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

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