12 minute read
The Amish and Healthcare
A Cultural Review and Communication Considerations for Healthcare Providers
DCMS Central PA Medicine
Tuesday, July 5, 2022
Name
Credentials
Sarah Hershberger
BS, BA
shershberger@pennstatehealth.psu.edu
Bio
Sarah Hershberger is a fourth-year medical student at Penn State University. She is interested in primary care, combating healthcare disparities, and improving communication strategies with patients.
Headshot
By SARAH HERSHBERGER, BS1, AND BERNICE HAUSMAN, PHD1
Department of Humanities, Pennsylvania State University College of Medicine, Hershey, PA, U.S.A.
Introduction
I still vividly remember the first train ride of my life. I was just a child and baffled by the sights, the speed, and the diversity of the people. My family and I were on our way to Tijuana, Mexico, and it was the first time I had left my home community in rural Indiana. This was not a traditional family vacation, though; it was a journey to access medical care for my father, who urgently needed a kidney operation. In Tijuana, the costs of care were lower, and the physicians had previously worked with other members of our community. We lived in a country with one of the most esteemed medical systems in the world, but we had no trust in it. We were an Amish family who did not feel understood or cared for by our Western medical system.
It would be years before I realized the implications of this story. As a medical student now evaluating the effects COVID-19 has had on our surrounding communities and their trust in medicine, I am reminded of the cultural differences that continue to impact how Amish populations access care and their attitudes towards mainstream medicine. As healthcare in rural contexts draws increased attention and rural healthcare workers interact more with these growing Amish communities, it is important for providers to understand both the shared features and differences between various Amish communities. There is still much to be explored about providing culturally competent care to and preventing misunderstanding about the Amish, especially their relationship to modern Western medicine. This article aims to review the common cultural themes and practices of Amish communities, and then discuss approaches to improving communication and healthcare. My experience of having grown up Amish affords me the unique perspective of a cultural insider, which is especially useful now as a medical student enrolled at an institution in a rural area with large adjacent Amish communities.
Origin and Demographics
The Amish are direct descendants from the Swiss Anabaptists, a group originating during the Radical Reformation of the seventeenth century. Their distinguishing beliefs included living simplistic lives and opposing infant baptism.1 The Amish became a distinct group in 1693 when Jacob Amman and his followers shunned excommunicated members to maintain a strict community within the church.2 Persistent persecution in Europe resulted in a mass emigration of the Amish to North America in the early eighteenth century, where, over time, they divided into Old Order and New Order Amish.1,2 A second wave of immigration then occurred during the nineteenth century.
Amish population studies have shown that their overall population doubles nearly every twenty years.3 2020 estimates found there are approximately 345,000 Amish in the United States, most notably within rural Pennsylvania, Ohio, and Indiana 3. Much of this growth is explained by the average Amish family having seven children and communities retaining over 80% of their youth.4 With this growth, over 2,500 different Amish districts now exist within this larger subculture across the United States.3 The districts that share similar beliefs and lifestyle regulations form more than 40 “affiliations,” which are groups of districts interlinked by shared practices across many geographic locations.5
Core Beliefs
The Amish are a religious and community-oriented group, with many shared values and a shared primary language (Pennsylvania German). They follow traditional Christian beliefs that prioritize accepting simplicity, humility, and nonviolence as core biblical teachings, believing that separation from the “outside world” is necessary to ensure these virtues are achieved.6,7 Shunning, where all contact is terminated with individuals who willfully and repeatedly violate Amish guidelines, is practiced by most districts. Shunning is believed to help excommunicated members recognize their errors, while also preventing unaccepted beliefs or actions from infiltrating and harming others within the community.8
The Amish are known for their strict rejection of modern technology and their plain dress. They regulate the use of any electricity, automobiles, tractors, phones, televisions, and other modern technologies. They aspire to avoid any “worldliness” within their communities, which they define as anything that seeks convenience, praises material things, or self-enhances.7 Yet modern conveniences are all evaluated for their potential uses, and some are even integrated into communities. Community members reach
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a consensus about how something would impact their community and collective social patterns to form a decision about whether or not it can be utilized within their district.9 Districts near each other often reach different agreements, ranging from if they will allow members to have landline phones, bicycles, or even different clothing designs. This adds to the diversity within the overall Amish community and allows districts to have independence on their respective lifestyle decisions.
Amish schools serve as a major socialization domain, alongside community and family, and are essential for reinforcing Amish values and beliefs.10 Amish children are formally educated to an eighth-grade level by attending parochial schools taught by members of the community; a Supreme Court ruling in Wisconsin v. Yoder in 1972 provided a religious exemption from further education.10,11 After finishing school, most Amish men work in construction or agricultural jobs while women are primarily homemakers and caregivers for children.7
Healthcare and Vaccinations
The Amish view health in terms of ability to work and contribute to the community, and it is considered a gift from their God.12 Preventative medicine, such as vaccinations, cancer screenings, and prenatal care, is not generally prioritized. If nonemergent problems do arise, Amish are likely to initially use complementary and alternative medicine, like salves, herbs, supplements, and spiritual practices.12,13 Modern medicine may be concurrently used if the benefit is clear and understood.6,12 However, functional health literacy has also been found to be lower within the Amish than the general population, which may contribute to their lower rates of healthcare utilization.14
The Amish have a religious exemption from traditional insurance and social security, so most will utilize mutual aid within their immediate and nearby districts to finance medical costs.15 In addition to paying out-of-pocket costs, securing travel arrangements can be a complicating logistic in accessing care. They often must hire drivers as an alternative to their horse-drawn carriages. While cost of access may be one reason Amish frequently prefer to use CAM, there is also an underlying distrust of American medical institutions, doctors, and pharmaceutical companies.12
Amish churches provide no direct guidance on vaccination, but a variety of cultural and personal beliefs result in Amish communities having lower rates of vaccination than non-Amish.16,17 Lower vaccination rates have been correlated with well-documented outbreaks of preventable infections, such as the outbreaks of measles, rubella, Haemophilus influenzae, polio, and pertussis, in various Amish communities.18-22 High vaccination uptake in response to prior community outbreaks has occurred historically, suggesting Amish families may be more inclined to receive vaccinations if the direct benefit to their community and the potential to endanger others is apparent.18
A 2011 study focusing on the largest Amish settlement in the United States (Holmes County, Ohio) found that only 45% of members were fully vaccinated, compared to 85% of the nonAmish population, and only 14% of Amish families denied all vaccines at that time.17 An updated study in 2021 found that now 59% of Amish families in the same community refused all vaccines, and only 25% were open to receiving COVID-19 vaccinations.23 In both periods, the most common reason for nonvaccination was parental concern of adverse effects.17,23 The drastic increase in nonvaccination highlights the flawed outreach of our medical system towards Amish communities, who do not refuse vaccination categorically based on religious belief, as is often surmised.
Approaches to Care
The COVID-19 pandemic has highlighted disparities in healthcare access across many communities, but reactive responses during an ongoing pandemic are insufficient for lasting solutions. After a COVID-19 outbreak in an Amish community in May 2020 brought these disparities to the forefront, the Centers for Disease Control and Prevention (CDC) issued a call for improving longitudinal relationships with Amish community leaders, which involves ensuring educational materials, testing, and care can be accessed and interpreted by Amish individuals.24 To achieve this goal, healthcare personnel and institutions need to approach these communities with culturally competent solutions.
COVID-19 provides important lessons about existing obstacles. Most of the guidelines intended to slow the spread of COVID-19 have been less feasible for Amish communities. Their collectivistic culture generates a broad definition of “family,” which emphasizes communal activities.25 Social-distancing and isolating for periods of quarantine are therefore not always possible, especially due to the large and multigenerational families who often live together. When considering their foundational, community-based social organization, public health guidance and vaccination campaigns for Amish communities should center on the benefit these actions have for others within the community.
For long-term connections, open and nonjudgmental communication about healthcare is essential for establishing and maintaining trusting relationships with Amish patients. Consider conversations pertaining to use of complementary and alternative medicine (CAM), which Amish patients utilize at high rates. Most physicians only receive training on the limitations of these approaches. Providers in areas that include Amish communities should educate themselves about common forms of CAM: herbal medicines, acupuncture, chiropractic, or naturopathy. These therapies are integral to many Amish communities and understanding their use and limitations may be key to maintaining open communication with patients.26 Being dismissive of CAM without a medical justification can impair developing trust in allopathic medicine for patients who are more comfortable with CAM.
Cost of care often influences how Amish patients choose to access care since most Amish communities opt for mutual aid funding instead of insurance.15 Costs of CAM are often upfront and known by the patients, while allopathic medicine can be difficult to predict. Being open and mindful of cost considerations of treatment options with Amish patients is therefore imperative for establishing trust.
Extra caution should also be used when assessing patient understanding to account for potentially lower health literacy and use of English as a second language. Practitioners may falsely assume that disagreements about care can be swayed with facts and medical information, but Amish people often use a different value system that centers their community’s beliefs when making decisions.27 While allopathic medicine is based on objective data, Amish patients may instead center their community’s acceptance and social beliefs in their decision-making. They often do not compare the relative trustworthiness of sources using the scientific method physicians are taught, but instead
a values system instilled through their religious and social groups.27 Framing the importance of these values into discussions with Amish patients can help establish trust without overshadowing the influence of their community.
My own family’s experience seeking medical care continues to resonate today and proves to be a common experience for many Amish families. While there is no instantaneous solution, ongoing effort and outreach are necessary to reach the underserved communities our healthcare system often neglects. This starts at the level of individual providers prioritizing communication with Amish patients that is culturally informed with the intention of developing mutual trust.
References:
1. Guss J. Persecution, division, and opportunity: The origins of the Old Order Amish. Pennsylvania Center for the Book; 2007. 2. Amish in America. PBS; 2012. 3. Young Center for Anabaptist and Pietist Studies EC. Amish Population Profile, 2020. http://groups.etown.edu/amishstudies/statistics. 4. Meyers TJ. The Old Order Amish: To remain in the faith or to leave. The Mennonite Quarterly Review; 1992. p. 1-22. 5. Studies YCfAaP. Organization. http://groups.etown.edu/ amishstudies/social-organization/organization/: Elizabeth College; 2021. 6. Banks MJ, Benchot RJ. Unique aspects of nursing care for Amish children. The American Journal of Maternal Child Nursing; 2001. p. 192-6. 7. Hostetler JA. Amish Society: Fourth Edition. The Johns Hopkins university Press; 1993. 8. Young Center for Anabaptist and Pietist Studies EC. Church Discipline. Elizabeth College. 9. Kidder RL, Hostetler JA. Managing ideologies: Harmony as ideology in Amish and Japanese societies.: Law and Society Review; 1990. p. 895-922. 10. Anderson C. Amish education: A synthesis. Journal of Amish and Plain Anabaptist Studies; 2015. p. 1-24. 11. McConnell DL, Hurst CE. No “Rip van Winkles” Here: Amish Education since “Wisconsin v. Yoder”. Anthropology & Education Quarterly; 2006. p. 236-254. 12. Anderson C, Potts L. The Amish health culture and culturally sensitive health services: An exhaustive narrative review. Social Science & Medicine; 2020. 13. von Gruenigen VE, Showalter AL, Gil KM, Frasure HE, Hopkins MP, Jenison EL. Complementary and alternative medicine use in the Amish Complementary Therapies in Medicine; 2001. p. 232-233. 14. Katz ML, Ferketich AK, Paskett ED, Bloomfield CD. Health literacy among the Amish: Measuring a complex concept among a unique population. 2013. p. 753-8. 15. Rohrer K, Dundes L. Sharing the load: Amish healthcare financing. Healthcare. 2016;4(4)doi:10.3390/ healthcare4040092 16. Yoder JS, Dworkin MS. Vaccination usage among an old-order Amish community in Illinois. Pediatric Infectious Disease Journal; 2006. p. 1182-3. 17. Wenger OK, McManus MD, Bower JR, Langkamp DL. Underimmunization in Ohio’s Amish: Parental Fears Are a Greater Obstacle Than Access to Care Pediatrics; 2011. p. 79-85. 18. Gastañaduy PA, Budd J, Fisher N, et al. A measles outbreak in an underimmunized Amish community in Ohio. New England Journal of Medicine; 2016. p. 1343-1354. 19. Briss PA, Fehrs LJ, Hutcheson RH, Schaffner W. Rubella among the Amish: resurgent disease in a highly susceptible community. Pediatric Infectious Disease Journal; 1992. p. 955-959. 20. Fry AM, Lurie P, Gidley M, et al. Haemophilus influenzae Type b disease among Amish children in Pennsylvania: Reasons for persistent disease. Pediatrics; 2001. 21. Prevention TCfDCa. Poliovirus infections in four unvaccinated children— Minnesota, August-October 2005. Journal of the American Medical Association; 2005. p. 2689-91. 22. Etkind P, S.M. L, Macdonald PD, Silva E, Peppa J. Pertussis outbreaks in groups claiming religious exemptions to vaccinations. 1992. p. 173-6. 23. Scott EM, Stein R, Brown MF, Hershberger J, Scott EM, Wenger OK. Vaccination patterns of the northeast Ohio Amish revisited. Vaccine; 2021. p. 1058-63. 24. Ali H, Kondapally K, Pordell P, et al. COVID-19 Outbreak in an Amish Community - Ohio, May 2020. US Department of Health and Human Services/Center for Disease Control and Prevention: Morbidity and Mortality Weekly Report; 2020. p. 1671-74. 25. Kraybill DB, Johnson-Weiner KM, Nolt SM. The Amish. Johns Hopkins University Press; 2013. 26. Steyer T. Complementary and alternative medicine: A primer. Family Practice Management: AAFP; 2001. p. 37-42. 27. Saudner M. Choosing whom to trust: Autonomy versus reliance on others in medical decision making among plain Anabaptists. Journal of Amish and Plain Anabaptist Studies; 2020. p. 59-64.
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