population. In states with relatively high concentrations of Amish who drive horse-drawn vehicles, blinking red lights and large red triangles attached to their vehicles are required by law. Research done on both adult and pediatric injuries show trends in trauma with accidents involving farming equipment, animal injuries, and buggy accidents [69]. Transportation-related injuries (buggy vs. car) con-tinue to be the biggest threat for all ages. Encourage Amish families need to monitor their children who operate farm equipment and transportation vehicles and to teach them about safety factors. Concern about accidents is evident in Amish newsletters, many of which have a regular column reporting accidents and asking for prayers or expressing gratitude that the injuries were not more severe, that God had spared the person, or that the community had responded in caring ways [23].

The ultra-conservative Amish rejected vaccines more often. Amish special needs children were more likely to receive vaccines than healthy Amish children. 75% responded they would reject a COVID-19 vaccine. Fear of adverse effects was the most common reason to reject vaccines. Families who accepted vaccines were more likely to cite a health-care worker as the

primary influence to vaccinate. Wives were more likely to cite their spouse as the primary influence to vaccinate. Families who rejected vaccines were more likely to state their bishop was the most influential person on vac-cinations [70].

NutritionAmong the Amish, food is recognized for its nutritional value. Most prefer to grow their own produce for economic reasons and because for gen-erations they have been aware of their connections with the earth. They believe that God expects people to be the caretakers of the earth and to make it flourish [71].

They generally eat foods produced in their own gardens or their farms. As a rule, they do not eat processed, store-bought foods such as corn flakes or potato chips. Homegrown fruits and vegetables, eaten fresh, canned, or frozen play a very important part in the Amish diet. Vegetables often found in Amish meals include peas, corn, zucchini, beets, beans, rhubarb, and many others. Cabbage and potatoes are especially important. Sauer-kraut—a type of pickled cabbage—appears at many Amish meals and is used in everything from soups to cakes. Grain products like bread, corn-meal, and oatmeal are also staples. Scrapple, a popular breakfast food, is made with fried cornmeal mush prepared with sausage and liverwurst [71].

Main meals are usually built around hearty meat dishes such as pork chops, ham, roast beef, or meatloaf. Dairy products, especially eggs and cheese, are also important dietary staples. The Amish are known through-out the country for the quality of the cheese they produce and market. Most Amish families keep at least a few chickens so they can eat freshly laid eggs all year round. In the wintertime, hearty soups are eaten regular-ly. Amish women bake a great deal, preparing breads, cookies, pies, and cakes. The best-known Amish desserts include shoofly pie, sugar cookies, and schnitz pie, which is made with dried apples. Favorite beverages in-clude coffee, tea, milk, and lemonade [71].

The Amish serve food in most social situations because food has a signif-icant social meaning. Visiting, a highly valued cultural function, occurs most weeks for visiting family, neighbors, and friends, especially those within their church district. Some of these visits are planned where snacks or meals are shared, sometimes with the guests helping provide the food. Even if guests come unexpectedly, it is customary in most Amish commu-nities for snacks and drinks to be offered.

Typical Amish meals include meat, potatoes, noodles, or both; a cooked vegetable; bread; something pickled (e.g., pickles, red beets); cake or pud-ding; and coffee. Beef is usually butchered by the family. If they do not have home freezing capabilities, then the meat is kept in the local com-mercially owned freezer for which they pay a rental storage fee. However, some more progressive Amish have freezer capabilities that are gasoline powered. Some families also preserve beef by canning, and most families have chickens and other fowl, such as ducks or geese which they raise for eggs and meat. Families value growing their own foods and usually have large gardens. A generation ago, this was an unquestioned way of life, but an increasing number of families living in small towns and working in factories and construction own insufficient land to plant enough food for the family’s consumption.

Snacks and meals in general tend to be high in fat and carbohydrates. A common snack is large, home-baked cookies about 3 inches in diameter. Commercial non-Amish companies have recognized large soft cookies as a marketable commodity and have advertised their commercially made products as “Amish” cookies, even though no Amish are involved in the production. Other common snacks are ice cream (purchased or home-made), pretzels, and popcorn [71].

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When Amish gather for celebrations such as weddings, birthdays, work bees, or quiltings, the tables are usually laden with a large variety of foods. The selection, usually provided by many people, includes several casse-roles, noodle dishes, sweet potatoes, cooked vegetables, a few salads, pick-led dishes, pies, cakes, puddings, and cookies. [19], provided a detailed ethnographic description of the meaning and practices surrounding an Amish wedding, including the food preparation, the wedding dinner and supper, and the roles and functions of various key individuals in this most important rite of passage.

In communities in which tourists flock to learn about the Amish, many entrepreneurs have used the Amish love of wholesome, simple foods to market their version of Amish cookbooks, food products, and restaurants that more aptly reflect the Pennsylvania German, commonly referred to as Pennsylvania Dutch, influence of communities such as Lancaster County Pennsylvania and other states. Many of these bear little resemblance to authentic Amish foods, and some even venture to sell “Amish highballs” or “Amish sodas” [19]. Some Amish families help to satisfy the public interest in their way of life by serving meals in their homes for tourists and local non-Amish. However, most Amish view their foods and food preparation as commonplace and functional, not something to be displayed in maga-zines and newspapers. Health-care providers need to discuss nutrition and food to promote healthy nutritional lifestyles.

A “place at the table” is symbolic of belonging [19]. Seating is traditionally arranged with the father at the head and boys seated youngest to oldest to his right. The mother sits to her husband’s left, with the girls also seated youngest to oldest or placed so that an older child can help a younger one. The table is where work, behavior, school, and other family concerns are discussed. During the busy harvesting season, preference is given to the men and boys who eat and return to the fields or barn. At mealtimes, all members of the household are expected to be present unless they are working away from home or visiting at a distance, making it difficult to return home.

Sunday church services, which for the Old Order Amish are held in their homes or barns, are followed by a simple meal for all who attended church. Church benches are transported from home to home wherever the church service is to be held. Meals become ritualized. The focus is on the oppor-tunity to visit over a simple meal. In one community, an Amish infor-mant who had not attended services because of a complicated pregnancy told the researcher that she missed the meal, which in that community consisted of bread, butter, peanut butter mixed with marshmallow creme and honey, apple butter, pickles, pickled red beets, soft sugar cookies, and coffee [23].

The Amish only eat foods that they have grown in their own personal gar-den, or they have grown on their farms. They hold farmers markets for each other, and they give other members of their community food and buy food grown on other member’s farms. They don’t usually buy food that is in stores or has been processed and packaged, although is becoming more common in some communities where the store hires Amish women to prepare the food. They will grow their own fruits and vegetables, which they can or freeze for later. Some of the most common vegetables that are grown include beans, zucchini, rhubarb, peas, corn, and others. The most important vegetable for the Amish is cabbage. They usually pickle the cabbage and make sauerkraut. Some have sauerkraut for every meal and is incorporated it into main dishes and sometimes into desserts. Grains are another important part of Amish food. A staple of the Amish culture is scrapple, a breakfast food made with fried cornmeal mush and can be served with sausage and liverwurst. The Amish are also known for their cheese which they sell in markets. They usually have a few chickens at all times so that they can have fresh eggs. They also are known for their des-sert pastries such as shoofly pie, shnitz pie, and sugar cookies [71].

Although some more progressive Amish have gasoline powered refrigera-tors, the ultra-conservative populations do not. For those who do not have more modern convenience for preserving meats and vegetable, they use neighborhood frozen food lockers (Purnell, personal communication).

Pregnancy and Childbearing PracticesWhen it comes to childbirth, many Amish women take a traditional herbal “Five-week formula” late in their pregnancy. This formula consists of sev-eral different herbs and natural medicines that aid with everything from uterine contractions to varicose veins [72]. Even though many Amish re-fuse modern medicine, more women are giving birth in modern hospitals. The Amish often delay seeking medical care and are at risk for compli-cations secondary to the initial problem (Weyer, Hustey, Rathbun, Arm-strong, Reed, Roynak, & Savrin, 2003). However, when it comes to child-birth more Amish women are now using hospitals and Amish Birthing Centers [30,72]. Healthcare providers should be prepared to learn about Amish cultural and folk medicine before pregnant women are admitted.The health risks for Amish are quite significant. Many Amish women do not practice birth control [73] and large families are encouraged. There-fore, the Amish are at risk for difficult pregnancies and complications due to pregnancies with late age. The Amish tend to marry within their com-munity which increases the risk for genetic diseases and the prevalence of recessive genetic disorders (Weyer et al., 2003).

Medical practitioners must acknowledge that the Amish believe in folk medicine and home remedies. Powwowing, or braucha, is a brand of faith healing practiced by some Amish (Weyer et al., 2003). Powwowing in-volves audible or silent incantations, touch, or moving near a sick person, provided by a person who has inherited a power to heal [74]. Braucha is a healing method with an “emphasis on the continuum of life and death” [66].

Children, viewed as a gift from God, are welcomed. Estimates place the av-erage number of live births per family at seven [75], although other sourc-es report 6 to 10 depending on the community. The Amish fertility pattern has remained constant during the past 100 years, while many others have declined. Household size varies from families with no children to couples with 15 or more children [76]. Even in large families, the birth of anoth-er child brings joy because of the core belief that children are “a heritage from the Lord,” and another member of the family and community means another person to help with the chores [19].

Having children has a different meaning for Old Order Amish than in the dominant European American culture. In a study on women’s roles and family production, the authors suggested that Amish women enjoy high status despite the apparent patriarchal ideology because of their childbearing role and their role as producers of food [77]. A large number of children benefit small labor-intensive farms. With large families comes the need for large quantities of food. Interpretation of this view of fertili-ty should always be moderated with recognition of the moral and ethical core cultural belief that children are a gift from God, given to a family and community to nurture in preparation for eternal life.

Scholars and researchers of long-term acquaintance with Old Order Amish agree that the pervasive Amish perception of birth control is that it interferes with God’s will and thus should be avoided [78]. Neverthe-less, fertility control does exist, although the patterns are not well known and very few studies have been reported. [79] discussed childbearing with Amish couples in a group interview and they conceded that some couples do use the rhythm method. In referring to birth control, one Amish fa-ther stated, “It is not discussed here, really. I think Amish just know they shouldn’t use the pill” [79]. Three physicians and three nurses were inter-viewed; they reported that some do ask about birth control methods, es-pecially those with a history of difficult perinatal histories and those with

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large families. Some Amish women use intrauterine devices, but this prac-tice is uncommon. Most women are reluctant to ask physicians and nurses and, therefore, should be counseled with utmost care and respect because this is a topic that generally is not discussed, even among themselves. Ap-proaching the subject obliquely may make it possible for the woman or man to sense the health provider’s respect for Amish values and thus en-courage discussion. “When you want to learn more about birth control, I would be glad to talk with you” is a suggested approach [67].

Amish tend to have their first child later than non-Amish. A retrospective chart review examining pregnancy outcomes of 39 Amish and 145 non-Amish women at a rural hospital found that Amish had their first child an average of one year later than non-Amish couples [80]. They had a nar-rower range of maternal ages and proportionately fewer teenage pregnan-cies. All subjects received prenatal care, with the Amish receiving prenatal care from Amish lay midwives during the first trimester.

In some communities, Amish have been reported to be reluctant to seek prenatal health care. Providers who gain the trust of the Amish learn that they want the best perinatal care, which fits with their view of children being a blessing [81]. However, they may choose to use Amish and non-Amish lay midwives who promote childbearing as a natural part of the life cycle. In a study of childbearing practices as described by Amish women in Michigan, [81] learned that they prefer home births even if they had limited formal knowledge of the childbirth process. Health-care providers were usually consulted only when there were perceived complications. Al-though many may express privately their preference for perinatal care that promotes the use of nurse-midwifery and lay midwifery services, home deliveries, and limited use of high technology, they tend to use the perina-tal services available in their community. In ethnographic interviews with informants, Wenger (1988) found that grandmothers and older women reported greater preference for hospital deliveries than did younger wom-en. The younger women tend to have been influenced by the increasing general interest in childbirth as a natural part of the life cycle and the de-emphasis on the medicalization of childbirth. Some communities have a long-standing tradition of using both lay midwifery and professional ob-stetric services, often simultaneously. Infant loss is frequently invisible to the rest of society. Parents may become frustrated when they are denied mourning time or asked why they are not “over it” yet. Nurses’ demon-stration of cultural sensitivity during perinatal loss facilitates grieving by validating each family’s “right” way to mourn their infant’s death [82].

An interview on 6/9/2020 with Melanie Chichester, RN, BSN, RNC-OB, CPLE a nurse specializing in perinatal death working in a large level 3 trauma center that receives Amish women with birthing complications re-port the most common reasons for pregnant Amish women to be admit-ted to the obstetric unit reports the most frequent reasons for admission the most common reasons are the mother has a cardiac condition, the baby is expected to have complications, placenta previa, uterine rupture, and hemorrhagic shock.

The Mt. Eaton Care Center in Ohio developed as a community effort in re-sponse to retirement of an Amish lay midwife known as Bill Barb (identi-fied by her spouse’s name). She provided perinatal services including labor and birth, with the collaborative services of a local Mennonite physician who believed in providing culturally congruent and safe health-care ser-vices. At one point in Bill Barb Hochstetler’s 30-year practice, the physi-cian moved a trailer with a telephone onto Hochstetler’s farm so that he could be called in case of an emergency. Other sympathetic physicians also delivered babies at Bill Barb’s home. After state investigation, which coin-cided with her intended retirement, Hochstetler’s practice was recognized to be in a legal grey area. The Mt. Eaton Care Center became a reality in 1985 after careful negotiation with the Amish community, Wayne County Board of Health, Ohio Department of Health, and local physicians and

nurses. Physicians and professional nurses and nurse-midwives, who are interested in Amish cultural values and health-care preferences, provide low-cost, safe, low-technology perinatal care in a homelike atmosphere. In 1997, the New Eden Care Center, modeled after the Mt. Eaton Care Center, was built in northern Indiana and, in recent years, has had more than 400 births per year [83].

Because the Amish want family involvement in perinatal care, outsiders may infer that they are open in their discussion of pregnancy and child-birth. In actuality, most Amish women do not discuss their pregnancies openly and make an effort to keep others from knowing about them until physical changes are obvious. Mothers do not inform their other children of the impending birth of a sibling, preferring for the children to learn of it as “the time comes naturally” (Wenger, 1988). This fits with the Amish cultural pattern of learning through observation that assumes intergen-erational involvement in life’s major events. Anecdotal accounts exist of children being in the house, though not physically present, during birth. Fathers are expected to be present and involved, although some may opt to do farm chores that cannot be delayed, such as milking cows.Amish women do participate in prenatal classes, often with their hus-bands [79]. Women are interested in learning about all aspects of perinatal care but may choose not to participate in sessions when videos are used. Prenatal class instructors should inform them ahead of time when vid-eos or films will be used so they can decide whether to attend. For some Amish in which the Ordnung (the set of unwritten rules prescribed for the church district) is more prescriptive and stricter, the individuals may be concerned about being disobedient to the will of the community. Even though the information on the videos may be acceptable, the type of me-dia is considered unacceptable.

In study of 1,836 pregnant Amish women by [84], 1733 birthed at home. More than one-third had high parity (gravida 5-13) with low rates of postpartum hemorrhage (n = 96, 5.5%). There were no maternal deaths. Nearly half of the maternal transfers to the hospital (n = 103, 5.6%) were for ruptured membranes without labor (n = 25, 1.4%) and/or failure to progress (n = 23, 1.3%). The neonatal hospital admission rate also was low (n = 13, 0.75%). Of the 7 (0.4%) early neonatal deaths, all were attributed to lethal congenital anomalies.

Amish have no major taboos or requirements for birthing. Men may be present; most husbands choose to be involved. However, they are likely not to be demonstrative in showing affection verbally nor physically. This does not mean they do not care; it is culturally inappropriate to show af-fection openly in public. The laboring woman cooperates quietly, seldom audibly expressing discomfort because many tend to be stoical with pain.

Given the Amish acceptance of a wide spectrum of health-care modalities, the nurse or physician should be aware that the woman in labor might be using herbal remedies to promote labor. Knowledge about and a respect for Amish health-care practices alert the physician or nurse to a discussion about simultaneous treatments that may be harmful or helpful. It is always better if these discussions can take place in a low stress setting before labor and birth [79].

As in other hospitalizations, the family may want to spend the least allow-able time in the hospital. This is generally related to the belief that birthing is not a medical condition and because most Amish do not carry health in-surance. In their three-generational family, and as a result of their cultural expectations for caring to take place in the community, many people are willing and able to assist the new mother during the postpartum period. Visiting families with new babies are expected and generally welcomed. Older siblings are expected to help care for the younger children and to learn how to care for the newborn. The postpartum mother resumes her family role managing, if not doing, all the housework, cooking, and child-

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care within a few days after childbirth. For a primiparous mother, her mother often comes to stay with the new family for several days to help with care of the infant and give support to the new mother. It also is com-mon for a teenage female relative who has completed schooling to come stay with the family to provide assistance in household chores and care of the children. She may stay a few weeks to a few months [65].

The day the new baby is first taken to church services is considered special. People who had not visited the baby in the family’s home want to see the new member of the community. The baby is often passed among the wom-en to hold as they become acquainted and admire the newcomer [79].

With a number of genetic disorders among the Amish and childbearing into their 40 and even 50 years of age put the woman’s pregnancy at a greater risk for complications and even death of the infant. Some may be reluctant for an autopsy unless it is required by law that varies among states. The health of others may be a deciding factor in the parents’ deci-sion for an autopsy. Although overtly it may appear that the father is mak-ing the decisions, both mother and father jointly make most decisions; therefore, the issue should be addressed all information to both parents (Chichester, 2007). Other members of the community may also be sought for advice, particularly grandparents and the local minister and bishop. The final decision regarding an autopsy rest with the parents [85,86].

Death RitualsIf death is a part of life and a portal to a better life, then individuals are well advised to consider how their lives prepare them for life after death. Non-Amish occasionally are baffled at reports of the Amish response to grave injury or even loss of life at the hands of others. Deeply held com-munity values, and especially constrained by love for others, Amish often eschew retaliatory or vengeful attitudes and actions when the majority culture might justify such means. Amish are socialized to sustain such injuries, grieve, and move on without fixing blame or seeking redress or punishment for the perpetrator. Most injuries, although not all of the re-sult in death, are the result of blunt force trauma (91.8%). The most fre-quent mechanisms were falls (42.6%), followed by animal-related (15.3%), and buggy (12.5%). Most injuries occurred at home (44.4%) or on a farm (33.9%). Hay hole falls were a unique source of injury [69].

Amish customs related to death and dying have dual dimensions. On the one hand, they may be seen as holdovers from an earlier time when, for most Americans, major life events such as birth and death occurred in the home. On the other hand, Amish retention of such largely outdated patterns is due to distinctively Amish understandings of the individual within and as an integral part of the family and community. Today, when 70 percent of elderly Americans die in hospitals and nursing homes, some still reflect nostalgically on death as it should be and as, in fact, it used to be, in the circle of family and friends, a farewell with familiarity and dig-nity. In Amish society today, in most cases this is still a reality. As physical strength declines, the expectation is that the family will care for the aging and the ill in the home [87,19], brief observation that Amish prefer to die at home is borne out by research findings.

Clearly, these preferences are motivated by more than a wish to dwell in the past or an unwillingness to change with the times. The obligation to help others in illness as in health provides the social network that supports Amish practices in the passage from life to death. It is a natural exten-sion of caregiving embraced as a social duty with religious motivation. The Amish accept literally the biblical admonition to “bear one another’s burdens.” This finds expression in communal support for the individual, whether suffering, dying, or bereaved. Life’s most intensely personal and private act becomes transformed into a community event [14].

Visiting in others’ homes for the Amish is a normal and reinforcement

of the bonds that tie individuals to extended family and community. An extension of this social interaction, visiting the ill takes on an added poi-gnancy, especially during an illness believed to be terminal. Members of the immediate family are offered verbal condolences and many supportive acts of kindness. Others close to prepare their food and take over other routine household chores to allow them to focus their attention and ener-gy on the comfort of the ailing family member [14].

Ties across generations across kinship and geographic lines are reinforced around death as children witness the passing of a loved one in the intimacy of the home. Death brings many visitors into the home of the bereaved. The church community takes care of accommodations for visitors from a distance as well as funeral arrangements. Thus, the immediate family is re-lieved of the responsibility for decision making which otherwise may add distraction to grief. In some settlements, a wake-like “sitting up” through the night provides an exception to normal visiting patterns. The verbal communication with the bereaved may be sparse, but the constant pres-ence of supportive others is proof of the Amish commitment to commu-nity. The return to normal life is eased through these visits by the resump-tion of conversations [88].

Both Amish and non-Amish friends and relatives come to pay their re-spects to both the deceased and the family. The funeral ceremony is as simple and unadorned as the rest of Amish life. A local Amish cabinet-maker frequently builds a plain wooden coffin. In the past, interment was in private plots on Amish farms, contrasting with the general pattern of burial in a cemetery in the churchyard of a rural church. Because Amish worship in their homes and have no church buildings, they also have no adjoining cemeteries. An emerging pattern is burial in a community cem-etery, sometimes together with other Mennonites. Burial restrictions may also result of town and county ordinances restricting burials to traditional cemeteries. Grief and loss are keenly felt, although verbal expression may seem muted to indicate stoic acceptance of suffering. In fact, the meaning of death as a normal transition is embedded in the meaning of life from the Amish perspective [88].

SpiritualityAmish share the general Christian view that salvation is ultimately in-dividual, preconditioned on one’s confession of faith, repentance, and baptism. These public acts are undertaken in the Amish context as part of preparing to fully assume one’s adult role in a community of faith. In contrast with the ideals of American individualism, the Amish surrender much of their individuality as the price of full acceptance as members of a community. In practical, everyday terms, the religiously defined com-munity is inextricably intertwined with a social reality, which gives it its distinctive shape. This is a means for strengthening family ties [89]. For the Amish, the importance of conformity to the will of the group is par-amount. To maintain group harmony, individuals often forgo their own wishes. In terms of faith-related behavior, outsiders sometimes criticize this “going along with” the local congregational group as an expression of religiosity, rather than spirituality. The practice of corporate worship with prayer and singing helps building this conformity. It is regularly tested in “counsel” sessions in the congregational assembly in which each individu-al’s commitment to the corporate religious contract is reviewed before tak-ing communion [25]. As seen in earlier sections on communication and their socioreligious provenance, many symbols of Amish faith point to the separated life living in accordance with God’s will. Over time, they have chosen to embody their faith rather than verbalize it. They seldom prose-lytize among non-Amish. This “primitive” form of Christianity emphasiz-es “right living.” The untrained religious leader offer views based on their interpretation of the Bible. Most members are content to submit to the congregational consensus on what right living means with the assumption that it is based on submission to the will of a loving benevolent God, an aspect of their spirituality that is seldom articulated [90]. Throughout his-

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tory the Amish have managed well in the court system despite their lack of involvement in the law since the United States upholds religious freedom [91]. Although Amish society is subject to the rules and regulations of the United States government, their loyalty lies within the leadership of the church. They live by the verse “Obey God rather than men” (Acts 5:29). Each district is governed by ordained officials known as servants who have varying levels of authority. Each district has one bishop, a servant with full powers; two to three ministers, “servants of the book;” and one bishop, the “servant to the poor” [92].

The Amish use a method of divine selection known as “the lot” in selecting their leaders. The chosen people who receive a select number of votes from the church members enter the lot. A bible verse is placed inside the cover of a hymnbook, and the members of the lot each select from a collection of hymnbooks. The candidate who chooses the hymnbook that contains the bible verse is the chosen leader. These church leaders are always men, but women are involved in the selection process.

The need to forgive is for the Amish is strong and considered to be “sec-ond nature. It does not indicate moral superiority or a heroic strength of forbearance in the face of adversity: rather it flows consistently from a bib-lical mandate to express love, even for an apparent adversary as a practi-cal application of the “The Golden Rule” (Matt. 7:12). A current example claiming national and international attention was the Amish response of forgiveness in the face of the Nickel Mines, Pennsylvania, tragedy when 10 Amish schoolgirls were held hostage and 5 of the girls were shot to death on October 2, [93]. Forgiveness in such situations may not come easily for many persons. [36] contend that for the Amish, forgiveness is part of the Anabaptist “habits” begun in the sixteenth century that continue to undergird Old Order Amish culture values incorporate a willingness to place tragedy in God’s hands without demanding divine explanation for injustice).

Amish settlements are subdivided into church districts with 30 to 50 fam-ilies in each district. Leaders are selected from their own community and are generally untrained and unpaid. Authority patterns are congregation-alist with consensus directed by local leadership designated as bishops, preachers, and deacons, all of whom are male. No regional or national church hierarchy exists to govern internal church affairs, although a na-tional committee may be convened to address external institutions of gov-ernment regarding issues affecting the broader Amish population [94].To become a member of the Amish church, community members receive instruction on beliefs and values. They are baptized between the ages of 16 and 24. Once someone becomes a member of the church, they are completely committed to the community and the Amish doctrine and practices [14]. Marriage does not occur until both members have been baptized. Amish traditions are centered around church services, baptisms, weddings, communion, and funerals. Every other Sunday, church services are held in the home of a family within the church district. On the “off ” Sundays, members will sometimes visit neighboring services in another church district [92].

Ministers often meet with youth to sing hymns and hold discussions. They live according to guidelines known as the Ordnung and follow a system of beliefs that includes adult baptism; separation of church and state; ex-communication from the church for those who break moral law; living life in accordance to the teachings of Christ; and refusal to bear arms, take oaths, or hold political office [33].

The organization of Amish society includes the extended family, church districts, settlements, and subgroup affiliations. Groups of extended fam-ilies are organized into church districts for governing and fellowship pur-poses. As the population grows the districts divide further [95]. Affilia-tions are formed between church districts who share similar practices and

lifestyle regulations. Settlements are the highest-level social organization because there is no national authority: the most significant authority re-mains within the church districts.

On specific holidays or in church the Amish might wear a black covering instead of their traditional white covering. Amish men wear mutza suits which are very straight and simple. Mutza suits do not have a collar, pock-ets, or lapels. In the summer some Amish men will wear a vest instead of the coat. They wear suspenders with trousers that are neatly pressed with no wrinkles. Amish men’s everyday trousers are made of a fabric known as Triblend Denim that is intended to be very durable. Their shirts are made of a 50/50 polyester/cotton blend fabric. Belts, sweaters, and neckties are forbidden. Clothing is fastened with either hooks and eyes or homemade buttons. Young Amish men are required to be clean shaven prior to being married; however, once a man is married, he is required to have a beard. Men are not allowed to have mustaches because they are seen as detracting from the humility and simplicity of life. All of the clothing and appearance is intended so the person does not stand out [96].

Amish children, who can be as delightfully animated as any other children at play, are taught to remain quiet throughout a worship service lasting more than two hours. They grow up in an atmosphere of restraint and re-spect for adults and elders. But privately, Amish are not so sober as to lack a sense of humor and appreciation of wit [97].

Health-Care PracticesBecause the predominant mode of transportation for the Amish is horse and carriage, travel to a doctor’s office, a clinic, or a hospital requires the same adjustment as any other travel outside their rural community for shopping, trading, or attending a wedding or funeral. The latter three reasons are important means of reinforcing relationship ties. On these occasions, they may use hired or public transportation, excluding flying. Extended trips related to medical treatments is not uncommon, such as a visit to radioactive mines in the Rocky Mountains or to a laetrile clinic in Mexico to cope with cancer (Wenger, 1988). A few participate in a type of “medical tourism” trips for care by renting a bus for transportation (King, 2017).

In one-on-one clinical contacts, Amish patients can be expected to ex-press openness and candor with unhesitating eye contact [98]. Among their own, personal space may be collapsed on occasions of crowding for group meetings or travel. In fact, Amish are seldom found alone; a solitary Amish person or family is the exception rather than the rule. But Amish are also pragmatic. In larger families, physical intimacy cannot be avoided in the home where childbearing and care of the ill and dying are accepted as normal parts of life. Once health-care providers recognize that Amish prefer to have such caregiving within the home and family circle, provid-ers will want to protect modest Amish patients who feel exposed in the clinical setting [34].

The Amish believe that the body is the temple of God and that human beings are the stewards of their bodies. Medicine and health care should be used with the understanding that it is God who heals. Nothing in the Amish understanding of the Bible forbids them from using preventive or curative medical services [65]. A prevalent myth among some health-care providers is that Amish are not interested in preventive services. Although it is true that many times the Amish do not use mainstream health ser-vices at the onset of recognized symptoms, they are highly involved in the practices of health promotion and illness prevention [65], (Purnell, personal communication). Although the directives of religious leaders are normative for many types of decisions, this appears not to be the case for health-care choices [34]. When choosing among health-care options, families usually seek counsel from religious leaders, friends, and extended family: the final decision resides with the immediate family. The sources of

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health-care information sought by many may not provide evidence-based guidance. Providers need to be aware of the Amish cultural context and need to adjust the normal routines of diagnosis and therapy to fit Amish patients’ socioreligious context.

Although the Amish have a reputation for honesty and forthrightness, they may withhold important medical information from providers by ne-glecting to mention folk and alternative care being pursued simultaneous-ly. When questioned, some admit to being less than candid about using multiple therapies, including herbal and chiropractic remedies because they believe that “the doctor wouldn’t be interested in them.” Choosing among folk, complementary, and professional health-care options does not necessarily indicate a lack of confidence or respect for the latter, but rather reflects the belief that one must be actively involved in seeking the best health care available (Wenger, 1994).

The Amish believe that it is their responsibility to be personally involved in promoting health. As in most cultures, health-care knowledge is passed from one generation to the next generally through women. In the Amish culture, men are involved in major health-care decisions and often accom-pany the family to the chiropractor, physician, or hospital. Grandparents are frequently consulted about treatment options.

A usual concern regarding responsibility for health care is payment for services. Many Amish do not carry any insurance, including health in-surance. However, in most communities, there is some form of agreement for sharing losses caused by natural disasters as well as catastrophic ill-nesses. Some have formalized mutual aid, such as the Amish Aid Society. [23], found that informants were opposed to such formalized agreements and wanted to do all they could to live healthy and safe lives, which they believed would benefit their community in keeping with their Christian calling. Many hospitals have been astounded by the Amish practice of paying their bills despite financial hardship. Because of this generally pos-itive community reputation, hospitals have been willing to set up payment plans for the larger bills.

Active participation was found to be a major theme in [34,67] studies on cultural context, health, and care. The Amish want to be actively involved in health-care decision making, which is a part of daily living. “To do all one can to help oneself ” involves seeking advice from family and friends, using herbs and other home remedies, and then choosing from a broad array of folk, alternative, and professional health-care services. One in-formant, who visited an Amish healer while considering her physician’s recommendation that she have a computerized axial tomography (CAT) scan to provide more data on her continuing vertigo, told the researcher, “I will probably have the CAT scan, but I am not done helping myself, and this [meaning the healer’s treatment] may help and it won’t hurt.” In this study, health-care decision making was found to be influenced by three factors: type of health problem, accessibility of health-care services, and perceived cost of the service. When the Amish use professional health-care services, they want to be partners in their health care and retain their right to choose from all culturally sanctioned health-care options.

The Amish way translates into the expectation that members of the culture be aware of the needs of others and fulfill the biblical injunction to bear one another’s burdens. Care is expressed in culturally encoded expecta-tions that they can best describe in their dialect as abwaarde, meaning “to minister to someone by being present and serving when someone is sick in bed [14]. A more frequently used term for helping is achtgewwe, which means to serve by becoming aware of someone’s needs and then to act by doing things to help. Helping others is expressed in gender-related and age-related roles, freindschaft (the three-generational family), church dis-trict, community (including non-Amish), Amish settlements, and world-wide [99]. No outsiders or health-care providers can be expected to fully

understand this complex, caring network, but health-care providers can learn about it in the local setting by establishing trust in relationships with their Amish patients.

When catastrophic illness occurs, the Amish community responds by be-ing present, helping with chores, and relieving family members so that they can be with the afflicted person in the acute care hospital. Some do opt to accept medical advice regarding the need for high-technology treatment, such as transplants or other high-cost interventions. The pa-tient’s family seeks prayers and advice from the bishop and deacons of their church and their family and friends, but the decision is generally a personal or family one.

Amish, as with all cultures, practice self-medication. Although most Amish regularly visit physicians and use prescription drugs, they also use herbs and other non-prescription remedies, often simultaneously. When discussing the meaning of health and illness, [23], found that her Amish informants considered it their responsibility to investigate their treatment options and to stay personally involved in the treatment process rather than to relegate their care to the judgment of the professional physician or nurse. Consequently, they seek testimonials from other family mem-bers and friends about what treatments work best. They may also seek care from Amish healers and other alternative-care practitioners, who may suggest nutritional supplements. One informant told how she would take “blue cohosh” pills with her to the hospital when she was in labor because she believed they would speed up the labor [35].

Because of the Amish practice of self-medication, it is essential that health-care providers inquire about the full range of remedies being used. For the Amish patient to be candid, the provider must develop mutual trust and respect. Within this context, the Amish patient can feel assured that the provider wants to consider and negotiate the most advantageous culturally congruent care.

Like many cultures, the Amish have an elaborate health-care belief system that includes traditional remedies passed from one generation to the next. Although the prevalence of specific health-care beliefs and practices such as use of chiropractic, Western medical and health-care science, reflexol-ogy, iridology, osteopathy, homeopathy, and folklore is influenced mainly by freindschaft [35], variations depend on geographic region and the con-servatism of the Amish community.

Herbal remedies are handed down by successive generations of mothers and daughters. One grandmother showed the researcher the cupboard where she kept cloths soaked in a herbal remedy and shared the recipe for it. The cupboard was where her grandmother kept those same remedies when her grandmother lived in the daadihaus [35].

Of all Amish folk health care, brauche has claimed the most interest of outsiders, who are often puzzled by its historical origins and contempo-rary application” [35]. Brauche is a folk-healing art that was practiced in Europe around the time of the Amish immigration to North America and is not unique to the Amish. It is a common healing art used among Penn-sylvania Germans. As with some other European practices, the Amish have retained brauche in some communities. In other communities, the practice is considered suspect and has been the focus of some church di-visions [35].

Brauche is sometimes referred to as sympathy curing or pow-wowing. It is unrelated to American Indian pow-wowing. The Amish refer to brauche as “warm hands,” the ability to feel when a person has a headache, or a baby has colic. Informants describe situations in which some individuals can “take” the stomachache from the baby into their own bodies in what is described by researchers as transference [34]. One 52-year-old Amish

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man told this author that he had warm hands.

A few folk illnesses have no Western scientific equivalents. The first is ab-nemme, which refers to a condition in which the child fails to thrive and appears undernourished. Specific treatments given to the child may in-clude incantations. Some of the older people remember these treatments, and some informants remember having been taken to a healer for the ail-ment. The second is aagwachse, or livergrown, meaning “hide-bound” or “grown together,” once a common ailment among Pennsylvania Germans [26]. Symptoms include crying and abdominal discomfort that is believed to be caused by jostling in rough buggy rides. Wenger (1988) reported accompanying an informant with her newborn baby to an Amish healer. The woman carried the baby on a pillow because she believed the baby to be suffering from aagwachse. As stated previously, Amish patients are more likely to discuss folk beliefs and practices with providers if the nurse or physician gives cues that it is acceptable to do so.

Barriers to health care include delay in seeking professional health care at the onset of symptoms, occasional overuse of home remedies, and a prevailing perception that health-care providers are not interested in or may disapprove of the use of home remedies and other alternative treat-ment modalities. Naturalistic books were the most used source of health information [100]. In addition, some families may live far from profes-sional health-care services, making travel by horse and buggy difficult or inadvisable. Because in some communities such as the Old Order Amish, telephones are not permitted in the home, there may be delays in com-munication with Amish patients [101,102]. Finally, the cost of health care without health insurance can deter early access to professional care, result-ing in more complex treatment regimens.

The Amish are unlikely to display pain and physical discomfort. The health-care provider may need to check changes in vital signs for pain and remind the patient that medication is available for pain relief if they choose to accept it.

Community for the Amish means inclusion of people who are chronically ill or physically or mentally different. Amish approaches these differences as a community responsibility. Children with mental or physical differ-ences are sometimes referred to as “hard learners,” who are expected to go to school and be incorporated into the classes with assistance from other students and parents. A culturally congruent approach is for the family and others to help engage those with differences in work activities, rather than to leave them sitting around and getting more anxious or depressed.[19], stated that “Amish themselves have developed little explicit thera-peutic knowledge to deal with cases of extreme anxiety” (p. 332). They do seek help from trusted physicians, and some are admitted to mental health centers or clinics [103]. However, the mentally ill are generally cared for at home whenever possible. Studies of clinical depression and manic-depres-sive illness were discussed in the section on biocultural ecology.

As previously mentioned when individuals are sick, other family mem-bers take on additional responsibilities. Little ceremony is associated with being sick; members know that to be healthy means to assume one’s role within the family and community. Caring for the sick is highly valued, but at the same time, receiving help is accompanied by feelings of humility. Amish newsletters abound with notices of thanks from individuals who were ill. A common expression is “I am not worthy of it all.” A care set identified in one research study is that giving care involves privilege and obligation, and receiving care involves expectation and humility [34]. The sick role is mediated by very strong values related to giving and receiving care.The Amish culture also sanctions time out for illness when the sick are relieved of their responsibilities by others who minister to their needs. A good analogy to the communal care of the ill is found in the support of-

fered by family and church members at the time of bereavement as noted in the section on dying. The informal social support network is an im-portant factor in the individual’s sense of well-being. However, an under-lying expectation is that healthy individuals will want to resume active work and social roles as soon as their recovery permits. With reasonable adjustments for age and physical ability, it is understood that a healthy person is actively engaged in work, worship, and social life of the family and community (Wenger, 1994). Work and rest are kept in balance. For the Amish, the accumulation of days or weeks of free time or time off for vacation outside the framework of normal routines and social interactions is a foreign idea.

In a study of Amish women’s construction of health narratives, [104] found that the collective descriptions [of] health included a sense of feel-ing well and the physical ability to complete one’s daily work responsibili-ties. Women’s health traditions included the use of herbal and other home remedies and consulting lay practitioners. In general, health values and beliefs are influenced by group membership and personal developmental history.

No cultural or religious rules or taboos prohibit Amish from accepting blood transfusions or organ transplantation and donation. In fact, with the genetic presence of hemophilia, blood transfusion has been a necessity for some families. Anecdotal evidence is available regarding individuals who have received heart and kidney transplants, although no research reports or other written accounts were found. Thus, some Amish may opt for or-gan transplantation after the family seeks advice from church officials, ex-tended family, and friends, but the patient or immediate family generally makes the final decision.

Health-care providers can expect all their Amish patients of school age and older to be fluent bilingual. They can readily understand spoken and written directions and answer questions presented in English, although their own terms for some symptoms and illnesses may not have exact equivalents in Deitsch and English. Amish patients may be more comfort-able consulting among themselves in Deitsch, but generally they intend no disrespect for those who do not understand their mother tongue.

Amish usually refer to their own healers by name rather than by title, al-though some say brauch-doktor or braucher. In some communities, both men and women provide these services. They may even specialize with some being especially good with bed-wetting, nervousness, women’s prob-lems, or livergrown. Some set up treatment rooms and people come early in the morning and wait long hours to be seen. They do not charge fees but do accept donations. A few also treat non-Amish patients. In some communities, Amish folk healers use a combination of treatment modal-ities, including physical manipulation, massage, brauche, herbs and teas, and reflexology. A few have taken short courses in reflexology, iridology, and various types of therapeutic massage. In a few cases, their practice has been reported to the legal authorities by individuals in the medical profession or others who were concerned about the potential for illegal practice of medicine.

For the Old Order Amish, health-care providers are always outsiders be-cause this sect has been unwilling to allow their members to attend medi-cal, nursing, or other health-related professional schools or to seek higher education in general. Therefore, the Old Order Amish must learn to trust individuals outside their culture for health care and medically related sci-entific knowledge. Hostetler (1993) contended that the Amish live in a state of flux when securing health-care services. They rely on their own tradition to diagnose and sometimes treat illnesses, while simultaneous-ly seeking technical and scientific services from professional health-care providers.

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Most Amish consult within their community to learn about physicians, dentists, and nurses with whom they can develop trusting relationships. For more information on this practice, see the Amish informants’ percep-tions of caring physicians and nurses in Wenger’s (1994) chapter and arti-cle on health and health-care decision making. Amish prefer health-care providers who discuss their health-care options, giving consideration to cost, need for transportation, family influences, and scientific information. They also like to discuss the efficacy of alternative methods of treatment, including folk care. When asked, many Amish claim that health-care pro-viders do not want to hear about non-traditional health-care modalities that do not reflect dominant American health-care values.

Amish hold all health-care providers in high regard. Health is integral to their religious beliefs and care is central to their worldview. They tend to place trust in people of authority when they fit their values and beliefs. Because Amish are not sophisticated in their knowledge of physiology and scientific healthcare, the provider who gains their trust should con-sider that because the Amish respect authority, they may unquestioning-ly follow orders. Therefore, health-care providers should make sure that their patients understand instructions. Role modeling and other concrete teaching strategies are recommended to enhance understanding.

Pleasure Reading NovelsA number of pleasures reading novels are available from Amazon.com and Barnes and Nobles. Search for Amish novels. The novels depict the Amish culture is various setting. Many of them center around family life, mar-riage, and love stories.

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Books Resources1. Kraybill, D.B., Nolt, S.M., & Weaver-Zercher, D.L. (2007). Amish

grace: How forgiveness transcended tragedy. San Francisco, CA: John Wiley and Sons.

2. Hurst, C.H.& McConnel D.L. An Amish paradox: Diversity and change in the world’s largest Amish community (Young Center Books in Anabaptist and Pietist Studies).

3. Nolt, S. (2015). A history of the Amish. New York, New York: Good-books Publishing.

4. Journal of Amish and Plain Anabaptist Studies. The journal is pub-lished twice a year by the Amish & Plain Anabaptist Studies Associ-ation (http://amishstudies.org) in collaboration with the University of Akron.

5. Amish Awareness Conference is an annual conference (since 2017) focusing in Amish and Anabaptist cultures and societies. https://www.amishawareness.com

Cite this article: Larry Purnell (2021) Amish Literature Review. Journal of Nursing and Researchers. 2: 66-83. *

Copyright: ©2021 Larry Purnell. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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