Culturally Sensitive Individually Responsive .• Penny Armstrong, A Midwife’s ... Personal Prayer

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  • Culturally SensitiveIndividually Responsive

    Randall Longenecker MDProfessor of Family Medicine and Assistant Dean Rural and Underserved ProgramsOhio University Heritage College of Osteopathic MedicineJanuary 12, 2017

  • Culturally Sensitive, Individually Responsive

    ...discussion with Amish parents/kids of anything remotely sexual is usually taboo. They seem to have a tendency to favor altmedservices, often for ridiculous reasons (chiropracters offering treatment for inborn errors, etc) but that may be merely anecdotal. How effective is their community funding approach for paying for medical care, used in place of Medicaid, BCMH, etc. Do they reimburse at 10%? 5%? Less than 1% Latter would be my guess.

  • Culturally Sensitive, Individually Responsive

    ...discussion with Amish parents/kids of anything remotely sexual is usually taboo. They seem to have a tendency to favor altmed services, often for ridiculous reasons (chiropracters offering treatment for inborn errors, etc) but that may be merely anecdotal. How effective is their community funding approach for paying for medical care, used in place of Medicaid, BCMH, etc. Do they reimburse at 10%? 5%? Less than 1% Latter would be my guess.

  • Culturally Sensitive, Individually Responsive

    When youve seen one Amishman,Youve seen one (Amish man)!

  • Objectives

    Consider theAmishunderstanding oflife, suffering, anddeathandhowthisimpactstheirhealthcare decisionsatthebeginningandendoflife

    Accountforthecollectivedecision-makingprocessofAmishcommunitiesandhowthiscanimpacthealthcare

    Recognize thebeliefsandpracticesofAmishpatientsthatimpactpatientcareandutilizestrategies tobetter incorporate these intotheir careplan

    Provideatoolforexploringculture

  • Mad River Family Practice

  • Case in Point: A Psychosocial Screen

  • Who are the Amish and Mennonites?

    AculturallyandgeneticallydistinctivegroupofpeopleofSwiss-Germandescent;areligiousgrouparisingoutoftheProtestant reformation -Anabaptistsorrebaptizers

    1693- Jakob Amann,separated fromthefollowersofMennoSimons(Mennonites) overtheuseofthebanandshunninginchurchdiscipline,awayofmaintainingpurityandanidentityseparate fromtheworld

    Asaresultofthisseparateness, theAmishhaveremaineddistinctive intheirdressandwayoflife

    Geneticallydistinctaswell,includingtheamplificationofrecessive geneticdisorderswithinaclosedcommunity

  • Amish in Ohio

  • Amish in Ohio

  • Who are the Amish and Mennonites?

    JohnHochstetler, AmishSociety DonaldKraybill,TheRiddleof

    AmishCulture EltonLehman,astoldtoDorcas

    SharpHoover,HouseCallsandHitchingPosts

    WayneWeaver,DustBetweenMyToes:AnAmishBoysJourney

    PennyArmstrong,AMidwifesStory

    ThirdWayCafwww.thirdway.com/Menno/

  • Unser Satt Leit: Our Sort of People

    1. Goddetermines lifeandisanactiveandpresent forceinthelivesofindividuals

    2. TheCommunityresponds tothisbelief inparticularways,including:a) AdefermentofindividualwilltothatoftheauthorityofGodandCommunity

    (Gelassenheit)b) Appreciation forasetofrulesguidingbehavior(Ordnung)c) [Stewardship]

    Wenger L. Unser Satt Leit: Our Sort of People - Health Understandings in the Old Order Mennonite and Amish Community, A thesis presented to the University of Waterlooin fulfillment of the thesis requirement for the degree of Master of Arts in Recreation and Leisure Studies, 2003. https://uwspace.uwaterloo.ca/handle/10012/723 (Accessed 12-23-2016)

  • Gelassenheit

    Thecalmness, coolness, composure,orcontentment thatcomesfromself-surrender andhumility;thesubjugationofmyownwilltothatofGodandtheCommunityoffaith

    MartinHeidegger, 20thcenturyGermanphilosopher - thewillingnessorabilitytoletthingsbeastheyare, intheiruncertaintyandmystery

    [Nottobeconfusedwithfatalismorpassivity] Let this mind be in you, which was also in Christ Jesus: Who, being in the form

    of God, thought it not robbery to be equal with God: But made himself of no reputation, and took upon him the form of a servant, and was made in the likeness of men: And being found in fashion as a man, he humbled himself, and became obedient unto death, even the death of the cross. (Phillipians 2:5-8)

  • Ordnung

    Orderororderliness; asharedunderstanding andframework forliving The people just know it, thats all. Rather than a packet of rules to memorize, the

    Ordnung is the understood behavior by which the Amish are expected to live. Donald Kraybill, The Riddle of Amish Culture

    Communal and local - a balance between tradition and change Not groupthink, but deliberate thinking as a group

    Thoughtful and not mindless in adoption of new rules Respectful of authority and the opinion of others, but also respectful of the

    redemptive nature of community Humble

    No central church government; each assembly is autonomous and its own governing authority

    Largely unwritten, yet defines the very essence of Amish identity

  • Stewardship

    Life (money, land, health) is a gift I do not own alone, something with which Ive been entrusted, to be appreciated and tended with respect

    With regard to finances, this is Gods money, the Communitys money, and I need to spend it wisely, as in the parable of the good steward

    A balance between individual responsibility and responsibility for each other and to each other

    Children, even those with profound disability, are also a gift, e.g. the Clinic for Special Children in Pennsylvania

    Do you think its necessary?

  • MostAmishandMennonitegroupsdonotopposemodernmedicine.Theirreadinesstoseekhealthservicesvariesfromfamilytofamily.NothingintheAmishunderstandingoftheBibleforbidsthemfromusingmodernmedicalservices, includingsurgery,hospitalization,dentalwork,anesthesia,bloodtransfusions,etc.Theydobelieve,however,thatgoodhealth,bothphysicalandmental,isagiftfromGodandrequirescarefulstewardshiponthepartoftheindividual.Withfewexceptions,physiciansratetheAmishasdesirablepatients:theyarestable,appreciative,andtheirbillswillbepaid.Theydonothavehospitalization insurance,buttheybandtogethertohelppaymedicalexpensesforanyoneoftheirgroupwhoneedsfinancialassistance.AdesignatedleaderintheAmishcommunity isgivenresponsibility fortheirmutualaidfund.AmishFAQhttps://amishreligiousfreedom.org/amishfaq.htm(Accessed12-23-2016)

  • Who Provides Primary Care?

    Self Mother Wife Other relative Herbalistorlaymidwife Bishop Chiropractor Familydoctor- Iamtheoctenary careproviderandfolksatthe

    tertiarycarecentersarewaybeyondthat! Iamoneofmanyconsultants Althoughveryrespected, IamnotGodandneither isanyoneelse!

  • Suggested Reframes

    Skepticalofoutsiderswhomaynotsharetheirvalues,world-view

    Stingyoroverlyfrugal Patriarchal(menrule!) Anti-technology Committed toalternativemedicine,

    non-compliant Demandingorinsistent Dontcareabouttheirhealth(e.g.

    prevention)

    Criticalthinkers- deliberate andthoughtful

    Pragmatic- whenfacedwithlimitedresources,youlearntobe judiciousandcreative

    Decisions aroundfinancesaremadebythemen,butthe intention isnotself-interest, butservant-leadership

    Notopposed totechnologyassuch,onlyitscost financial costaswellasitscosttotheirwayoflife

    Thinkofalternativemedicine assimplyoneofmanypotentiallycomplimentarymethods

    Perception InReality

  • Suggested Reframes

    Skepticalofoutsiderswhomaynotsharetheirvalues,world-view

    Stingyoroverlyfrugal Patriarchal(menrule!) Anti-technology Committed toalternativemedicine,

    non-compliant Demandingorinsistent Dontcareabouttheirhealth(e.g.

    prevention)

    TheAmishdefinition ofhealth istheabilitytoworkandcontribute tothecommunity.

    Doesnthurttoask!

    Perception InReality

  • What about Sex?

    AnaturalGod-given partoflife, reserved foracommittedrelationship inmarriage

    Anearthy,organicunderstandingofreproduction - forbetterorworse,derived fromgrowinguponthefarm

    Refreshinglycandid- ascomparedwiththedominantculturesobsessionwithsexandsexualizedbodyimage

    Contraception isnot(maybenot) anoption- Childrenareagift Periodicabstinence is anoption

  • Transportation is a Challenge

    Amish lifeiscircumscribedbythedistance ahorsecantravelinaday

    Costoftransportationbyothermethods (e.g.hiringadriver)caneasilyexceedthecostofthevisititself

    Itisimportanttomaketheirtripstoacitycount(multiple specialists onthesameday;advanceaccessschedulingforimmediate consultation)

  • Amish Pleural Medicine

    Amish Plural

    Medicine

    Chiropractic Care

    Biomedical Care

    MidwiferyHome Care

    & Community

    Medical Tourism

    King, M. Cultural Contexts of Health and Illness Among the Lancaster Amish. Found at https://cdr.lib.unc.edu/record/uuid:d7a73fed-1531-4397-8cff-1379cf64dfc0 .

  • Amish Healthcare Providers

    ProviderType CareType

    Chiropractor 92%

    MedicalDoctor 90%

    CertifiedMidwife 52%

    Lay Midwife 28%

    Herbalist 31%

    MassageTherapist 27%

    Supplements &Vitamins 83%

    PersonalPrayer 59%

    HerbalMedicine 52%

    Detox orCleanse 51%

    Reflexology 41%

    Homeopathy 39%

    Meditation 16%

    Medical Tourism 8%

    Acupuncture 4%

    Yoga 4%

    Have you ever visited the types of providers (even only once in your lifetime) or participated in this form of healthcare?

    King, M. Cultural Contexts of Health and Illness Among the Lancaster Amish. Found at https://cdr.lib.unc.edu/record/uuid:d7a73fed-1531-4397-8cff-1379cf64dfc0 .

  • Amish Pleural Medicine Interface With Biomedicine

    Amish Community

    Emphasis on GroupSeparation from Dominant CultureNegotiate