Journal of Nursing and Researchers

Review Article

**Corresponding author Amish Literature Review Larry Purnell, Professor Emeritus, University of Delaware Adjunct Professor, Excelsior College PhD Program, Univer- sity of Panama. Transcultural Nursing Scholar Larry Purnell Professor Emeritus, University of Delaware, Adjunct Professor, Excelsior Col- Submitted: 29 July 2021 lege, PhD Program, University of Panama, Transcultural Nursing Scholar Accepted: 31 July 2021 Published: 04 Aug 2021

Copyright © 2021 Larry Purnell OPEN ACCESS Abstract* As 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.

Introduction have disappeared from Europe. The formal separation of this new group This review of the literature is organized around the 12 domains of the occurred on January 21, 1525, when believers re-baptized themselves and Purnell Model for Cultural Competence. This model has classified as ho- took on the new name of Anabaptist, meaning to be re-baptized [1]. The lographic complexity grand theory and is applicable to all health profes- group later separated again and led to the formation of the Mennonites. sionals. The model has an extensive assessment guide. The 12 domains are In 1693 Jacob Ammann led another separation from the Mennonites of a overview/heritage, cultural communication patterns, family roles and or- more conservative group to be known as the Amish [2]. ganization, workforce issues, biocultural ecology, high-risk health behav- iors, nutrition, pregnancy, death rituals, spirituality, health-care practices, The Amish settled in the United States in 1737 [1]. Today, the greatest and health-care practitioners. 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 Overview Heritage and Residence statistics for the Amish population in the United States [3]. The Ohio The Amish are a loosely connected network of conservative Anabaptist population is estimated at 56,430. The next two most populated states are communities that originated in Switzerland. They broke from the Men- Pennsylvania and Indiana with 51,435 and 39,960, respectively [4]. These nonites between 1693 and 1697 and are followers of Jakob Ammann who statistics include both Old- and New-Order Amish groups, but excludes spearheaded the schism because he favored harsher excommunication some less conservative groups including the Amish Mennonites [5]. practices and more conservative modes of dress. Currently, the more pro- gressive conservative Mennonite population are expanding women’s dress The Amish are not a homogeneous population. Diversity occurs among (Mong & Clifton). The Mennonites and Amish still share basic Anabaptist and within each group. Theoretically, the Amish are divided into four values such as opposition to war and infant baptism. Amish communities groups. Swartzentruber Amish, a subset of the Old Order, see themselves Journal of Nur & Res 2021 Volume 2 | Issue 5 | 66 as the truest heirs to the Anabaptist Amish tradition. They are stricter instruction in reading, writing, spelling, history, and arithmetic, but the than most Old Order Amish and have a lower standard of living. They are primary goal is to obtain real life skills they can contribute to Amish so- quicker to excommunicate and are usually more isolated from non-Amish ciety. These skills include homemaking, farming, and carpentry which people. Their standards of dress are harsher; members may not even ride are necessary to thrive in the Amish community. The curriculum focuses in cars owned by non-Amish people, except in some emergencies [6]. An on the important Amish values of cooperation, respect, and the natural off shoot of the Swartzentruber Amish is the Andy Weaver group who only world instead of independent thinking and critical analysis which are em- exists in Holmes County, Ohio. This “subgroup” was formed in 1952 over phasized more in public education. The teachers themselves have only an the issue of shunning. They are less conservative than the Swartzentruber eighth-grade education, but they receive further training from other expe- Amish but more conservative than the Old Order Amish [7]. They have rienced educators [14]. A local board of fathers are responsible for hiring a stricter approach to shunning but are more liberal with tobacco and al- teachers and approving the curriculum. Despite their seemingly substan- cohol use. Their parochial schools are less rigorous than the usual eighth dard level of education, students have proved to achieve high scores on grade education provided in Old Order Amish schoolhouses [8]. 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 The Old Order Amish constitute the largest group of rural [15,16], reported that some Amish wanted their children to attend public Amish settlements descended from the Amish Mennonites. Their stricter schools for the following reasons: (a) the desire to have students relate to rules involving dress often prohibit the use of buttons and zippers. They English children and the wider world, (b) the desire to gain life skills, (c) wear dark colors, mostly black. The communities regulate hair length -- the desire to have quality teachers, and (d) the desire to take advantage of men grow beards at an acceptable length. Women are not allowed to get the draw of public schools. haircuts [9]. They oppose church buildings, preferring to meet in individ- ual homes. This reflects their wariness of organized religion; in general, Before 1950, most Amish children attended public schools. These were they think of their house meetings as more organic and unregulated. They small rural public schools organized by parents. As the public schools be- also eschew modern technologies like cars, electricity, and tractors [10]. gan to grow, parents were slowly losing control over the education of their The New Order Amish, sometimes called the Amish Brotherhood, have children. The community began to favor private Amish Schools. These settlements that grew out of the Old Order Amish communities in the schools allowed a method of passing their traditions to younger genera- mid-20th century. They are similar to the Old Order Amish with slightly tions in order to preserve their way of life. The separate schooling limited relaxed rules governing dress and technology. Colorful clothing is per- their exposure to the non-Amish world and prevented children from be- mitted and men are allowed to trim beards. The communities allow some ing exposed to the technology used in public schools. Their children were modern technologies such as telephones, tractors, and even airplane trav- no longer exposed to the influences of peer pressure. Another benefit of el. Telephones, however, are usually not permitted in the house and may private Amish schools is the ability to incorporate Bible study and wor- be in the barn or a separate shed. Telephones and even cell phone are now ship. A larger population of Amish students are in public schools in areas used by some who have businesses but the phone must not be allowed dominated by traditional Mennonites. Some parents choose to place their to ring in the main house [11,12]. In a study by Rivka, female research children in the public school system to better prepare them for contact participants reported that the distance from English/secular media not with the “English.” They are required to pay taxes that go towards public only raises their status in their communities but also gives them multiple education; there are no further costs for entering the public school sys- opportunities to invest time and considerable power in face-to-face—not tem. A third option that some parents choose is homeschooling, but this digital—social capital and strong social network connectedness, collective is much less common [4]. activities, and in formal social engagement. The lack of certification of the teachers and the decision of the Amish to The Beachy Amish broke from the Old Order Amish at the turn of the remove children from school at a young age became controversial but in 20th century, largely because of disputes over evangelicalism in the Unit- 1972 the Supreme Court ruled in the case Wisconsin vs. Yoder that it was ed States. They admired the revivalism of many churches in the country, lawful for Amish families to discontinue their children’s formal education like the Baptists and Methodists, and were convinced by their messages at age fourteen years. This decision was made based on the issues of “Pa- of individual salvation. The Beachy Amish began holding their own tent rental rights and Religious freedom”. It is not an Amish practice to defend revivals, a practice firmly opposed by the larger Old Order Amish settle- themselves in a court of law, so the National Committee for Amish Reli- ments. The group is more relaxed when it comes to technology and dress gious Freedom took action and defended the issue in court [17]. Although than other Amish communities based on the grounds that they do not find the Amish are permitted to vote in state and federal elections, most refrain biblical references that prohibit the use of buttons and some other basic from involvement in politics unless it directly involves their communi- innovations. They also allow cars, home electricity, and send missionaries ty. They do, however, cooperate with local elected officials. There have to proselytize throughout the world [13]. been numerous conflicts between the Amish community and the Federal government. Conflicts have centered around social security, child labor, Clothing, dress, and appearance are based solely on Amish basic beliefs education, and military service. The Amish separate themselves from the and their faith. They believe that their appearance and clothing is a very Federal government, but they are required to pay state and federal income simple way to express their faith to the world. They choose fabrics that rep- taxes, sales tax, real estate tax, and public-school tax. The only tax that they resent humility and being separate from the rest of the world. They make are exempt from is social security if they are self-employed since they do their own clothing, mainly from dark simple fabrics. On occasion some not receive its benefit. Close-knit Amish communities ensure that each groups will use light fabrics for children’s clothing or for summer apparel. member is taken care of throughout their life; thus, federal assistance is Women wear dresses without any patterns, usually with long sleeves and unnecessary [18], (Do Amish Pay Taxes?). 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 Communication not cut their hair, wearing it in a bun or a braid of some kind that is cov- Like most people, the Amish vary their language usage depending on the ered with a small white cap [9]. Plain dress is to reject worldliness, vanity, situation and the individuals being addressed. American English is only and materialism. one of three language varieties in their repertoire. For the Amish, English is the language of school, written and printed communications, and, above Amish education is unique to their lifestyle and based on homemaking vo- all, the language used in contacts with most non-Amish outsiders, espe- cational skills. Children receive traditional education through the eighth cially business contacts. Because English serves a useful function as the grade and are then sent out into the workforce. The education includes Journal of Nur & Res 2021 Volume 2 | Issue | 67 contact language with the outside world, Amish schools use English as Much of the nonverbal behavior of Amish is also symbolic. Many of the the language of instruction with the strong support of parents because details of Amish dress and customs were once general characteristics with- elementary schooling offers the best opportunity for Amish children to out any particular religious significance in Europe. However, in the Amer- master the language. Within Amish homes and communities, English is ican setting, they are closely regulated and serve to distinguish the Amish discouraged in favor of the vernacular Deitsch, or Pennsylvania German. as a self-consciously separate ethnoreligious group [25]. Because all Amish except preschool children are literate in their second language; American English helps to define their cultural space [19]. 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 The first language of most Amish is Deitsch, an amalgamation of several texts in Hochdeitsch and the oral interpretation of them in Deitsch are upland German dialects that emerged from the interaction of immigrants crucial to an understanding of two German values that have an impact on from the Palatinate and Upper Rhine areas of modern France, Germa- Amish nonverbal behavior. Demut, German for “humility,” is a priority ny, and Switzerland. Their regional linguistic differences were resolved in value, the effects of which may be seen in the height of the crown of a man’s an immigrant language better known in English as “Pennsylvania Ger- hat, as well as in very general features such as the modest and unassuming man” (also known as “Pennsylvania Dutch”). Amish immigrants who lat- bearing and demeanour usually shown in public. This behavior is rein- er moved more directly from the Swiss Jura and environs to midwestern forced by frequent verbal warnings against hochmut, which means “pride” states (with minimal mixing in transit with Deitsch-speakers) call their or “arrogance,” and should be avoided [26]. home language Düütsch, a related variety with marked Upper Alemannic features. Today, Deitsch and Düütsch both show a strong admixture of A second term, gelassenheit, is embodied in behavior more than it is ver- vocabulary borrowed from English. The basic structure remains nonstan- balized. Gelassenheit is treasured for its earlier religious meanings denot- dard German. Both dialects have practically the same functional distribu- ing quiet acceptance and reassurance encapsulated in the biblical formula tion [20]. “godliness with contentment” (1 Tim. 6:5). The Amish paradigm for the good life flows from the calm assurance found through inner yielding and Deitsch is spoken in the home and in conversation with fellow Amish and forgoing one’s ego for the good of others: relatives, especially during visiting, a popular social activity by which news is disseminated orally. It is important to note that Deitsch is primarily a 1. One’s life rests secure in the hands of a higher power. spoken language. Some written material has been printed in Pennsylvania 2. A life so divinely ordained is therefore a good gift. German, but Amish seldom encounter it in this form. Even Amish publi- 3. A godly life of obedience and submission will be rewarded in the life cations urging the use of Deitsch in the family circle are printed in English hereafter [25]. (What is in a language? 1986). These inner qualities, an unpretentious quiet manner, and modest outward The third language used by Amish deserves mention in this cultural pro- dress in plain colors lacking any ornament, jewelry, or cosmetics presents file to complete the scope of their linguistic repertoire. Amish proficien- a striking contrast to contemporary fashions both in clothing styles and cy in English varies according to the type and frequency of contact with in personal self-actualization. Public behavior is seen as deliberate rath- non-Amish, but it is increasing. The use of Pennsylvania German is in er than rash, deferring to others instead of being assertive or aggressive, decline outside the Old Order Amish community. Its retention, despite the avoiding confrontational speech styles and public displays of emotion in inroads of English, has been related to religious communities’ persistent general. recourse to Hochdeitsch, or Amish High German, their so-called third language [21]. Amish should be greeted with a handshake and a smile. Amish use the same greeting among themselves and with outsiders, but little touching Amish do not use Standard Modern High German, but an approximation, follows the handshake. Younger children are touched and held with affec- which gives access to texts printed in an archaic German with some re- tion, but adults seldom touch socially in public [27]. However, therapeutic gional variations [22]. Rote memorization and recitation for certain cere- touch appeals to many Amish and is practiced informally by some who monial and devotional functions, for selected printed texts from the Bible, find communal affirmation for their gift of warm hands (see the section from the venerable Ausbund hymnbook, and from devotional literature on health-care practices). In public, the avoidance of eye contact with non- are a part of public and private prayer and worship. Such restricted and Amish may be seen as an extension of the general reserve and measured non-productive use of a third language hardly justifies the term “trilin- larger body movements related to a modest and humble being. gual” because it does not encompass a fully developed range of discourse. However, Amish High German does provide a situational-functional com- After generations of rural life guided by the rhythms of daylight and plement to their other two languages [22]. Its retention is one more sym- seasons, the Amish manage the demands of clock time in the dominant bol of a consciously separated way of life. culture. They are generally punctual and conscientious about keeping ap- pointments, although they may seem somewhat inconvenienced by not Within a highly contextual subculture, the base of shared information and owning a telephone or car. These communication conveniences, deemed experience is proportionately larger. Thus, less overt verbal communica- essential by the dominant American culture, are viewed by the most con- tion is required than in the relatively low-contextual American culture and servative Amish as technological advances that could erode the deeply more reliance is placed on implicit, unspoken understandings. Children held value of community in which face-to-face contacts are easily made. and youth may learn adult roles more through modeling than through Therefore, telephones (cell phones are now being used by a few) and auto- explicit teaching. The many and diverse kinds of multigenerational social mobiles are generally owned by nearby non-Amish neighbors and used by activities on the family farm provide an optimal framework for encultura- Amish only when it is deemed essential, such as for reaching health-care tion. Although this may facilitate the transmission of traditional accepted facilities [28], or visiting family and friends in distant location. knowledge and values within a high-context culture, this same informa- tion network may impede new information imparted from the outside, Using first names are appropriate, particularly because generations of in- which entails some behavior changes. Wenger [14,23,24], suggested that termarriage have resulted in a limited number of surnames. It is preferable health-care providers should consider role modeling as a teaching strategy to use first names during personal contacts rather than titles such as Mr. or when working with Amish patients. Mrs. Miller. With so many Millers, Lapps, Yoders, Bylers, and Zooks, given names like Mary, Sarah, Rebecca, John, Amos, and Samuel are overused so Journal of Nur & Res 2021 Volume 2 | Issue 5 | 68 some might be identified by nicknames, residence, a spouse’s given name, communities. They view the city as a place of evil and wickedness. Com- or a patronymic, which may reflect three or more generations of patrilin- munity is of utmost importance. They often socialize through helping each eal descent. For example, a particular John Byler may be known as “Blond other through building projects or helping on each other’s farms. Because John,” or “Tall John,” or “Ruth’s John,” or “Sam’s Eli’s Lap’s John.” 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 Family Roles and Organization often retire to the dawdyhaus, which is a smaller house that is built next to Amish families are large. Six to 10 children are common [29], (ohio- the main farmhouse [31,33,34]. samishcountry.com). If parents are unable to have children, adoption is available either within the Amish community or from outside the Amish From the time of marriage, the man’s role as husband is defined by the re- community [30]. The defining aspect of the Amish social structure is each ligious community to which he belongs. Titular patriarchy is derived from person’s commitment to his or her family and the other members of the the Bible: Man is the head of the woman as Christ is the head of the church community. This is evident when the people come together to support (I Cor. 3). This patriarchal role in Amish society is balanced or tempered those in need, regardless of the situation. The Amish hold “frolics” when a by realities within the family; the wife is accorded high status and respect neighbor requires help raising a house, barn or other large project. A frolic for her vital contributions to the success of the family. Practically speak- is a work party of men from several neighboring families with the women ing, husband and wife may share equally in decisions regarding the family preparing food for the entire gathering. 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 Large extended families maintain contact by sending letters through the listen to the voices of Amish women themselves as they reflect on their mail or sending them to “The Budget,” an Amish publication. Families values and roles within the Amish family and their shared ethnoreligious usually adhere to traditional gender roles, although this varies from family cultural community [35]. 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 The highest priority is child rearing, an ethnoreligious expectation in the house and the children, although many sell quilts, fruits, jam, honey, pas- Amish culture. With a family averaging at least 5 (and frequently more) tries, pies and cakes, and flowers. However, these roles are not concrete as children, the mother contributes physically and emotionally to the bur- men offer support in the home and women may assist with physical labor geoning growth in the Amish population [36]. She also has an important that is consistent with the general trend in modernization of the Amish role in providing food and clothing needs, as well as a major share in child culture [29]. nurturing. Amish society expects the husband and father to contribute guidance, serve as a role model, and discipline the children. This shared Men are the primary spiritual leaders, but men and women share the de- task of parenting takes precedence over other needs, including economic cision making within the household. As gender roles have become less or financial success in the family business. On the family farm, all must defined, changes in the traditional Amish courtship are apparent. The Old help as needed, but in general field, barn work, and animal husbandry Order Amish adhered to the custom of bedroom courtship, but in modern are primarily the work of men and boys. Food production and preserva- times Amish youth spend more time engaging in social activities that may tion, clothing production and care, and management of the household are be associated with courtship. However, bedroom courtship continues for mainly the province of women. some ultra-conservative groups (Purnell, personal communication, 2017). The Amish demonstrate humility and modesty. They avoid personal Children and youth represent a key to the vitality of the Amish culture. praise, manifestations of individualism and attention seeking activities Babies are welcomed as a gift from God; the high birth rate is one factor because these behaviors lead to pride and self-sufficiency that does not in their population growth. Another is the surprisingly high retention of come from the Lord. Their only traces of pride can be seen in their home youth; an estimated 75 percent or more choose as adults to remain in the exteriors, yards, and fancy buggy trimmings and harnesses [32]. Amish way [37].

The Ordnung dictates what is and what is not appropriate within the Young people over 16 years of age may work away from home to gain Amish culture. For example, you will not find electricity or telephones experience or because of insufficient work at home or on the family farm. in very traditional Amish households. In order to avoid electricity, they Their wages are still usually sent home to the parental household because use kerosene, gasoline, and batteries to power lights and generators. These of the cultural value that the whole family contributes to the welfare of the generators can power washing machines, water pumps, and agricultural family. equipment. Windmills are also sometimes used to power machinery. Most Amish, especially Old Order Amish, rely on horse drawn buggies for trans- Some experimentation with non-Amish dress and behavior among teen- portation. They also rely on horses to pull farm machinery. Some technol- agers is tolerated during Rumspringa [38]. Rumspringa, also spelled Rum- ogies that they use that are not prohibited by the Ordnung include inline schpringe or Rumshpringa, is a rite of passage during adolescence, trans- skates, disposable diapers, and gas grills. The technologies that Amish use lated in English as “jumping or hopping around,” used in some Amish greatly depend on the order of which they are a part. The Swartzentruber communities. For Amish youth, the Rumspringa normally begins around order is very conservative and does not allow battery powered lights to be the ages of 14–16 and ends when the youth choose to be baptized in the used. Some of the Swartzentruber communities do not allow bicycles but Amish church or to leave the community. This is a period of relative leni- scooters without rubber tires are acceptable. The Old Order Amish don’t ency, but the expectation is that an adult decision to be baptized before use modern technology, but they are allowed to ride in motorized vehicles, marriage will call young people back to the discipline of the church as they as long as they do not own them. New Order Amish are more lenient, al- assume adult roles [39]. Some children do not return to the Amish com- lowing automobiles, modern farming machines and electricity [31]. munity; however, research according to Cory (2021) reports that wealth- ier Amish retain more of their children in the order than do less wealthy. The Amish believe in living separately with an emphasis on humility. Their Perhaps this is because more amenities help them have contact with the education avoids subjects associated with self-exaltation, pride, and en- outside world. joyment of power. They believe that God is pleased when people work in harmony with nature; therefore, they put great value into manual labor In recent years, the media have been fascinated with this period of Amish and hard work. This is another reason why the Amish always live-in rural teenage life as Americans in general have learned more about the Amish Journal of Nur & Res 2021 Volume 2 | Issue 5 | 69 as a distinctive culture. Meyers and Nolt (2005) contended that although the principle of mutual aid or “helping out,” which is almost synonymous some Amish teenagers do experiment with behaviors that are incongru- with the Amish way of life. 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 There is little variation from the culturally sanctioned expectations for choose to participate in behaviors, some of which may involve the legal parents and their unmarried children to live together in the same house- system, they do so in ways that are not common to American teenagers hold while maintaining frequent contact with the extended family. Un- in general. For example, Amish youth will usually experiment with other married children live in the parents’ home until marriage, which usually Amish youth, rather than with non-Amish teenagers. However, children takes place between the ages of 20 and 30 years of age. Some young adults of richer Amish parents are less likely to leave the community [40]. may move to a different community to work and live as a boarder with another Amish family. Being single is not stigmatized, although almost The Amish family pattern is referred to as the freindschaft, the dialectical Amish do marry. Single adults are included in the social fabric of the com- term used for the three-generational family structure. This kinship net- munity with the expectation that they will want to be involved in family- work includes consanguine relatives consisting of the parental unit and oriented social events [43]. the households of married children and their offspring. All members of the family personally know their grandparents, aunts, uncles, and cousins, Individuals of the same gender do not live together except in situations in with many knowing their second and third cousins as well [29]. which their work may make it more convenient. For example, two female schoolteachers may live together in an apartment or home close to the Individuals are identified by their family affiliation. Children and young Amish school where they teach. There are no available statistics on the adults may introduce themselves by giving their father’s first name or both incidence of homosexuality in Amish culture. Isolated incidents of ho- parents’ names so they can be placed geographically and genealogically. mosexual practice may come to the attention of health providers, but ho- Families are the units that make up church districts; the size of a church mosexual lifestyles do not fit with the deeply held values of Amish family district is measured by the number of families rather than by the number life and procreation (Purnell personal communication 2019). However, of church members (see the section on Spirituality). This extended family alternative lifestyles do occur as with any population. The website LGBTA- pattern has many functions. Families visit together frequently, thus learn- mish.com [44], offers support, education, networking opportunities, and ing to anticipate caring needs and preferences. Health-care information friendship to those who are interested in and practice alternative lifestyle. often circulates through the family network, even though families may be This is a safe place to share stories and struggles, a place to find under- geographically dispersed. [41], found that informants referred to freind- standing, support, and community. schaft when discussing the factors influencing the selection of health-care options. “The functions of family care include maintaining freindschaft Workforce Issues ties, bonding family members together intergenerationally, and living In every generation except the present one, the Amish have worked almost according to God’s will by fulfilling the parental mandate to prepare the exclusively in agriculture and farm-related tasks. Their large families were family for eternal life” [41]. ideally suited to labor intensive work on the family farm. As the number of family farms has been drastically reduced because of competition from As grandparents turn over the primary responsibility for the family farm agribusinesses that use mechanized and electronically controlled produc- or business to their children, they continue to enjoy respected status as tion methods, few options are available for Amish youth; therefore, many elders, providing valuable advice and sometimes material support and have relocated to other states, Honduras, Belize, Bolivia, and Mexico. They services to the younger generation. Many nuclear families live on a farm are not always well-accepted in these environments. For example, in Be- with an adjacent grandparent’s cottage, or a smaller apartment attached to lize, they are not well accepted because they are farmers and considered the main farmhouse promoting frequent interactions across generations. lower-class (Purnell - Person communication in Belize). Grandparents provide childcare and help in rearing grandchildren and, in return, enjoy the respect generally paid by the next generations. This emo- Traditionally, the Amish have placed a high value on hard work with little tional and physical proximity to older adults facilitates elder care within time off for leisure or recreation. Productive employment for all is the ide- the family setting. In an ethnonursing study on care in an Amish commu- al and the intergenerational family provides work roles appropriate to the nity Wenger (1988) reported that an informant discussed the reciprocal age and abilities of each person. However, prospects have begun to narrow benefits of having her grandparents living in the attached daedihaus and with the increased concentration of family farms in densely settled Amish her own parents living in a house across the road. Her 3-year-old daughter communities as their population increased [4]5. Amish are more physi- could go across the hall to spend time with her great-grandfather, which cally active than many other cultural groups because of their lifestyle [46]. the mother reported was good for him in that he was needed. The child Several cultural factors combine to limit the opportunities for young benefited from knowing her great-grandfather; the young mother gained Amish to adapt to new work patterns. Children attending school through some time to do chores. There is no set retirement age among the Amish. only eight grades have a limited basis for vocational training in many work Grandmothers continue in active roles as advisers and assistants to young- areas other than agriculture. Avoiding compromising associations with er mothers. “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 Assuming full adult membership and responsibility means the willingness time a good option for unmarried youth, has become an economic neces- to put group harmony ahead of personal desire. In financial terms, it is an sity for some, although it is considered less acceptable for social reasons. obligation to help others in the brotherhood. This mutual aid commitment Fathers who “work away,” sometimes called “lunch pail daddies,” have less provides a safety net, allowing Amish to rely on others for help in emer- contact with children during the workday which has impacted the tradi- gencies. Consequently, the Amish do not seek federal pension or retire- tional father’s modeling role and places more of the responsibility for child ment support. They have their own informal “social security” plan. Amish rearing on stay-at-home mothers. This shift in traditional parental roles is of varying degrees of affluence enjoy approximately the same social status; a source of some concern, although the effects are not yet clear [25]. 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 Another concern in relation to the workplace is the use of technologies informal brotherhood alternative to commercial insurance coverage [42]. that may be of concern. Hurst and McConnell (2001) describe survey re- The costs of high-technology medical care present a new and severe test of sults of Amish in Holmes County, Ohio where 9 out of 10 persons “believe Journal of Nur & Res 2021 Volume 2 | Issue 5 | 70 there are some technologies that are harmful to the stability and integrity with genetic disorders [49]. Because Amish tend to live in settlements with of Amish culture, regardless of how they are used” (p. 210). Computers, relatively little domiciliary mobility, and because they keep extensive ge- Internet, and TV were mentioned the most. These technologies are perva- nealogical and family records, genetic studies are more easily done than sive in non-Amish lifestyles and workplaces. Their concern is the difficul- with more mobile cultural groups [50]. Many years of collaboration be- ty in using these technologies in healthy ways that uphold Amish beliefs tween the Amish and geneticists from the Johns Hopkins Hospital and the and values. External and internal factors have converged and cause doubt Clinic for Special Children have resulted in mutually beneficial projects. about the continued viability of Amish farming communities. Exorbitant The Amish received printed community directories. Geneticists compiled land prices triggered group movement and resettlement in states to the computerized genealogies for the study of genetic diseases that continue to west and south. The declining availability of affordable prime farmland benefit society in general [51]. 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 Essentially the Amish are a closed population with exogamy very rare- of suburban sprawl. A powerful internal force is at work as well in the ly occurring. However, they are not a singular genetically closed popu- population growth rate among the Amish, now well above the national av- lation. The larger and older communities are consanguineous, meaning erage. So, contrary to popular notions that such a “backward” subculture that within the community the people are related through bloodlines with is bound to die out, the Amish today are thriving. common ancestors. Several consanguine groups have been identified in which relatively little intermarriage occurs between the groups. The sep- Population growth continues even without a steady influx of new immi- arateness of these groups is supported by the history of the immigration grants from the European homeland or significant numbers of new con- into each area, by the uniqueness of the family names in each community, verts to their religion or way of life [25]. The Young Center for Anabaptist by the distribution of blood groups, and by the different hereditary dis- and Pietist Studies at Elizabethtown College (2019) reports that the esti- eases that occur in each of these groups [19]. These diseases are one of the mated population of the Amish of North America (adults and children) as indicators of distinctiveness among the groups. 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 Hostetler [19] cautioned that although “inbreeding” is more prevalent in 2018, the Amish in North America (adults and children) increased from Amish communities than in the general population, it does not inevita- 123,500 in 1991 to 330,270 in 2017, an overall growth of 260 percent. This bly result in hereditary defects. In some societies, marriages between first population growth has been attributed largely to the size of families and and second cousins were relatively common without major adverse effects. the retention rate of young adults [5,47]. However, in the Amish gene pool there are several recessive tendencies that in some cases are limited to specific Amish communities in which the The pressures to control the changes in their way of life while maintaining consanguinity coefficient (degree of relatedness) is high for the specific its religious basis, particularly the high value placed on in-group harmony, genes of at least 12 recessive diseases, 4 should be noted here [19,52]. have challenged the Amish to develop adaptive strategies. One outcome is an increasingly diversified employment base with a trend toward cottage Dwarfism has long been recognized in several Amish communities. El- industries and related retail sales, as well as wage labor to generate cash for lis–van Creveld syndrome, known in Europe and named for Scottish and higher taxes and increasing medical costs. Another recent development Dutch physicians, is especially prevalent among the Lancaster County, includes a shift from traditional multigenerational farmsteads as some re- Pennsylvania, Amish. This syndrome is characterized by short stature tirees and crafts workers employed off the farm have begun to relocate to and an extra digit on each hand with some individuals having a congen- the edges of country towns. Thus, pressures to secure a livelihood with- ital heart defect and nervous system involvement resulting in a degree of in the Amish tradition have heightened awareness of the tension within mental deficiency. The Lancaster County Amish community, the second which the Amish coexist with the surrounding majority American culture largest Amish settlement in the United States, is the only one in which [5]. Ellis–van Creveld syndrome is found [53]. The lineage of all affected peo- Because English is the language of instruction in schools and is used with ple has been traced to a single ancestor, Samuel King who immigrated in business contacts in the outside world, there is generally no language bar- 1744 [52]. 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. Cartilage hair hypoplasia, also a dwarfism syndrome, has been found in The shift from agriculture as the primary income for Amish families is nearly all Amish communities in the US and Canada, although it is not partially due to the increasing cost and scarcity of land. There have been unique to the Amish [54]. This syndrome is characterized by short stat- increasing numbers of Amish owned small businesses popping up around ure and fine, silky hair. There is no central nervous system involvement; the country and perhaps the most well-known being Amish furniture therefore, no mental deficiency. Most affected individuals have deficient stores. Other successful business ventures include quilt shops, greenhous- cell-mediated immunity increasing their susceptibility to viral infections es, and bakeries. Amish men also work in construction. They form con- [52]. struction crews within a settlement and travel between rural towns con- tracting work from non-Amish people. In some settlements the majority A rare blood cell disorder, pyruvate kinase anemia, was described by Bow- of the people work at non-Amish owned factories or restaurants. Those man and Procopio in 1963. The lineage of all affected individuals can be who choose to make their primary income away from agriculture still of- traced to Jacob Yoder (known as “Strong Jacob”) who immigrated to Mif- ten continue farming as a hobby. Despite the new diversity in the Amish flin County, Pennsylvania, in 1792 [19,52]. This same genetic occurs in work habits, the primary goal remains finding work that supports an indi- the Geauga County, Ohio Amish community. Notably, the families of all vidual family and also serve the community as a whole [48]. those who were affected were from the “Strong Jacob” lineage. Symptoms with jaundice and anemia usually appear soon after birth. Transfusions Biocultural Ecology during the first few years of life and eventual removal of the spleen are Since 1962, several hereditary diseases have been identified among the considered cures. Amish. The earliest findings of the genetic studies have been published by Dr. Victor McKusick of the Johns Hopkins University. The Clinic for Spe- Hemophilia B, another blood disorder, is disproportionately high, espe- cial Children in Strasburg, PA was started in 1989 by Dr. Holmes Morton cially in Ohio. [55], reported on an Amish man who was treated for a rup- and continues to provide medical care for Amish and Mennonite children tured spleen. It was discovered that he had grandparents and 10 cousins Journal of Nur & Res 2021 Volume 2 | Issue 5 | 71 who were hemophiliacs; five of the cousins had died from hemophilia. Re- quested prior to delivery. This information may be helpful in childbirth search on causative mutations indicated a strong probability that a specific decisions made in collaboration with health-care providers. mutation may account for much of the mild hemophilia B in the Amish population [56]. Extensive studies of manic-depressive illnesses have been conducted in the Amish population. Comparative studies have been done on both Amish Through the vigilant and astute observations of some public-health nurs- [62] and non-English families [62] to determine the genetic basis of men- es, a major health-care problem was noted in a northern Indiana Amish tal disorders. While new information on the genome has been obtained, community. A high prevalence of phenylketonuria (PKU) was found in the specific locus for bipolar disorders had not yet been found. Attempts the Elkhart-Lagrange Amish settlement [50,57]. Those affected are unable have been made to gain knowledge about the affective response the Amish to metabolize the amino acid phenylalanine, resulting in high blood lev- have to their ethnoreligious cultural identity and experience [62,63], stud- els of the substance and eventually severe brain damage if the disorder is ied the protective factors of the Amish lifestyle in mental health disorders. untreated. Through epidemiological studies, the health department found The incidence of alcohol and drug abuse, which can complicate psychiat- that 1 in 62 Amish were affected, whereas the ratio in the general popu- ric diagnoses, is much lower among the Amish than in the general Unit- lation is 1 in 25,000. Through the leadership of these nurses, the county ed States population, thus contributing to the importance of the Amish and the state improved case funding for PKU and health-care services for sample. Although the incidence of bipolar affective disorder is not found affected families throughout Indiana, which was followed by improved to be higher in the Amish, some large families with several affected mem- health services in Amish communities in other states as well. bers continue to contribute to medical science by being subjects in the genetic studies. Because the Old Order Amish descend from 30 pioneer In recent years, a biochemical disorder called glutaric aciduria has been couples whose descendants have remained genetically isolated in the Unit- studied by Dr. Holmes Morton, a Harvard-educated physician who has ed States, have relatively large kindred groups with multiple living gener- chosen to live and work among the Amish in Lancaster County, Penn- ations, and generally live in close geographic proximity, they are an ideal sylvania. Morton made house calls, conducted research at his own ex- population for genetic studies [61]. pense because funding was not forthcoming, and established a clinic in the Amish community to screen, diagnose, and educate people to care for No drug studies specifically related to the Amish were found in the liter- individuals afflicted with the disease [58]. By observing the natural histo- ature. Given the genetic disorders common among selected populations, ry of glutaric aciduria type I, the researchers postulated that the onset or astute clinicians are tailoring interventions to provide the safest medical progression of neurological disease in Amish patients can be prevented care of Amish [51]. The impact of genetic variance in pharmacogenetics is by screening individuals at risk; restricting dietary protein; thus, limiting one area in which more research needs to be conducted. protein catabolism, dehydration, and acidosis during illness episodes. High-Risk Behavior Dr. Morton was well received in the Amish community. Many people re- Amish, traditionally agrarian, prefer a lifestyle that provides intergener- ferred friends and relatives to him. When he noted the rapid onset of the ational and community support systems to promote health and mitigate symptoms and the high incidence among the Amish, he did not wait for the prevalence of high-risk behaviors. Genetic studies using Amish popu- them to come to his office. He went to their homes and spent evenings and lations are seldom confounded by the use of alcohol and other substances. weekends driving from farm to farm, talking with families, running tests, However, health providers should be alert to potential alcohol and recre- and compiling genealogical information [59]. In 1991, he built a clinic ational drug use in some Amish communities, especially among young, with the help of donations, in part the result of an article in the Wall Street unmarried men. When young adult men exhibit such behavior as straying Journal about the need for this non-profit clinic. Hewlett-Packard donat- from the Amish way of life and “sowing their wild oats” before becoming ed the needed spectrometer, local companies provided building materi- baptized church members and before marriage, it is tacitly tolerated. Al- als, and an Amish couple donated the building site. Although volunteers though this may be considered a high-risk behavior, it is not prevalent in helped to build the clinic, a local hospital provided temporary clinic space all communities, nor is it promoted in any. Parents confide in each other lease-free because the community recognized the very important contri- and sometimes in trusted outsiders that this behavior causes many heart- bution Morton was making, not only to the Amish and the advancement aches. At the same time, they try to be patient and keep contact with the of medical science but also to the public health of the community. youth so they may choose to espouse the Amish lifeways.

A countywide screening program is now in place. Health-care providers Another lifestyle pattern that poses potential health risks is nutrition. are able to recognize the onset of symptoms. Research continues on this Amish tend to eat high-carbohydrate and high-fat foods with a relatively metabolic disorder, its relationship to cerebral palsy in the Amish pop- high intake of refined sugar. Wenger (1994) reported that in an ethnonurs- ulation, and the biochemical causes and methods of preventing spastic ing study on health and health-care perceptions, informants talked about paralysis in the general population. However, education remains a highly their diet being too high in “sweets and starches” and knowing they should significant feature of any community health program. Nurses and phy- eat more vegetables. Obesity was found to be greater among Amish women sicians need to plan for family and community education about genetic than for women in the general population [64]. In this major health-risk counseling, screening newborns and recognizing of symptoms during ac- survey of 400 Amish adults and 773 non-Amish adults, the authors found iduric crises in affected children In The New York Times Magazine [58], that the pattern of obesity in Amish women begins in the 25-year-old and Dr. Morton was called “a doctor for the future”’ because he practices what older cohort with the concentration occurring between the ages of 45 and is now referred to as genetic medicine, which recognizes genetics as part 64. An explanation for the propensity for weight gain among the Amish of all medicine. To the Amish, he is their friend who cares about their may be related to the central place assigned to the consumption of food children, knows their families by name, and comes to their homes to see in their culture and the higher rates of pregnancy throughout their child- how they are able to cope with the manifestations of these genetic diseases. bearing years (Wenger, 1994). However, in recent studies related to eating Similar to the views of non-Amish parents, there is great variability in pa- behaviors, obesity, and diabetes, the Old Order Amish cohorts showed rental willingness to obtain genetic counselling [60]. As in most health some significant differences from other Whites in the majority culture. care decisions, obtaining genetic counselling remains with the individual. Family members, friends, and religious leaders may give advice. Genetic The Old Order Amish sample evidenced diabetes approximately half as counselling may or may not be done before pregnancy and may be re- Journal of Nur & Res 2021 Volume 2 | Issue 5 | 72 frequently as did other Whites. There has been additional research done primary influence to vaccinate. Wives were more likely to cite their spouse on linkage of familial hypercholesterolemia and diabetes among related as the primary influence to vaccinate. Families who rejected vaccines were Amish families (Xu et al., 2017). An important difference was the level of more likely to state their bishop was the most influential person on vac- daily physical activity which was reported to be higher among both Amish cinations [70]. men and women than among other White cohorts [46]. Nutrition Health-Care Practices Among the Amish, food is recognized for its nutritional value. Most prefer Much of what passes for “general knowledge” in an information-rich pop- to grow their own produce for economic reasons and because for gen- ular culture is screened, or filtered, out of Amish awareness. The Amish erations they have been aware of their connections with the earth. They have restricted their access to print media, permitting only a few news- believe that God expects people to be the caretakers of the earth and to papers and periodicals. Most have also rejected the electronic media, be- make it flourish [71]. ginning with radio and television, but also including entertainment and information applications of films, computers, and cell phones. However, They generally eat foods produced in their own gardens or their farms. As the Amish are openly curious about the world beyond their own cultur- a rule, they do not eat processed, store-bought foods such as corn flakes al horizons, particularly regarding literature that deals with health and or potato chips. Homegrown fruits and vegetables, eaten fresh, canned, quality-of-life issues. They especially value the oral and written personal or frozen play a very important part in the Amish diet. Vegetables often testimonial as a mark of the efficacy of a particular treatment or health-en- found in Amish meals include peas, corn, zucchini, beets, beans, rhubarb, hancing product or process. [23]. identified testimonials from Amish and many others. Cabbage and potatoes are especially important. Sauer- friends and relatives as a key source of information in making choices kraut—a type of pickled cabbage—appears at many Amish meals and is about health-care providers and products [65]. used in everything from soups to cakes. Grain products like bread, corn- meal, and oatmeal are also staples. Scrapple, a popular breakfast food, is Fondness and love for family members are held deeply but privately. Some made with fried cornmeal mush prepared with sausage and liverwurst health-care providers have observed the cool, almost aloof behavior of [71]. 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 Main meals are usually built around hearty meat dishes such as pork suffering are not entirely subdued by dour or stoic silence but are clearly chops, ham, roast beef, or meatloaf. Dairy products, especially eggs and not outwardly demonstrative or exuberant [66,67]. Most are physically cheese, are also important dietary staples. The Amish are known through- active, largely due to their agrarian lifestyle and farming as a preferred out the country for the quality of the cheese they produce and market. occupation. Physical labor is valued. Men, women, and children help with Most Amish families keep at least a few chickens so they can eat freshly farm work. Household chores and gardening, generally considered to be laid eggs all year round. In the wintertime, hearty soups are eaten regular- women’s work, require physical exertion, particularly because the Amish ly. Amish women bake a great deal, preparing breads, cookies, pies, and choose not to use electrically operated appliances in the home or machin- cakes. The best-known Amish desserts include shoofly pie, sugar cookies, ery that conserve human energy. The impact of increased physical activity and schnitz pie, which is made with dried apples. Favorite beverages in- is found in comparison studies of Amish and non-Amish children [68]. clude coffee, tea, milk, and lemonade [71]. Nevertheless, many women do contend with a tendency to be overweight. It is not uncommon to find Amish women seeking help for weight control. The Amish serve food in most social situations because food has a signif- Physical contact should be kept to a minimum: it is inappropriate for con- icant social meaning. Visiting, a highly valued cultural function, occurs tact between members of the opposite sex. Thus, nursing care should be most weeks for visiting family, neighbors, and friends, especially those performed by members of the same sex if at all possible. Health educators within their church district. Some of these visits are planned where snacks who venture into the Amish community should adhere to modesty prac- or meals are shared, sometimes with the guests helping provide the food. tices depending on their gender in order to facilitate the best quality of Even if guests come unexpectedly, it is customary in most Amish commu- communication. nities for snacks and drinks to be offered.

Farm and traffic accidents continue to be an increasing health concern Typical Amish meals include meat, potatoes, noodles, or both; a cooked in communities with a dense Amish population. In states with relatively vegetable; bread; something pickled (e.g., pickles, red beets); cake or pud- high concentrations of Amish who drive horse-drawn vehicles, blinking ding; and coffee. Beef is usually butchered by the family. If they do not red lights and large red triangles attached to their vehicles are required have home freezing capabilities, then the meat is kept in the local com- by law. Research done on both adult and pediatric injuries show trends in mercially owned freezer for which they pay a rental storage fee. However, trauma with accidents involving farming equipment, animal injuries, and some more progressive Amish have freezer capabilities that are gasoline buggy accidents [69]. Transportation-related injuries (buggy vs. car) con- powered. Some families also preserve beef by canning, and most families tinue to be the biggest threat for all ages. Encourage Amish families need have chickens and other fowl, such as ducks or geese which they raise for to monitor their children who operate farm equipment and transportation eggs and meat. Families value growing their own foods and usually have vehicles and to teach them about safety factors. Concern about accidents large gardens. A generation ago, this was an unquestioned way of life, but is evident in Amish newsletters, many of which have a regular column an increasing number of families living in small towns and working in reporting accidents and asking for prayers or expressing gratitude that the factories and construction own insufficient land to plant enough food for injuries were not more severe, that God had spared the person, or that the the family’s consumption. community had responded in caring ways [23]. Snacks and meals in general tend to be high in fat and carbohydrates. A The ultra-conservative Amish rejected vaccines more often. Amish special common snack is large, home-baked cookies about 3 inches in diameter. needs children were more likely to receive vaccines than healthy Amish Commercial non-Amish companies have recognized large soft cookies as children. 75% responded they would reject a COVID-19 vaccine. Fear of a marketable commodity and have advertised their commercially made adverse effects was the most common reason to reject vaccines. Families products as “Amish” cookies, even though no Amish are involved in the who accepted vaccines were more likely to cite a health-care worker as the production. Other common snacks are ice cream (purchased or home- made), pretzels, and popcorn [71]. Journal of Nur & Res 2021 Volume 2 | Issue 5 | 73 When Amish gather for celebrations such as weddings, birthdays, work Although some more progressive Amish have gasoline powered refrigera- bees, or quiltings, the tables are usually laden with a large variety of foods. tors, the ultra-conservative populations do not. For those who do not have The selection, usually provided by many people, includes several casse- more modern convenience for preserving meats and vegetable, they use roles, noodle dishes, sweet potatoes, cooked vegetables, a few salads, pick- neighborhood frozen food lockers (Purnell, personal communication). led dishes, pies, cakes, puddings, and cookies. [19], provided a detailed ethnographic description of the meaning and practices surrounding an Pregnancy and Childbearing Practices Amish wedding, including the food preparation, the wedding dinner and When it comes to childbirth, many Amish women take a traditional herbal supper, and the roles and functions of various key individuals in this most “Five-week formula” late in their pregnancy. This formula consists of sev- important rite of passage. eral different herbs and natural medicines that aid with everything from uterine contractions to varicose veins [72]. Even though many Amish re- In communities in which tourists flock to learn about the Amish, many fuse modern medicine, more women are giving birth in modern hospitals. entrepreneurs have used the Amish love of wholesome, simple foods to The Amish often delay seeking medical care and are at risk for compli- market their version of Amish cookbooks, food products, and restaurants cations secondary to the initial problem (Weyer, Hustey, Rathbun, Arm- that more aptly reflect the Pennsylvania German, commonly referred to as strong, Reed, Roynak, & Savrin, 2003). However, when it comes to child- Pennsylvania Dutch, influence of communities such as Lancaster County birth more Amish women are now using hospitals and Amish Birthing Pennsylvania and other states. Many of these bear little resemblance to Centers [30,72]. Healthcare providers should be prepared to learn about authentic Amish foods, and some even venture to sell “Amish highballs” or Amish cultural and folk medicine before pregnant women are admitted. “Amish sodas” [19]. Some Amish families help to satisfy the public interest The health risks for Amish are quite significant. Many Amish women do in their way of life by serving meals in their homes for tourists and local not practice birth control [73] and large families are encouraged. There- non-Amish. However, most Amish view their foods and food preparation fore, the Amish are at risk for difficult pregnancies and complications due as commonplace and functional, not something to be displayed in maga- to pregnancies with late age. The Amish tend to marry within their com- zines and newspapers. Health-care providers need to discuss nutrition and munity which increases the risk for genetic diseases and the prevalence of food to promote healthy nutritional lifestyles. recessive genetic disorders (Weyer et al., 2003).

A “place at the table” is symbolic of belonging [19]. Seating is traditionally Medical practitioners must acknowledge that the Amish believe in folk arranged with the father at the head and boys seated youngest to oldest to medicine and home remedies. Powwowing, or braucha, is a brand of faith his right. The mother sits to her husband’s left, with the girls also seated healing practiced by some Amish (Weyer et al., 2003). Powwowing in- youngest to oldest or placed so that an older child can help a younger volves audible or silent incantations, touch, or moving near a sick person, one. The table is where work, behavior, school, and other family concerns provided by a person who has inherited a power to heal [74]. Braucha is are discussed. During the busy harvesting season, preference is given to a healing method with an “emphasis on the continuum of life and death” the men and boys who eat and return to the fields or barn. At mealtimes, [66]. 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 Children, viewed as a gift from God, are welcomed. Estimates place the av- return home. 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 Sunday church services, which for the Old Order Amish are held in their has remained constant during the past 100 years, while many others have homes or barns, are followed by a simple meal for all who attended church. declined. Household size varies from families with no children to couples Church benches are transported from home to home wherever the church with 15 or more children [76]. Even in large families, the birth of anoth- service is to be held. Meals become ritualized. The focus is on the oppor- er child brings joy because of the core belief that children are “a heritage tunity to visit over a simple meal. In one community, an Amish infor- from the Lord,” and another member of the family and community means mant who had not attended services because of a complicated pregnancy another person to help with the chores [19]. told the researcher that she missed the meal, which in that community consisted of bread, butter, peanut butter mixed with marshmallow creme Having children has a different meaning for Old Order Amish than in and honey, apple butter, pickles, pickled red beets, soft sugar cookies, and the dominant European American culture. In a study on women’s roles coffee [23]. and family production, the authors suggested that Amish women enjoy high status despite the apparent patriarchal ideology because of their The Amish only eat foods that they have grown in their own personal gar- childbearing role and their role as producers of food [77]. A large number den, or they have grown on their farms. They hold farmers markets for of children benefit small labor-intensive farms. With large families comes each other, and they give other members of their community food and buy the need for large quantities of food. Interpretation of this view of fertili- food grown on other member’s farms. They don’t usually buy food that is ty should always be moderated with recognition of the moral and ethical in stores or has been processed and packaged, although is becoming more core cultural belief that children are a gift from God, given to a family and common in some communities where the store hires Amish women to community to nurture in preparation for eternal life. 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 Scholars and researchers of long-term acquaintance with Old Order grown include beans, zucchini, rhubarb, peas, corn, and others. The most Amish agree that the pervasive Amish perception of birth control is that important vegetable for the Amish is cabbage. They usually pickle the it interferes with God’s will and thus should be avoided [78]. Neverthe- cabbage and make sauerkraut. Some have sauerkraut for every meal and less, fertility control does exist, although the patterns are not well known is incorporated it into main dishes and sometimes into desserts. Grains and very few studies have been reported. [79] discussed childbearing with are another important part of Amish food. A staple of the Amish culture Amish couples in a group interview and they conceded that some couples is scrapple, a breakfast food made with fried cornmeal mush and can be do use the rhythm method. In referring to birth control, one Amish fa- served with sausage and liverwurst. The Amish are also known for their ther stated, “It is not discussed here, really. I think Amish just know they cheese which they sell in markets. They usually have a few chickens at all shouldn’t use the pill” [79]. Three physicians and three nurses were inter- times so that they can have fresh eggs. They also are known for their des- viewed; they reported that some do ask about birth control methods, es- sert pastries such as shoofly pie, shnitz pie, and sugar cookies [71]. pecially those with a history of difficult perinatal histories and those with Journal of Nur & Res 2021 Volume 2 | Issue 5 | 74 large families. Some Amish women use intrauterine devices, but this prac- nurses. Physicians and professional nurses and nurse-midwives, who are tice is uncommon. Most women are reluctant to ask physicians and nurses interested in Amish cultural values and health-care preferences, provide and, therefore, should be counseled with utmost care and respect because low-cost, safe, low-technology perinatal care in a homelike atmosphere. this is a topic that generally is not discussed, even among themselves. Ap- In 1997, the New Eden Care Center, modeled after the Mt. Eaton Care proaching the subject obliquely may make it possible for the woman or Center, was built in northern Indiana and, in recent years, has had more man to sense the health provider’s respect for Amish values and thus en- than 400 births per year [83]. courage discussion. “When you want to learn more about birth control, I would be glad to talk with you” is a suggested approach [67]. Because the Amish want family involvement in perinatal care, outsiders may infer that they are open in their discussion of pregnancy and child- Amish tend to have their first child later than non-Amish. A retrospective birth. In actuality, most Amish women do not discuss their pregnancies chart review examining pregnancy outcomes of 39 Amish and 145 non- openly and make an effort to keep others from knowing about them until Amish women at a rural hospital found that Amish had their first child an physical changes are obvious. Mothers do not inform their other children average of one year later than non-Amish couples [80]. They had a nar- of the impending birth of a sibling, preferring for the children to learn of rower range of maternal ages and proportionately fewer teenage pregnan- it as “the time comes naturally” (Wenger, 1988). This fits with the Amish cies. All subjects received prenatal care, with the Amish receiving prenatal cultural pattern of learning through observation that assumes intergen- care from Amish lay midwives during the first trimester. erational involvement in life’s major events. Anecdotal accounts exist of children being in the house, though not physically present, during birth. In some communities, Amish have been reported to be reluctant to seek Fathers are expected to be present and involved, although some may opt to prenatal health care. Providers who gain the trust of the Amish learn that do farm chores that cannot be delayed, such as milking cows. they want the best perinatal care, which fits with their view of children Amish women do participate in prenatal classes, often with their hus- being a blessing [81]. However, they may choose to use Amish and non- bands [79]. Women are interested in learning about all aspects of perinatal Amish lay midwives who promote childbearing as a natural part of the life care but may choose not to participate in sessions when videos are used. cycle. In a study of childbearing practices as described by Amish women Prenatal class instructors should inform them ahead of time when vid- in Michigan, [81] learned that they prefer home births even if they had eos or films will be used so they can decide whether to attend. For some limited formal knowledge of the childbirth process. Health-care providers Amish in which the Ordnung (the set of unwritten rules prescribed for were usually consulted only when there were perceived complications. Al- the church district) is more prescriptive and stricter, the individuals may though many may express privately their preference for perinatal care that be concerned about being disobedient to the will of the community. Even promotes the use of nurse-midwifery and lay midwifery services, home though the information on the videos may be acceptable, the type of me- deliveries, and limited use of high technology, they tend to use the perina- dia is considered unacceptable. tal services available in their community. In ethnographic interviews with informants, Wenger (1988) found that grandmothers and older women In study of 1,836 pregnant Amish women by [84], 1733 birthed at home. reported greater preference for hospital deliveries than did younger wom- More than one-third had high parity (gravida 5-13) with low rates of en. The younger women tend to have been influenced by the increasing postpartum hemorrhage (n = 96, 5.5%). There were no maternal deaths. general interest in childbirth as a natural part of the life cycle and the de- Nearly half of the maternal transfers to the hospital (n = 103, 5.6%) were emphasis on the medicalization of childbirth. Some communities have a for ruptured membranes without labor (n = 25, 1.4%) and/or failure to long-standing tradition of using both lay midwifery and professional ob- progress (n = 23, 1.3%). The neonatal hospital admission rate also was low stetric services, often simultaneously. Infant loss is frequently invisible to (n = 13, 0.75%). Of the 7 (0.4%) early neonatal deaths, all were attributed the rest of society. Parents may become frustrated when they are denied to lethal congenital anomalies. mourning time or asked why they are not “over it” yet. Nurses’ demon- stration of cultural sensitivity during perinatal loss facilitates grieving by Amish have no major taboos or requirements for birthing. Men may be validating each family’s “right” way to mourn their infant’s death [82]. present; most husbands choose to be involved. However, they are likely not to be demonstrative in showing affection verbally nor physically. This An interview on 6/9/2020 with Melanie Chichester, RN, BSN, RNC-OB, does not mean they do not care; it is culturally inappropriate to show af- CPLE a nurse specializing in perinatal death working in a large level 3 fection openly in public. The laboring woman cooperates quietly, seldom trauma center that receives Amish women with birthing complications re- audibly expressing discomfort because many tend to be stoical with pain. port the most common reasons for pregnant Amish women to be admit- ted to the obstetric unit reports the most frequent reasons for admission Given the Amish acceptance of a wide spectrum of health-care modalities, the most common reasons are the mother has a cardiac condition, the the nurse or physician should be aware that the woman in labor might be baby is expected to have complications, placenta previa, uterine rupture, using herbal remedies to promote labor. Knowledge about and a respect and hemorrhagic shock. 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 The Mt. Eaton Care Center in Ohio developed as a community effort in re- better if these discussions can take place in a low stress setting before labor sponse to retirement of an Amish lay midwife known as Bill Barb (identi- and birth [79]. fied by her spouse’s name). She provided perinatal services including labor and birth, with the collaborative services of a local Mennonite physician As in other hospitalizations, the family may want to spend the least allow- who believed in providing culturally congruent and safe health-care ser- able time in the hospital. This is generally related to the belief that birthing vices. At one point in Bill Barb Hochstetler’s 30-year practice, the physi- is not a medical condition and because most Amish do not carry health in- cian moved a trailer with a telephone onto Hochstetler’s farm so that he surance. In their three-generational family, and as a result of their cultural could be called in case of an emergency. Other sympathetic physicians also expectations for caring to take place in the community, many people are delivered babies at Bill Barb’s home. After state investigation, which coin- willing and able to assist the new mother during the postpartum period. cided with her intended retirement, Hochstetler’s practice was recognized Visiting families with new babies are expected and generally welcomed. to be in a legal grey area. The Mt. Eaton Care Center became a reality in Older siblings are expected to help care for the younger children and to 1985 after careful negotiation with the Amish community, Wayne County learn how to care for the newborn. The postpartum mother resumes her Board of Health, Ohio Department of Health, and local physicians and family role managing, if not doing, all the housework, cooking, and child- Journal of Nur & Res 2021 Volume 2 | Issue 5 | 75 care within a few days after childbirth. For a primiparous mother, her of the bonds that tie individuals to extended family and community. An mother often comes to stay with the new family for several days to help extension of this social interaction, visiting the ill takes on an added poi- with care of the infant and give support to the new mother. It also is com- gnancy, especially during an illness believed to be terminal. Members of mon for a teenage female relative who has completed schooling to come the immediate family are offered verbal condolences and many supportive stay with the family to provide assistance in household chores and care of acts of kindness. Others close to prepare their food and take over other the children. She may stay a few weeks to a few months [65]. routine household chores to allow them to focus their attention and ener- gy on the comfort of the ailing family member [14]. 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 Ties across generations across kinship and geographic lines are reinforced new member of the community. The baby is often passed among the wom- around death as children witness the passing of a loved one in the intimacy en to hold as they become acquainted and admire the newcomer [79]. of the home. Death brings many visitors into the home of the bereaved. The church community takes care of accommodations for visitors from a With a number of genetic disorders among the Amish and childbearing distance as well as funeral arrangements. Thus, the immediate family is re- into their 40 and even 50 years of age put the woman’s pregnancy at a lieved of the responsibility for decision making which otherwise may add greater risk for complications and even death of the infant. Some may distraction to grief. In some settlements, a wake-like “sitting up” through be reluctant for an autopsy unless it is required by law that varies among the night provides an exception to normal visiting patterns. The verbal states. The health of others may be a deciding factor in the parents’ deci- communication with the bereaved may be sparse, but the constant pres- sion for an autopsy. Although overtly it may appear that the father is mak- ence of supportive others is proof of the Amish commitment to commu- ing the decisions, both mother and father jointly make most decisions; nity. The return to normal life is eased through these visits by the resump- therefore, the issue should be addressed all information to both parents tion of conversations [88]. (Chichester, 2007). Other members of the community may also be sought for advice, particularly grandparents and the local minister and bishop. Both Amish and non-Amish friends and relatives come to pay their re- The final decision regarding an autopsy rest with the parents [85,86]. 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- Death Rituals maker frequently builds a plain wooden coffin. In the past, interment was If death is a part of life and a portal to a better life, then individuals are in private plots on Amish farms, contrasting with the general pattern of well advised to consider how their lives prepare them for life after death. burial in a cemetery in the churchyard of a rural church. Because Amish Non-Amish occasionally are baffled at reports of the Amish response to worship in their homes and have no church buildings, they also have no grave injury or even loss of life at the hands of others. Deeply held com- adjoining cemeteries. An emerging pattern is burial in a community cem- munity values, and especially constrained by love for others, Amish often etery, sometimes together with other Mennonites. Burial restrictions may eschew retaliatory or vengeful attitudes and actions when the majority also result of town and county ordinances restricting burials to traditional culture might justify such means. Amish are socialized to sustain such cemeteries. Grief and loss are keenly felt, although verbal expression may injuries, grieve, and move on without fixing blame or seeking redress or seem muted to indicate stoic acceptance of suffering. In fact, the meaning punishment for the perpetrator. Most injuries, although not all of the re- of death as a normal transition is embedded in the meaning of life from sult in death, are the result of blunt force trauma (91.8%). The most fre- the Amish perspective [88]. 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 Spirituality (33.9%). Hay hole falls were a unique source of injury [69]. Amish share the general Christian view that salvation is ultimately in- dividual, preconditioned on one’s confession of faith, repentance, and Amish customs related to death and dying have dual dimensions. On the baptism. These public acts are undertaken in the Amish context as part one hand, they may be seen as holdovers from an earlier time when, for of preparing to fully assume one’s adult role in a community of faith. In most Americans, major life events such as birth and death occurred in contrast with the ideals of American individualism, the Amish surrender the home. On the other hand, Amish retention of such largely outdated much of their individuality as the price of full acceptance as members of patterns is due to distinctively Amish understandings of the individual a community. In practical, everyday terms, the religiously defined com- within and as an integral part of the family and community. Today, when munity is inextricably intertwined with a social reality, which gives it its 70 percent of elderly Americans die in hospitals and nursing homes, some distinctive shape. This is a means for strengthening family ties [89]. For still reflect nostalgically on death as it should be and as, in fact, it used to the Amish, the importance of conformity to the will of the group is par- be, in the circle of family and friends, a farewell with familiarity and dig- amount. To maintain group harmony, individuals often forgo their own nity. In Amish society today, in most cases this is still a reality. As physical wishes. In terms of faith-related behavior, outsiders sometimes criticize strength declines, the expectation is that the family will care for the aging this “going along with” the local congregational group as an expression of and the ill in the home [87,19], brief observation that Amish prefer to die religiosity, rather than spirituality. The practice of corporate worship with at home is borne out by research findings. prayer and singing helps building this conformity. It is regularly tested in “counsel” sessions in the congregational assembly in which each individu- Clearly, these preferences are motivated by more than a wish to dwell in al’s commitment to the corporate religious contract is reviewed before tak- the past or an unwillingness to change with the times. The obligation to ing communion [25]. As seen in earlier sections on communication and help others in illness as in health provides the social network that supports their socioreligious provenance, many symbols of Amish faith point to the Amish practices in the passage from life to death. It is a natural exten- separated life living in accordance with God’s will. Over time, they have sion of caregiving embraced as a social duty with religious motivation. chosen to embody their faith rather than verbalize it. They seldom prose- The Amish accept literally the biblical admonition to “bear one another’s lytize among non-Amish. This “primitive” form of Christianity emphasiz- burdens.” This finds expression in communal support for the individual, es “right living.” The untrained religious leader offer views based on their whether suffering, dying, or bereaved. Life’s most intensely personal and interpretation of the Bible. Most members are content to submit to the private act becomes transformed into a community event [14]. 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 Visiting in others’ homes for the Amish is a normal and reinforcement aspect of their spirituality that is seldom articulated [90]. Throughout his- Journal of Nur & Res 2021 Volume 2 | Issue 5 | 76 tory the Amish have managed well in the court system despite their lack of lifestyle regulations. Settlements are the highest-level social organization involvement in the law since the United States upholds religious freedom because there is no national authority: the most significant authority re- [91]. Although Amish society is subject to the rules and regulations of the mains within the church districts. 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). On specific holidays or in church the Amish might wear a black covering Each district is governed by ordained officials known as servants who have instead of their traditional white covering. Amish men wear mutza suits varying levels of authority. Each district has one bishop, a servant with full which are very straight and simple. Mutza suits do not have a collar, pock- powers; two to three ministers, “servants of the book;” and one bishop, the ets, or lapels. In the summer some Amish men will wear a vest instead of “servant to the poor” [92]. 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 The Amish use a method of divine selection known as “the lot” in selecting Triblend Denim that is intended to be very durable. Their shirts are made their leaders. The chosen people who receive a select number of votes from of a 50/50 polyester/cotton blend fabric. Belts, sweaters, and neckties are the church members enter the lot. A bible verse is placed inside the cover forbidden. Clothing is fastened with either hooks and eyes or homemade of a hymnbook, and the members of the lot each select from a collection of buttons. Young Amish men are required to be clean shaven prior to being hymnbooks. The candidate who chooses the hymnbook that contains the married; however, once a man is married, he is required to have a beard. bible verse is the chosen leader. These church leaders are always men, but Men are not allowed to have mustaches because they are seen as detracting women are involved in the selection process. from the humility and simplicity of life. All of the clothing and appearance is intended so the person does not stand out [96]. 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 Amish children, who can be as delightfully animated as any other children forbearance in the face of adversity: rather it flows consistently from a bib- at play, are taught to remain quiet throughout a worship service lasting lical mandate to express love, even for an apparent adversary as a practi- more than two hours. They grow up in an atmosphere of restraint and re- cal application of the “The Golden Rule” (Matt. 7:12). A current example spect for adults and elders. But privately, Amish are not so sober as to lack claiming national and international attention was the Amish response of a sense of humor and appreciation of wit [97]. 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 Health-Care Practices on October 2, [93]. Forgiveness in such situations may not come easily Because the predominant mode of transportation for the Amish is horse for many persons. [36] contend that for the Amish, forgiveness is part of and carriage, travel to a doctor’s office, a clinic, or a hospital requires the the Anabaptist “habits” begun in the sixteenth century that continue to same adjustment as any other travel outside their rural community for undergird Old Order Amish culture values incorporate a willingness to shopping, trading, or attending a wedding or funeral. The latter three place tragedy in God’s hands without demanding divine explanation for reasons are important means of reinforcing relationship ties. On these injustice). occasions, they may use hired or public transportation, excluding flying. Extended trips related to medical treatments is not uncommon, such as a Amish settlements are subdivided into church districts with 30 to 50 fam- visit to radioactive mines in the Rocky Mountains or to a laetrile clinic in ilies in each district. Leaders are selected from their own community and Mexico to cope with cancer (Wenger, 1988). A few participate in a type of are generally untrained and unpaid. Authority patterns are congregation- “medical tourism” trips for care by renting a bus for transportation (King, alist with consensus directed by local leadership designated as bishops, 2017). preachers, and deacons, all of whom are male. No regional or national church hierarchy exists to govern internal church affairs, although a na- In one-on-one clinical contacts, Amish patients can be expected to ex- tional committee may be convened to address external institutions of gov- press openness and candor with unhesitating eye contact [98]. Among ernment regarding issues affecting the broader Amish population [94]. their own, personal space may be collapsed on occasions of crowding for To become a member of the Amish church, community members receive group meetings or travel. In fact, Amish are seldom found alone; a solitary instruction on beliefs and values. They are baptized between the ages of Amish person or family is the exception rather than the rule. But Amish 16 and 24. Once someone becomes a member of the church, they are are also pragmatic. In larger families, physical intimacy cannot be avoided completely committed to the community and the Amish doctrine and in the home where childbearing and care of the ill and dying are accepted practices [14]. Marriage does not occur until both members have been as normal parts of life. Once health-care providers recognize that Amish baptized. Amish traditions are centered around church services, baptisms, prefer to have such caregiving within the home and family circle, provid- weddings, communion, and funerals. Every other Sunday, church services ers will want to protect modest Amish patients who feel exposed in the are held in the home of a family within the church district. On the “off” clinical setting [34]. Sundays, members will sometimes visit neighboring services in another church district [92]. 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 Ministers often meet with youth to sing hymns and hold discussions. They be used with the understanding that it is God who heals. Nothing in the live according to guidelines known as the Ordnung and follow a system Amish understanding of the Bible forbids them from using preventive or of beliefs that includes adult baptism; separation of church and state; curative medical services [65]. A prevalent myth among some health-care ex-communication from the church for those who break moral law; living providers is that Amish are not interested in preventive services. Although life in accordance to the teachings of Christ; and refusal to bear arms, take it is true that many times the Amish do not use mainstream health ser- oaths, or hold political office [33]. vices at the onset of recognized symptoms, they are highly involved in the practices of health promotion and illness prevention [65], (Purnell, The organization of Amish society includes the extended family, church personal communication). Although the directives of religious leaders districts, settlements, and subgroup affiliations. Groups of extended fam- are normative for many types of decisions, this appears not to be the case ilies are organized into church districts for governing and fellowship pur- for health-care choices [34]. When choosing among health-care options, poses. As the population grows the districts divide further [95]. Affilia- families usually seek counsel from religious leaders, friends, and extended tions are formed between church districts who share similar practices and family: the final decision resides with the immediate family. The sources of Journal of Nur & Res 2021 Volume 2 | Issue 5 | 77 health-care information sought by many may not provide evidence-based understand this complex, caring network, but health-care providers can guidance. Providers need to be aware of the Amish cultural context and learn about it in the local setting by establishing trust in relationships with need to adjust the normal routines of diagnosis and therapy to fit Amish their Amish patients. patients’ socioreligious context. When catastrophic illness occurs, the Amish community responds by be- Although the Amish have a reputation for honesty and forthrightness, ing present, helping with chores, and relieving family members so that they may withhold important medical information from providers by ne- they can be with the afflicted person in the acute care hospital. Some glecting to mention folk and alternative care being pursued simultaneous- do opt to accept medical advice regarding the need for high-technology ly. When questioned, some admit to being less than candid about using treatment, such as transplants or other high-cost interventions. The pa- multiple therapies, including herbal and chiropractic remedies because tient’s family seeks prayers and advice from the bishop and deacons of they believe that “the doctor wouldn’t be interested in them.” Choosing their church and their family and friends, but the decision is generally a among folk, complementary, and professional health-care options does personal or family one. 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 Amish, as with all cultures, practice self-medication. Although most best health care available (Wenger, 1994). Amish regularly visit physicians and use prescription drugs, they also use herbs and other non-prescription remedies, often simultaneously. When The Amish believe that it is their responsibility to be personally involved discussing the meaning of health and illness, [23], found that her Amish in promoting health. As in most cultures, health-care knowledge is passed informants considered it their responsibility to investigate their treatment from one generation to the next generally through women. In the Amish options and to stay personally involved in the treatment process rather culture, men are involved in major health-care decisions and often accom- than to relegate their care to the judgment of the professional physician pany the family to the chiropractor, physician, or hospital. Grandparents or nurse. Consequently, they seek testimonials from other family mem- are frequently consulted about treatment options. bers and friends about what treatments work best. They may also seek care from Amish healers and other alternative-care practitioners, who may A usual concern regarding responsibility for health care is payment for suggest nutritional supplements. One informant told how she would take services. Many Amish do not carry any insurance, including health in- “blue cohosh” pills with her to the hospital when she was in labor because surance. However, in most communities, there is some form of agreement she believed they would speed up the labor [35]. for sharing losses caused by natural disasters as well as catastrophic ill- nesses. Some have formalized mutual aid, such as the Amish Aid Society. Because of the Amish practice of self-medication, it is essential that [23], found that informants were opposed to such formalized agreements health-care providers inquire about the full range of remedies being used. and wanted to do all they could to live healthy and safe lives, which they For the Amish patient to be candid, the provider must develop mutual believed would benefit their community in keeping with their Christian trust and respect. Within this context, the Amish patient can feel assured calling. Many hospitals have been astounded by the Amish practice of that the provider wants to consider and negotiate the most advantageous paying their bills despite financial hardship. Because of this generally pos- culturally congruent care. itive community reputation, hospitals have been willing to set up payment plans for the larger bills. Like many cultures, the Amish have an elaborate health-care belief system that includes traditional remedies passed from one generation to the next. Active participation was found to be a major theme in [34,67] studies on Although the prevalence of specific health-care beliefs and practices such cultural context, health, and care. The Amish want to be actively involved as use of chiropractic, Western medical and health-care science, reflexol- in health-care decision making, which is a part of daily living. “To do all ogy, iridology, osteopathy, homeopathy, and folklore is influenced mainly one can to help oneself” involves seeking advice from family and friends, by freindschaft [35], variations depend on geographic region and the con- using herbs and other home remedies, and then choosing from a broad servatism of the Amish community. array of folk, alternative, and professional health-care services. One in- formant, who visited an Amish healer while considering her physician’s Herbal remedies are handed down by successive generations of mothers recommendation that she have a computerized axial tomography (CAT) and daughters. One grandmother showed the researcher the cupboard scan to provide more data on her continuing vertigo, told the researcher, where she kept cloths soaked in a herbal remedy and shared the recipe for “I will probably have the CAT scan, but I am not done helping myself, and it. The cupboard was where her grandmother kept those same remedies this [meaning the healer’s treatment] may help and it won’t hurt.” In this when her grandmother lived in the daadihaus [35]. study, health-care decision making was found to be influenced by three factors: type of health problem, accessibility of health-care services, and Of all Amish folk health care, brauche has claimed the most interest of perceived cost of the service. When the Amish use professional health- outsiders, who are often puzzled by its historical origins and contempo- care services, they want to be partners in their health care and retain their rary application” [35]. Brauche is a folk-healing art that was practiced in right to choose from all culturally sanctioned health-care options. 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- The Amish way translates into the expectation that members of the culture sylvania Germans. As with some other European practices, the Amish be aware of the needs of others and fulfill the biblical injunction to bear have retained brauche in some communities. In other communities, the one another’s burdens. Care is expressed in culturally encoded expecta- practice is considered suspect and has been the focus of some church di- tions that they can best describe in their dialect as abwaarde, meaning “to visions [35]. 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 Brauche is sometimes referred to as sympathy curing or pow-wowing. It is means to serve by becoming aware of someone’s needs and then to act by unrelated to American Indian pow-wowing. The Amish refer to brauche doing things to help. Helping others is expressed in gender-related and as “warm hands,” the ability to feel when a person has a headache, or a age-related roles, freindschaft (the three-generational family), church dis- baby has colic. Informants describe situations in which some individuals trict, community (including non-Amish), Amish settlements, and world- can “take” the stomachache from the baby into their own bodies in what wide [99]. No outsiders or health-care providers can be expected to fully is described by researchers as transference [34]. One 52-year-old Amish Journal of Nur & Res 2021 Volume 2 | Issue 5 | 78 man told this author that he had warm hands. 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- A few folk illnesses have no Western scientific equivalents. The first is- ab portant factor in the individual’s sense of well-being. However, an under- nemme, which refers to a condition in which the child fails to thrive and lying expectation is that healthy individuals will want to resume active appears undernourished. Specific treatments given to the child may in- work and social roles as soon as their recovery permits. With reasonable clude incantations. Some of the older people remember these treatments, adjustments for age and physical ability, it is understood that a healthy and some informants remember having been taken to a healer for the ail- person is actively engaged in work, worship, and social life of the family ment. The second is aagwachse, or livergrown, meaning “hide-bound” or and community (Wenger, 1994). Work and rest are kept in balance. For “grown together,” once a common ailment among Pennsylvania Germans the Amish, the accumulation of days or weeks of free time or time off for [26]. Symptoms include crying and abdominal discomfort that is believed vacation outside the framework of normal routines and social interactions to be caused by jostling in rough buggy rides. Wenger (1988) reported is a foreign idea. accompanying an informant with her newborn baby to an Amish healer. The woman carried the baby on a pillow because she believed the baby In a study of Amish women’s construction of health narratives, [104] to be suffering from aagwachse. As stated previously, Amish patients are found that the collective descriptions [of] health included a sense of feel- more likely to discuss folk beliefs and practices with providers if the nurse ing well and the physical ability to complete one’s daily work responsibili- or physician gives cues that it is acceptable to do so. ties. Women’s health traditions included the use of herbal and other home remedies and consulting lay practitioners. In general, health values and Barriers to health care include delay in seeking professional health care beliefs are influenced by group membership and personal developmental at the onset of symptoms, occasional overuse of home remedies, and a history. prevailing perception that health-care providers are not interested in or may disapprove of the use of home remedies and other alternative treat- No cultural or religious rules or taboos prohibit Amish from accepting ment modalities. Naturalistic books were the most used source of health blood transfusions or organ transplantation and donation. In fact, with the information [100]. In addition, some families may live far from profes- genetic presence of hemophilia, blood transfusion has been a necessity for sional health-care services, making travel by horse and buggy difficult or some families. Anecdotal evidence is available regarding individuals who inadvisable. Because in some communities such as the Old Order Amish, have received heart and kidney transplants, although no research reports telephones are not permitted in the home, there may be delays in com- or other written accounts were found. Thus, some Amish may opt for or- munication with Amish patients [101,102]. Finally, the cost of health care gan transplantation after the family seeks advice from church officials,- ex without health insurance can deter early access to professional care, result- tended family, and friends, but the patient or immediate family generally ing in more complex treatment regimens. makes the final decision.

The Amish are unlikely to display pain and physical discomfort. The Health-care providers can expect all their Amish patients of school age health-care provider may need to check changes in vital signs for pain and older to be fluent bilingual. They can readily understand spoken and and remind the patient that medication is available for pain relief if they written directions and answer questions presented in English, although choose to accept it. their own terms for some symptoms and illnesses may not have exact equivalents in Deitsch and English. Amish patients may be more comfort- Community for the Amish means inclusion of people who are chronically able consulting among themselves in Deitsch, but generally they intend no ill or physically or mentally different. Amish approaches these differences disrespect for those who do not understand their mother tongue. as a community responsibility. Children with mental or physical differ- ences are sometimes referred to as “hard learners,” who are expected to go Amish usually refer to their own healers by name rather than by title, al- to school and be incorporated into the classes with assistance from other though some say brauch-doktor or braucher. In some communities, both students and parents. A culturally congruent approach is for the family men and women provide these services. They may even specialize with and others to help engage those with differences in work activities, rather some being especially good with bed-wetting, nervousness, women’s prob- than to leave them sitting around and getting more anxious or depressed. lems, or livergrown. Some set up treatment rooms and people come early [19], stated that “Amish themselves have developed little explicit thera- in the morning and wait long hours to be seen. They do not charge fees peutic knowledge to deal with cases of extreme anxiety” (p. 332). They do but do accept donations. A few also treat non-Amish patients. In some seek help from trusted physicians, and some are admitted to mental health communities, Amish folk healers use a combination of treatment modal- centers or clinics [103]. However, the mentally ill are generally cared for at ities, including physical manipulation, massage, brauche, herbs and teas, home whenever possible. Studies of clinical depression and manic-depres- and reflexology. A few have taken short courses in reflexology, iridology, sive illness were discussed in the section on biocultural ecology. and various types of therapeutic massage. In a few cases, their practice has been reported to the legal authorities by individuals in the medical As previously mentioned when individuals are sick, other family mem- profession or others who were concerned about the potential for illegal bers take on additional responsibilities. Little ceremony is associated with practice of medicine. 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 For the Old Order Amish, health-care providers are always outsiders be- at the same time, receiving help is accompanied by feelings of humility. cause this sect has been unwilling to allow their members to attend medi- Amish newsletters abound with notices of thanks from individuals who cal, nursing, or other health-related professional schools or to seek higher were ill. A common expression is “I am not worthy of it all.” A care set education in general. Therefore, the Old Order Amish must learn to trust identified in one research study is that giving care involves privilege and individuals outside their culture for health care and medically related sci- obligation, and receiving care involves expectation and humility [34]. The entific knowledge. Hostetler (1993) contended that the Amish live in a sick role is mediated by very strong values related to giving and receiving state of flux when securing health-care services. They rely on their own care. tradition to diagnose and sometimes treat illnesses, while simultaneous- The Amish culture also sanctions time out for illness when the sick are ly seeking technical and scientific services from professional health-care relieved of their responsibilities by others who minister to their needs. A providers. good analogy to the communal care of the ill is found in the support of- Journal of Nur & Res 2021 Volume 2 | Issue 5 | 79 Most Amish consult within their community to learn about physicians, Nature. dentists, and nurses with whom they can develop trusting relationships. 15. Wang, L. C. (2020). Religious prohibition and sacrifice: Evidence For more information on this practice, see the Amish informants’ percep- from the Amish restriction on high school education. Journal of De- tions of caring physicians and nurses in Wenger’s (1994) chapter and arti- mographic Economics, 86, 403–434. doi:10.1017/dem.2020. cle on health and health-care decision making. Amish prefer health-care 16. Thalheimer, S. 2021. A little more in the world: Why Amish parents providers who discuss their health-care options, giving consideration to choose to send their Children to public schools. Journal of Amish cost, need for transportation, family influences, and scientific information. and Plain Anabaptist Studies 9: 27-54. They also like to discuss the efficacy of alternative methods of treatment, 17. Johnson-Weiner, K. (2015). Old Order Amish education: The Yoder including folk care. When asked, many Amish claim that health-care pro- decision in the 21st century. Journal of Amish and Plain Anabaptist viders do not want to hear about non-traditional health-care modalities Studies, 3: 25-44. that do not reflect dominant American health-care values. 18. Adams, C. E., & Loverland, M. B. (1986). The effects of religious -be liefs on the health care practices of the Amish. Nurse Practitioner, Amish hold all health-care providers in high regard. Health is integral to 11: 58-67. their religious beliefs and care is central to their worldview. They tend to 19. Hostetler, J.A. (1993). Amish society (4th ed.). Baltimore, MD: Johns place trust in people of authority when they fit their values and beliefs. Hopkins University Press. Because Amish are not sophisticated in their knowledge of physiology 20. Meyers, T.J., & Nolt, S.M. (2005). An Amish patchwork: Indiana’s Old and scientific healthcare, the provider who gains their trust should con- Orders in a modern world. Bloomington, IN: Quarry Books, Indiana sider that because the Amish respect authority, they may unquestioning- University Press. Kraybill, (2001). The riddle of Amish culture. ly follow orders. Therefore, health-care providers should make sure that 21. Huffins, M.L. (1994). Seventy-five years of Amish studies their patients understand instructions. Role modeling and other concrete 22. Enninger, W., & Wandt, K.-H. (1982). Pennsylvania German in the teaching strategies are recommended to enhance understanding. context of an Old Order Amish settlement. Yearbook of German American Studies, 17: 123–143. Pleasure Reading Novels 23. Wenger, A.F.Z. (1988). The phenomenon of care in a high-context A number of pleasures reading novels are available from Amazon.com and culture: The Old Order Amish. Doctoral dissertation, Wayne State Barnes and Nobles. Search for Amish novels. The novels depict the Amish University. Dissertation Abstracts International, 50/02B. culture is various setting. Many of them center around family life, mar- 24. Wenger, A.F.Z. (1991c). The role of context in culture-specific care. In riage, and love stories. P.L. Chinn (Ed.), Anthology of caring (pp. 95–110). 25. Kraybill, D.B. (2001). The riddle of Amish culture (rev. ed.). Balti- more, MD: Johns Hopkins University Press. References 26. Hostetler, J.A. (1993). Amish society (4th ed.). Baltimore, MD: Johns 1. Kreps, M.W., Donnemeyer, J.F., & Kreps, G.M. (1997). A contempo- Hopkins University Press. rary view of Amish society. 27. About Amish (2012). An Amish Handshake. Retrieved from saloma- 2. Powell, A. (2020). Amish origins, beliefs, and lifestyle: History of furlong.com. Europe migration to the US and the Amish lifestyle. Retrieved 28. Nolt, S. (2016). The Amish: A concise introduction. Baltimore, MD: fromhttps://www.learnreligions.com/guide-to-the-amish-life- Johns Hopkins University Press. style-2707217 29. Amish Family Life (2021). Retrieved from https://ohioamish coun- 3. Sawe, B.E. (2017, August 1). US States by Amish Population. Re- try.com/articles/amish-family life. trieved from https://www.worldatlas.com/articles/us-states-by- 30. Purnell, L. (2020). The Purnell model and theory for cultural compe- amish-population.html tence. Textbook for transcultural health care: A population approach. 4. Kraybill, D.B, Johnson-Weiner, K., & Nolt, S.M. (2010) Amish Stud- (2020). Springer Nature. ies. Young Center for Anabaptist and Pietist. 31. Weyer, S.M., Hustey, V.R., Rathbun, L., Armstrong, V. l., Reed, S. A., 5. Amish Population by State. (2021). Retrieved from https://worldpop- Ronyak, J., & Savrin, C. (2013). A look into the Amish culture: What ulationreview.com/state-rankings/amish-population should we learn. Journal of Transcultural Nursing, 2: 139-145. 6. Lee, C. (2017). What are some of the sects of Amish people? (2017). 32. Peaceful societies, (2006). Retrieved from https://peacefulsocieties. Retrieved from https://classroom.synonym.com/what-are-some-of- uncg.edu/ the-sects-of-amish-people-12087067.html 33. Andreoli, E. M., & Miller, J. S. (1998). Aging in the Amish Commu- 7. Amish America.com. Retrieved from https://amishamerica.com/ nity. Nursing Connections, 11: 5-11. who-are-the-andy-weaver-amish/comment-page-1/ 34. Wenger, A.F.Z. (1991a). The culture care theory and the Old Order 8. Hurst, C.H.& McConnel D.L. An Amish paradox: Diversity and Amish. In M.M. Leininger (Ed.), Cultural care diversity and univer- change in the world’s largest Amish community (Young Center sality: A theory of nursing (pp. 147–178). New York: National League Books in Anabaptist and Pietist Studies). for Nursing 9. Amish Dress. (2010). Retrieved from https://amishamerica.com/ 35. Wenger, A.F.Z. (1991b). Culture-specific care and the Old Order why-do-the-amish-wear-plain-clothing/ Amish. Imprint, 38: 81–82, 84, 87, 93. 10. Amish and Tractors. (2020). Retrieved from AmishReader.com. 36. Kraybill, D.B, Johnson-Weiner, K., & Nolt, S.M. (2010) Amish Stud- 11. 11. Granville, K. & Gilbertson, A. (2017). In Amish Country, the ies. Young Center for Anabaptist and Pietist. Future is Calling. New York Times, (166) 57723, 9/17/2017. Sunday 37. Kraybill, D.B., Johnson-Weiner, K. & Nolt, S. (2013). The Amish. Bal- Business. p. 6-7. timore, MD: John Hopkins University Press. 12. Purnell, L. (2020). The Purnell model and theory for cultural compe- 38. Stevick, R. (2014). Growing Up Amish: The rumspringa years (Young tence. Textbook for transcultural health care: A population approach. Center Books in Anabaptist and Pietist Studies. 2nd ed. Baltimore, (2020). Springer Nature. MD: John Hopkins University Press. 13. Beachy Amish – Mennonites. (2020). Retrieved from www.beachyam. 39. Mendez Ruiz, A. (2017). The Amish rule of order: Conformity and org deviance among Amish youth. Arcadia University Scholar Works, 14. Nelson-Tuttle, C. (2021). People of Amish heritage, chapter 7, pp. Arcadia University, Glenside. 187-216. In L. Purnell & E. Fenkl Chapter 7 (pp.187-2169). Springer 40. Choy, J.P. (2020). Religious rules as a means of strengthening family Journal of Nur & Res 2021 Volume 2 | Issue 5 | 80 ties: Theory and evidence from the Amish. Journal of Comparative Health risk factors among Amish: Results of a survey. Health Educa- Economics 48: 729-748. tion Quarterly, 17: 197–211. 41. Wenger, A.F.Z. (1988). The phenomenon of care in a high-context 65. Nelson-Tuttle, C. (2021). People of Amish heritage, chapter 7, pp. culture: The Old Order Amish. Doctoral dissertation, Wayne State 187-216. In L. Purnell & E. Fenkl Chapter 7 (pp.187-2169). Springer University. Dissertation Abstracts International, 50/02B. Nature. 42. Kraybill, D. (2019). The Amish of Lancaster County. 2nd ed. Guil- 66. Sharpnack, P., Quinn, G., Benders, A., Fitzpatrick, J. (2010). Spiritual ford, CT: Stackpole Books. and Alternative Healthcare Practices of the Amish. Holistic Nursing 43. Purnell, L. & Fenkl, E. (2019). Handbook for culturally competent Practice, 24: 64-72. care. Springer Nature. 67. Wenger, A.F.Z. (1995). Cultural context, health and health-care deci- 44. LGBTAmish.com. (2021). sion making. Journal of Transcultural Nursing, 7: 3–14. 45. McConnell, D. L. (2001). Retrieved from groups.etown.edu/amish- 68. Hairston, K., Ducharme, J., Treuth, M., Hsueh, W., Jastreboff, A., et al. studies/experts/david-l-mcconnell. (2013). Comparison of BMI and physical activity between old order 46. Katz, M.L., Ferketich, A.K., Broder-Oldach, B. et al. (2012). Physi- Amish children and non-Amish children. Diabetes. 36: 873-878. cal activity among Amish and Non-Amish adults living in Ohio Ap- 69. Strotmeyer, S., Koff, A., Honeyman, J.N. (2019) Injuries among palachia. Journal of Community Health 37: 434–440, doi:10.1007/ Amish children: Opportunities for prevention. Injury Epidemiology, s10900-011-9460-9. 6, (49) doi:10.1186/s40621-019-0223-x. 47. Sawe, B.E. (2017, August 1). US States by Amish Population. Re- 70. Scott, E. M., Stein, R., Brown, M.F., Hershberger, J., & Scott, E., & trieved from https://www.worldatlas.com/articles/us-states-by- Wenger, O.K. (2021). Vaccination patterns of the Northeast Ohio amish-population.html Amish revisited. Vaccine, 39: 1058-1063. 48. Johnson-Weiner, K. (2015). Old Order Amish education: The Yoder 71. United States Amish and Pennsylvania Dutch (2010). Retrieved decision in the 21st century. Journal of Amish and Plain Anabaptist March 27, 2010, from http://www.foodbycountry.com/Spain-to-Zim- Studies, 3: 25-44. babwe-Cumulative-Index/United-States-Amish-and-Pennsylvania- 49. Strauss, K. (2015). Genomics for the People. Science American, 313: Dutch.html 66-73. 72. Lemon, E. S. (2006). Amish healthcare practices in an obstetric set- 50. Bass, P., & Waggoner, D. (2018). Red flags for genetic disorders. Con- ting. temporary Pediatrics, 35: 22-25. 73. Campanella, K., Korbin, J.E., & Acheson, L. (1993). Pregnancy and 51. Strauss, K., Puffenberger, E., & Morton, D. (2012). One community’s childbirth among the Amish. Social Science Medicine, 36: 333-342. effort to control genetic disease. American Journal of Public Health, 74. Adams, C. E., & Loverland, M. B. (1986). The effects of religious -be 102: 1300-6. liefs on the health care practices of the Amish. Nurse Practitioner, 52. Troyer, H. (1994). Medical Considerations of the Amish. Internal and 11: 58-67. perspectives on the Amish and Mennonite life. University of Essen, 75. Elajami, T., Giuseffi, J., Avila, M., Hovnanians, N., Mukamal, K., et al. Essen, 68-78. (2016). Parity, coronary heart disease and mortality in the Old Order 53. Baby, T., Pillai, R., Bindhu, P.R., & Thomas, P. (2016). Ellis-van Crev- Amish. Atherosclerosis, 254: 14-19. eld Syndrome: A case report of two brothers. Oral and Maxillofacial 76. Myers, T.J. & Nolt, S. (2005), An Amish patchwork: Indiana’s Old Or- Pathology Journal, 7: 698-701. ders in a Modern World. Quarry Books. Indiana University Press, 54. Riley, P., Weiner, D., Leighley, B., Jonah, D., Morton, D.H., et al. Bloomington. (2015). Cartilage hair hypoplasia: characteristics and orthopedic 77. Lipon, T. (1985). Husband and wife work roles and the organization manifestations. Journal of Children’s Orthopedics, 9: 145-152. and operation of family farms. Journal of Marriage and Family, 47: 55. Ratnoff, O.D. (1958). Hereditary defects in clotting mechanisms. Ad- 759-764. vances in Internal Medicine 9: 107-109. 78. Kraybill, D.B., & Hostetter, C.N. (2001). Anabaptist World USA. 56. Ketterling, R.P., Bottema, C.D., Koberl, D.D., Setsuko. I, & Sommer, Scottdale, PA: Herald Press. S.S. (1991). T296M, a common mutation causing mild hemophilia B 79. Wenger, A.F. (1980). Acceptability of perinatal services among the in the Amish and others: Founder effect, variability in factor IX activ- Amish. Paper presented at a March of Dimes symposium, Future Di- ity assays, and rapid carrier detection. Human Genetics, 87: 333–337. rections in Perinatal Care, Baltimore, MD. 57. Martin, P.H., Davis, L., & Askew, D. (1965). High incidence of phe- 80. Lucas, C.A., O’Shea, R.M., Zielezny, M.A., Freudenheim, J.L., & nylketonuria in an isolated Indiana community. Journal of the Indi- Wold, J.F. (1991). Rural medicine and the closed society. New York ana State Medical Association, 56: 997–999. State Journal of Medicine, 91: 49–52. 58. Allen, F. (1989). Country doctor: How a physician solved the riddle 81. Miller, N.L. (1997). Childbearing practices as described by Old Order of rare disease in children of Amish. Wall Street Journal, September Amish Women. Dissertation Abstracts International, UMI 1388555. 20, pp. 1, A16. 82. Chichester, M. (2005). Multicultural issues in perinatal loss. Nursing 59. Wolkomir, R., & Wolkomir, J. (1991). The Doctor Who Conquered a for Women’s Health, 9: 312-320. Killer. Reader’s Digest, 139: 161-166. 83. Meyers, T.J., & Nolt, S.M. (2005). An Amish patchwork: Indiana’s Old 60. Teapole, B. (2019). Amish perspectives of the counseling process. Orders in a modern world. Bloomington, IN: Quarry Books, Indiana 61. Gill, K., Cardenas, S., Kassem, L., Schulze, T., & McMahon, F. University Press. Kraybill, (2001). The riddle of Amish culture. (2016). Symptom profiles and illness course among Anabaptist and 84. Cox, K.J., Schlegel, R., Payne, P., Teaf, D., & Albers, L. (2013). Out- Non-Anabaptist adults with major mood disorders. International comes of planned home births attended by certified midwives in Journal of Bipolar Disorders, 4: 1-7. southeastern Pennsylvania – 1983-2008.Journal of Midwifery & 62. Foroud, T., Casteluccio, P., Kollar, D., Edenberg, H., Miller, M., & Women’s Health, 58: 145-149. Boman, L. (2000). Suggestive evidence of a locus on chromosome 85. Chichester, M. (2007). Perinatal autopsy. Maternal child health 12: 10p using the NIMH genetics initiative bipolar affective disorder 81-86. pedigrees. American Journal of Medical Genetics, 96: 18–23. 86. Chichester, M., & Wool, C. (2015). The meaning of food and mul- 63. Lantz, G. (2019). Perception of lifestyle as mental health protective ticultural considerations for perinatal palliative care. Nursing for factors among Midwestern Amish. Women’s Health 19: 226-235. 64. Fuchs, J.A., Levinson, R., Stoddard, R., Mullet, M., & Jones, D. (1990). 87. Farrar, H., Kulig, J., & Sullivan-Wilson, J. (2018). Older adult caregiv- Journal of Nur & Res 2021 Volume 2 | Issue 5 | 81 ing in the Amish: An integrative review. Journal of Cultural Diversity, Panel on Census Requirements in the Year 2000 and beyond. Wash- 25: 54-65 ington, DC: National Academy Press. 88. Amish on Death and Dying. (2021). Retrieved from 116. Ehrenberg, S., Vockley, C.W., & Nelson, E., Baker, J., Arciere, M., 89. Choy, J.P. (2021). APAS Webinar. Lindberger, J., & Ghaloul-Gonzalez, L. (2021). Under-referral of 90. Kraybill, D.B. (2019). Riddle of Amish culture. Plain community members for genetic services despite being qual- 91. Lindholm, Rev. W. US Supreme Court Case: Is There Religious Free- ified for genetic evaluation. Journal of Genetic Counseling (2021). dom in America-for the Amish? http:// amishreligiousfreedom.com, Wiley Periodicals. DOI: 10.1002/jgc4.1395 retrieved 11-20-2019. The freedom of religion guarantee of the Con- 117. Ericksen, J. A., Ericksen, E.P., Hostetler, J. A., & Huntington, G. E. stitution of the United States. (1979) Fertility patterns and trends among the Old Order Amish. 92. Amish Religious Traditions. (2021). Retrieved from https://www.dis- Population Studies 33: 255–276. coverlancaster.com/amish/religious-traditions/ 118. Ehreberg, S., Walsh Vickery, C., Nelson, J., Baker, J., Arcerri, M., Lin- 93. Complete Coverage Nickel Mines disaster, (2006). Retrieved denberger, J, & Ghaloul-Gonzales, L. (2020). Under-referral of plain from https://www.google.com/search?rlz=1C1CHBF_enU- community Members for genetic services despite being qualified for S842US842&q=complete+coverage+nicole+mines+disas- genetic evaluation. (2021). Journal of Genetic Counseling, 2021: 1–7. ter&spell=1&sa=X&ved=2ahUKEwjq95iq5PPxAhVXOs0KHcCY- https://doi. org/10.1002/jgc4.139. BucQBSgAegQIARA1&biw=983&bih=471 119. Enninger, W., & Wandt, K.-H. (1982). Pennsylvania German in the 94. How are Amish Communities Organized (2021). Retrieved from context of an Old Order Amish settlement. Yearbook of German https://amishamerica.com/how-are-amish-communities-organized/ American Studies, 17: 123–143. 95. Amish Church District. (2021). Retrieved from https://amishameri- 120. Granville, K. & Gilbertson, A. (2017). In Amish Country, the Future ca.com/the_amish_churc/ is Calling. New York Times, (166) 57723, 9/17/2017. Sunday Busi- 96. Amish Clothing. (2021). Retrieved from https://amishamerica.com/ ness. p. 6-7. clothing/ 121. Hostetler, J.A. (1994). Amish Society (4ed.). 97. Wenger, A.F.Z. (1991c). The role of context in culture-specific care. In 122. Hurst, E., & McDonnell, D.L. (2011). An Amish Paradox. P.L. Chinn (Ed.), Anthology of caring (pp. 95–110). 123. Huffins, M.L. (1994). Seventy-five years of Amish studies. 98. McIntyre, K. (2014). Cultural Diversity – Healthcare and the Amish. 124. Johnson-Weiner, K. (2014). Technological diversity and cultural Retrieved from Cultural Diversity - Health Care & The Amish (slide- change among contemporary Amish groups. Mennonite Quarterly share.net) Review, 88: 5-22. 99. Škender, V. (2020). “Flesh, Freundschaft, and Fellowship: Towards a 125. Kreps, M.W., Donnemeyer, J.F., & Kreps, G.M. (1997). A contempo- Holistic Model of the Amish Kinship System. Journal of Amish and rary view of Amish society. Plain Anabaptist Studies 8: 1-22. 126. Lee, C. (2017). What are some of the sects of Amish people? (2017). 100. Rohr, J.M., Spears, K.L., Geske, J. (2019). Utilization of health care re- Retrieved from https://classroom.synonym.com/what-are-some-of- sources by the Amish of a rural county in Nebraska. Journal of Com- the-sects-of-amish-people-12087067.html munity Health 44: 1090–1097. doi:10.1007/s10900-019-00696-9. 127. Lutz, M. (2017). The Amish in the Market: Competing against the 101. Ems, L. (2014). Amish workarounds: Towards a dynamic, contextu- Odds? American Studies Journal, 63: 1-7. alized view of technology use. Journal of Amish and Plain Anabaptist 128. McKusick, V.A., Egeland, J.A., Eldridge, D., Krusen, E.E., (1994). Studies, 2: 42-58. Dwarfism in the Amish: The Ellis van Creveld Syndrome. Bull John 102. Ems, L. (2019). Amish philosophies on information communication Hopkins Hospital, 115: 306-330. technology design and use. In CHI’19 Extended Abstracts: standing 129. Mong, M. & Clifton, J.M. Modern dress through the eyes of seven on the shoulders of giants: Exploring the intersection of philosophy conservative Mennonite women. The Voices of Plain Anabaptist Peo- and HCI. Retrieved from https://doi.org/10.1145 ple (9,1). 103. Cates, J. (2014). Serving the Amish. Baltimore, MD: Johns Hopkins 130. Morton, D.H. (2011). The Glutaric Acidurias of the Amish A Sense of University Press. Progress 1988-2011. Retrieved from GA1 A Sense of Progress 1988- 104. Nelson, W.A. (1999). A Study of Amish Women’s Construction of 2011 (etown.edu) Health Narratives. Kent State University. 131. Nolt, S. (2015). A history of the Amish. Goodbooks Publishing, New 105. Amish America.com. Retrieved from https://amishamerica.com/ York. who-are-the-andy-weaver-amish/comment-page-1/ 132. Ohio’s Amish Community (2020). Retrieved from Amish family life | 106. https://amishtraditions.com/index.php/2018/11/15/the-amish-on- Ohio’s Amish Country (ohiosamishcountry.com) death-and-dying/ 133. Powell, A. (2020). Amish origins, beliefs, and lifestyle: History of 107. Amish Dress. (2010). Retrieved from https://amishamerica.com/ Europe migration to the US and the Amish lifestyle. Retrieved why-do-the-amish-wear-plain-clothing/ fromhttps://www.learnreligions.com/guide-to-the-amish-life- 108. Amish Population by State. (2021). Retrieved from https://worldpop- style-2707217 ulationreview.com/state-rankings/amish-population 134. Purnell, L. & Fenkl, E. (2019). Handbook for culturally competent 109. Amish and Tractors. (2020). Retrieved from AmishReader.com. care. Springer Nature. 110. Amish Studies. Young Center for Anabaptist & Pietist Studies, Eliza- 135. Rivka, Neriya Ben-Shahar (2021). ‘I am just a part of the community’: bethtown College, 2020. Amish and ultra-orthodox women and the third person perception. 111. Beachy Amish – Mennonites. (2020). Retrieved from www.beachyam. Journal of Amish and Plain Anabaptist Studies 9: 83-98. org 136. Thalheimer, S. 2021. A little more in the world: Why Amish parents 112. Cates, J. A. (2014). Serving the Amish: A cultural guide for profes- choose to send their Children to public schools. Journal of Amish sionals. Johns Hopkins University Press. and Plain Anabaptist Studies 9: 27-54. 113. Do Amish pay taxes? Retrieved from amishamerica.com. 137. Wang, L. C. (2020). Religious prohibition and sacrifice: Evidence 114. Edmonston, B. (2002) The Undercount in the 2000 Census. Balti- from the Amish restriction on high school education. Journal of De- more, Maryland: The Annie E. Casey. a. Foundation and the mographic Economics, 86, 403–434. doi:10.1017/dem.2020. Population Reference Bureau. 115. Edmonton, B., & Schultze, C. (1995) Modernizing the U.S. Census: Journal of Nur & Res 2021 Volume 2 | Issue 5 | 82 Books Resources 4. Journal of Amish and Plain Anabaptist Studies. The journal is pub- 1. Kraybill, D.B., Nolt, S.M., & Weaver-Zercher, D.L. (2007). Amish lished twice a year by the Amish & Plain Anabaptist Studies Associ- grace: How forgiveness transcended tragedy. San Francisco, CA: John ation (http://amishstudies.org) in collaboration with the University Wiley and Sons. of Akron. 2. Hurst, C.H.& McConnel D.L. An Amish paradox: Diversity and 5. Amish Awareness Conference is an annual conference (since 2017) change in the world’s largest Amish community (Young Center focusing in Amish and Anabaptist cultures and societies. https:// Books in Anabaptist and Pietist Studies). www.amishawareness.com 3. Nolt, S. (2015). A history of the Amish. New York, New York: Good- books Publishing.

*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. Journal of Nur & Res 2021 Volume 2 | Issue 5 | 83