The Amish Health Culture and Culturally Sensitive Health Services: An Exhaustive Narrative Review

Abstract

As the Amish population is growing exponentially, researcher and practitioner interest in Amish health is also growing. This is largely due to demand from practitioners for population-specific cultural guidance. Once a small area of study, health-themed publications in Amish studies (n=246) now account for approximately one-fourth of all peer-reviewed publications, and a sizeable percentage address the health culture, i.e. Amish beliefs, practices, attitudes, decision-making processes, financing, and values. In this article, we provide a first-ever exhaustive, narrative review of the Amish health culture literature (addressing Amish health conditions elsewhere). Specifically, we address Amish use of modern medicine, complementary & alternative medicine, support and care for the sick and aged, health knowledge, payment for services, barriers to service access, service provider effectiveness, health programming, and ethical conflicts. Our overreaching goal is to organize the literature, synthesize research findings, identify orienting perspectives, and clarify research questions and directions. Following our synthesis, we reflect on the current state of Amish health culture research, drawing particular attention to strengths and limitations of the oft-used cultural competency paradigm, underexplored questions raised by program/service access studies, gaps in the literature, and the relative in/stability of Amish health culture across time and place.

Introduction

The Amish—a Swiss/German, Anabaptist-Christian people in rural North America—are of increasing interest to health researchers and practitioners. The Amish population is growing and, consequently, expanding (Anderson & Kenda, 2015). With a U.S. population of 241,356 in 2010 (Grammich et al., 2012) and doubling time of 20.5 years, the U.S.-Canadian population should reach 500,000 by 2030 (Donnermeyer, 2015). As rural healthcare providers increasingly interact with Amish, they will need well-researched, informational resources about Amish; such resources are all the more important for rural areas with a limited medical infrastructure (Danis, 2008; Hanlon & Kearns, 2016; L. W. Morton, 2003). In academia, the Amish have provided an opportunity to better understand illness through comparison with non-Amish. Many Amish health studies document how lifestyle patterns attributed to Amish culture and religion may increase or decrease the risk of certain illnesses. Geneticists, in particular, find Amish endogamy ideal for studying inherited health conditions.

Amish health research occupies approximately one-fourth of all Amish-focused publications since 1942, and it is one of two major autonomous subject-areas emerging by 2012 (Anderson, 2017). Not only is the time ripe to review the entire literature, but without periodic reviews, a research area may lose (1) organization, e.g. studies are not embedded in the most relevant literature, (2) coherence, e.g. poorly formulated research questions or use of incompatible measures for similar studies, and (3) direction, e.g., lack of consensus about research questions or unidentified holes in knowledge.

To help bring organization, coherence, and direction to Amish health research, we offer two primary objectives: organize the literature into topical groupings and then offer syntheses of these topics, that is, instigate new research agendas by identifying novel, reoccurring, unresolved, and contradicting assertions (Torraco, 2005). While many reviews begin with a honed research question that guides study inclusion (Cooper, 1998), our review addresses a population and topic, which, though broadly conceived, yet remains purposeful and focused (Whittemore & Knafl, 2005), for our “research problem” is to better organize and understand the multifaceted research about a growing population’s health.

Method

To define the Amish health literature, we used criteria that provided a straight-forward, meaningful formula: research design focuses on “Amish” exclusively or comparatively and the research addresses physical or mental well-being. We then snowball sampled all bibliographies until no new studies emerged. To identify uncited but valuable literature from the past decade, we conducted a date-limited search of the terms “Amish” and “health” in Google Scholar—a wide-spectrum research database that reflected our review’s interdisciplinary orientation—until we reached the search’s limit. We identified 246-health related, peer reviewed publications in journals and edited volumes.

The literature and our goals guided our review format selection. Systematic protocols such as PRISMA (Moher et al., 2009) and statistical meta-analyses (Patall & Cooper, 2008) emphasize a narrow research question, replicability, and epistemologically similar literature (Johnson & Hennessy, 2019; Tranfield et al., 2003), offering generalizable facts that validate scientific predictions. However, we were approaching an epistemologically diverse literature with conceptual goals, rendering common systematic procedures inappropriate (Green et al., 2001; Greenhalgh et al., 2018). Conversely, the narrative review provided needed flexibility. It is a scholar-managed—versus mechanically produced—literature synthesis allowing judicious, meta-based interpretation, reflection, and critique across multiple epistemologies. The end goal is fresh field insight, vis-à-vis Kuhn’s (1962) representation of scientific breakthroughs as paradigm shifts (Ferrari, 2015; Greenhalgh et al., 2018; Torraco, 2005; Whittemore & Knafl, 2005). Narrative reviews also respond well to applied subjects by helping to inform public health and policy workers, who employ multiple perspectives in their work (Greenhalgh et al., 2018; C. J. M. Whitty, 2015b).

We conducted an exhaustive review of the literature for several reasons. First, some topics are underdeveloped; as one objective is to identify topics, omitting several studies could eliminate a topic or omit important evidence. Second, we value reoccurring assertions across the epistemologically diverse literature. While a service provider’s anecdotal study may be methodologically thinner than an ethnographic study, cited alongside a statistical study, the three offer cross-methodological triangulation; or, a practitioner’s anecdotal publication could provide hypotheses that preconceived research designs miss. Third, we avoid identifying a false literature gap. Finally, the narrative approach allows us to manage dubious content on a case-by-case basis; such judicial decision-making frees us to include valuable content otherwise omitted if employing stricter inclusion protocols.

Our analytical protocol consisted of annotating all publications: identifying the research questions, methods, key findings, and Amish settlements/affiliations studied. We conducted several joint sessions where we reviewed annotations, developed topical categories into which we classified annotations (which could occupy multiple categories), and revised categories as needed. Our final categories are the subject headings in the results section. An advantage of this collaborative process was our ability to identify and discuss any disagreements as they arose.

Potential narrative review weaknesses include subjectivity, biased bibliographies, methodological non-disclosure, and rhetorical enshrinement of “the expert” (Green et al., 2001; M. Hunt, 1997; Mulrow, 1987; Yuan & Hunt, 2009). We addressed these weaknesses by disclosing and rationalizing our protocol, using an exhaustive review to avert literature selection bias, and establishing a collaboration between an experienced and junior scholar of the Amish (Bryman, 2008; Cooper, 1998; Greenhalgh et al., 2018; Hammersley, 2001; Torraco, 2005; C. J. Whitty, 2015a).

Amish health research is divisible into health conditions and health culture literature, with some references addressing both (Anderson & Potts, 2021b); correspondingly, we divided our lengthy review into two publications. Herein, we focus on the culture literature; elsewhere, we address health conditions literature (Anderson & Potts, 2021a). Of 246 Amish health references, 138 address culture.

Results: Syntheses of the Amish Health Culture Literature

We identified eight topics and synthesize the literature accordingly, rendering the literature’s assertions faithfully and withholding most observations until the discussion section. We name Amish communities and affiliations when available; see Anderson ([forthcoming]) for descriptions.

Use of Modern and Complementary & Alternative (or “Pluralistic”) Medicine

Amish actively base healthcare decisions on the problem type, cultural beliefs, social patterns, and information gathered from friends, family, the church, and trusted practitioners (Crawford et al., 2009; Wenger, 1994). Though Amish use modern medicine, a strong predilection exists for complementary and alternative medicine (CAM), namely, alternative health practitioners, folk medicine, and spiritual practice. Use is especially high for chronic illness (Hostetler, 1976). Resembling ethnographic results a half century prior in Kalona, IA (Von Heeringen & McCorkle, 1958), an updated study found nearly all Amish participants use CAM. About half of CAM usage was for minor traumas (Gerdner et al., 2002). In Geauga County, OH, 100% of Amish respondents used some sort of spiritual practice, 85.7% used supplements, 59.5% used herbal or home remedies, 11.3% used massage therapy, and 7.5% used reflexology (Sharpnack et al., 2010). A Holmes County, OH, study found that dietary supplements, chiropractic, prayer, and massage therapy were the most common forms of CAM (Reiter et al., 2009). Amish are liable to continue using CAM even when it fails or makes them feel worse (Gillum & Staffileno, 2011), as they prefer to trust their co-religionists, who often promote CAM (Sauder, 2020).

Modern Medicine:

Amish avoid modern medicine when able. They tend to distrust the American medical and pharmaceutical industry as profit-oriented extensions of the government and large-scale corporations (Ballou, 2004). They also feel culturally disoriented in these environments (King, 2017). At least since the 1950s, Amish have accepted modern medical findings such as “germ theory” (Von Heeringen & McCorkle, 1958), but they prefer treatments perceived as natural—such as CAM—over the unnatural—such as prescription drugs, which many Amish feel are too strong, have undesirable side effects, are too expensive, and occur in an unfamiliar, institutional setting. Amish will, however, use modern medicine, such as a general practitioner, specialist, or surgeon, when necessary, as with obstetrical and traumatic needs, but often in conjunction with CAM (Gerdner et al., 2002; Huntington, 1984; Sharpnack et al., 2010; Von Heeringen & McCorkle, 1958; Wenger, 1994). In one study in Elkhart-LaGrange, IN, no significant difference existed between Amish and non-Amish as to whether they had seen a physician in the past year (Trier, 1991). However, a reputable Holmes County, OH-based general practitioner reported having many more Amish clients but proportionately fewer visits, and that Amish rarely request a routine physical (Lehman, 1994). In another Holmes County study, Amish and non-Amish used modern medicine at comparable rates despite higher Amish use of CAM (Reiter et al., 2009). In a Milverton, ON, study, Amish and Old Order Mennonite respondents accessed modern health care providers the most (66%) followed by complementary (52%) and alternative (44%) providers (Gesink et al., 2017).

Alternative Health Practitioners:

Amish reported using chiropractors, folk healers—i.e., “Brauchers” (L. Miller, 1981)—massage therapists, reflexologists, and advice from friends and family (Schwieder & Schwieder, 1975; Wiggins, 1983) significantly more often than non-Amish (Reiter et al., 2009; Trier, 1991), although some practices, especially Brauche, are controversial and unevenly endorsed (Hurst & McConnell, 2010, Ch7; L. Miller, 1981). In Kalona, nearly all Amish interviewed had used a chiropractor (Gerdner et al., 2002; Von Heeringen & McCorkle, 1958) and a majority had seen a reflexologist and/or osteopathic doctor (Gerdner et al., 2002). The attraction to alternative practitioners is “sympathy healing,” that is, practitioner-provided intimacy and supportive concern during a patient’s demoralizing chronic illness (Hostetler, 1976; L. Miller, 1981; Wenger, 1994). As a result of Amish preference for natural care, they are targets for dubious services, including chelation, radon mines, and Tijuana clinics. With ads published in Amish-targeted publications, purveyors of questionable treatments use rhetoric loaded with scientific jargon, Bible verses, and testimonial advertisements (Weyer et al., 2003).

Natural Remedies and Supplements:

The Amish use supplements—including vitamins, minerals, and herbs, and, for women, fibers and enzymes—commonly and more frequently than neighboring non-Amish, as reported in Holmes County, OH (Cuyún Carter et al., 2012; Reiter et al., 2009), Geauga County, OH (Sharpnack et al., 2010), Kalona, IA (Gerdner et al., 2002), and Northern Indiana (Trier, 1991). However, Amish are significantly less likely to use aspirin (Cuyún Carter et al., 2012). In Holmes County, Echinacea and garlic were the most common herbal supplements, while, for women, vitamin C and calcium were the most common vitamins/minerals (Cuyún Carter et al., 2012).

Spiritual Practice:

A religious outlook is central to their approach to healthcare (Armer & Radina, 2006; Gesink et al., 2017; Reiter et al., 2009; Sharpnack et al., 2010). It emphasizes proactively working to overcome challenges, especially through prayer and God-given natural remedies. They also believe that God is in control and that healing intervention is His choice (Garrett-Wright et al., 2016; Gerdner et al., 2002; Gillum et al., 2011; Sharpnack et al., 2010, 2011). Amish use spiritual healing much more than non-Amish neighbors and national averages (Reiter et al., 2009; Sharpnack et al., 2010; Trier, 1991). In Geauga Co. (Sharpnack et al., 2010) and Milverton (Gesink et al., 2017), respectively, participant involvement in spiritual activities included regularly reading “spiritual materials” / “the Bible” (100% / 84%), praying (74.7% / 89%), and other health-focused spiritual practices, such as helping or visiting others.

Support and Care for the Sick and Aged

Amish generally have strong support systems that provide psychological, social, and material care during illness (Farrar et al., 2018a), and it may be one reason Amish live longer than non-Amish despite lower hospital use (Mitchell et al., 2012). Care is the main responsibility of, respectively, the immediate family, the extended family, and the church. Care may include direct interventions and support, home visits, volunteered labor around the home and farm, and monetary gifts to cover expenses (Wenger, 1994; Wiggins, 1983). Amish prefer home-based care, a familiar institutional setting close to family and co-religionists. When someone is hospitalized, other Amish are frequently present (Cavan, 1984; Huntington, 1984).

Amish offspring express religious conviction for honoring parents through homecare; at home, elderly remain meaningfully involved in daily social affairs (Cavan, 1978; Farrar et al., 2018b; Palmer, 1992; Tripp-Reimer & Schrock, 1982; Wenger, 1994; K. K. Yoder, 1997). Offspring feel that it is satisfying and a privilege to provide care, even if intense and emotionally draining (Farrar et al., 2018a). Large families make home eldercare feasible (Hewner, 1998; Longhofer, 1994); inversely, childless couples and the unmarried, elderly without close Amish neighbors, elderly with little wealth, and those requiring intensive care are more likely to be institutionalized (Hewner, 2001; Tripp-Reimer et al., 1988). Amish elderly generally do not “retire” because they fear losing their ability to contribute and becoming a burden on someone else (Andreoli & Miller, 1998; Hewner, 2001). When no longer active, the elderly rarely value extensive life-saving measures for the preservation of life, particularly if they create further disabilities (K. K. Yoder, 1997).

From ethnographic work among the Northern Indiana Amish, Wenger (1991a, b) has cataloged several socio-cultural themes informing Amish care practices. First, care is central to the culture. The word “care” is expressed in four Pennsylvania Dutch words, as (i) serving someone in his presence, (ii) watching over and protecting, (iii) being aware of needs and acting, and (iv) thinking about a person. Giving care is an obligation and privilege of belonging; humbly receiving is similarly expected. Care is intergenerational and group-focused. Second, social patterns diffuse awareness of others’ needs—e.g. routine social activities, close neighborhoods, large kinship webs, long-term relationships, and chatty Amish periodicals—providing many opportunities to observe others caring and to mimic. Third, active participation in health decision-making involves care seeking and advice sharing, which strengthens social bonds that reinforce care. Fourth, while health actions vary among individuals—e.g. home vs. hospital births or supplement types—social bonds and shared values reinforce integration despite variation in health-related behavior. And despite variation in religious values and practices, individuals must remain aware of group expectations and conform, for “to care is to help people who want to fit [in]” (Wenger, 1991b, p. 105).

Health Knowledge: Information Seeking, Health Literacy, and Screenings

Information Seeking:

Amish actively seek health information. However, Amish often first seek the advice of family—especially from spouses and across generations (Wenger, 1994)—then friends (Armer & Radina, 2006; Gesink et al., 2017; Trier, 1991). Additional endorsements of health practices and remedies come from Amish-produced periodicals and books. Information usually addresses rather than prevents complications (Garrett-Wright et al., 2016; Oyabu & Oyabu, 2014). The main sign of illness, and hence the beginning of information seeking, is not a collection of symptoms but rather interference with daily activity (Armer & Radina, 2006; Garrett-Wright et al., 2016; Wiggins, 1983).

Having a rich body of insider and traditional health knowledge, Amish often avoid non-Amish intervention when practitioners would encourage it (DeRue et al., 2002; Reiling, 2002a; Sauder, 2020). Amish are less averse to consulting professionals when for practical services, if the professional is perceived as culturally respectful, and when the Amish individual is male. Even then, professional advice is usually assessed alongside community advice (Ballou, 2004; Campanella et al., 1993; Dickinson et al., 1996; Garrett-Wright et al., 2016; Wenger, 1994).

Health Literacy:

Amish health literacy and knowledge, at least of modern medicine, tends to be lower than non-Amish (Brensinger & Laxova, 1995; Gillum et al., 2011; Katz et al., 2013); however, these studies are preliminary and insufficient for generalizations. Gillum et al.’s (2011) ethnographic study focused only on cardiovascular knowledge and never led to quantitative measurement. In Holmes County, OH, Katz et al. (2013) measured health literacy by participants pronouncing terms from the Rapid Estimate of Adult Literacy in Health scale. Not only did these religiously strict participants’ scores suffer due to mispronouncing sexual terms but the spoken English of the Holmes County Amish has some interference from Pennsylvania Dutch (Downing, 2019).

Health Screenings:

Health screenings are intended to identify potential complications early on. Much literature casually infers that the Amish as uninterested in preventive care. (Alternatively, Henderson and Anbar (2009) argue that the Amish are interested in preventative care, but the modern medical culture alienates them with culturally insensitive offerings.) Studies focusing on Amish screening perceptions, practices, and programs have found some interest in screenings, although Gesink, et al. (2017) report low interest for cancer screenings from respondents, with 31% simply choosing not to be screened and 21% forgoing screenings since a provider never recommended one. Whatever the interest level, barriers exist for Amish to use preventative services, including a lack of knowledge about screenings, considerable hesitation in using these services, service inaccessibility, and personal shyness (Brensinger & Laxova, 1995; Documét et al., 2008; Gesink et al., 2017; Law, 2014; S. Miller & Schwartz, 1992; Sieren et al., 2016). While one study identified respondents’ sense of low personal risk as a barrier to seeking breast cancer screenings (Katz et al., 2011), this barrier appears absent for other screening types, including genetic counseling and disorders (Brensinger & Laxova, 1995; Law, 2014; Sieren et al., 2016). In a cystic fibrosis screening attitudes survey, Amish expressed increasing uncertainty the more the screening might impact one’s family life, such as carriers not able to marry carriers or, with 100% opposition, aborting a child based on prenatal screenings (S. Miller & Schwartz, 1992). Overall, attitudes may be changing—e.g. the recent surprising success of the Clinic for Special Children’s carrier screenings for Spina Muscular Atrophy¹—but we currently lack citable program reviews.

Payment for Services

Amish believe in caring for each other and not relying on government programs or insurance. Legal provision respecting religious freedom allows Amish church members to opt out of Social Security, Medicare, and related programs. Most Amish do not carry medical insurance (Graham & Cates, 2006; Greksa & Korbin, 1999; Kraybill & Gilliam, 2012; Rohrer & Dundes, 2016; Weller, 2017) and pay directly for services (Dellasega et al., 1999; Finn, 1995; Garrett-Wright et al., 2016; Weyer et al., 2003). Amish will generally accept hospital or foundation support and personal donations (Huntington, 1984). When faced with enormous bills or chronic illness, Amish may accept government aid (Farrar et al., 2018a; Miller-Fellows et al., 2018). A Geauga County, OH-based study predicts that as more Amish work for non-Amish, as in factories, Amish will increasingly accept company-provided insurance (Greksa & Korbin, 1997).

While for many families, paying directly is a hardship (Finn, 1995; Sherman, 2014), some support comes from church alms (Graham & Cates, 2006). Additionally, some Amish churches have formal hospital aid programs (Greksa & Korbin, 1997). These programs work like insurance but are exclusively Amish-funded. If individuals or families choose to participate, they pay monthly fees that go toward members’ medical expenses (Rohrer & Dundes, 2016). Some non-Amish employers pay into the plan instead of company insurance (Blair & Hurst, 1997).

As with commercial insurance, Amish aid is policy-based; hence, pay-ins determine pay-outs and plans rarely cover all expenses. When a family cannot pay beyond what a plan covers, additional support may come through alms, community fundraisers (e.g. auctions), or payment plans with local hospitals (Greksa & Korbin, 1997). Furthermore, the plan does not cover physical disability costs and may not cover health needs related to prohibited activities (Rohrer & Dundes, 2016).

Some Amish criticize aid plans as programs by and for wealthy communities and individuals, which militates against the charitable spirit of alms. Poorer families with particularly burdensome medical expenses may receive less support since they cannot pay in as much, and if families cannot pay in at all, they cannot receive assistance. In this way, aid programs may leave poorer members with more expenses than wealthier members (Blair & Hurst, 1997; Huntington, 1984, 1994).

Barriers to Service Access

While Amish accept most modern medical services (Banks & Benchot, 2001), several logistical barriers exist to using them.

First, Amish may be unaware of services; several strategies can increase awareness. In the literature, practitioners are advised to use networks to make connections, use a contact person—be it an Amishman or a trusted non-member—to help spread word and gain trust (Elmlinger, 2014; Finn, 1995; Fisher, 2002), hold informative meetings, and distribute written material, as Amish tend to be careful readers. Written material can provide information about local services and your contact information (Elmlinger, 2014). Avoid materials that appear like advertisements for services of questionable need (Gershenson & Levine, 2016). Work with local bishops and opinion leaders who can legitimize a program and provide feedback about its appropriateness. Involve Amish in program promotion and administration, such as through an advisory board (Greksa & Korbin, 1999; Showalter, 2000; Weber et al., 2010; K. K. Yoder, 1997). Allow time for word to get out, since mass communication is limited (Elmlinger, 2014).

Second, Amish transportation is limited to a taxi or slow-moving vehicle, so accessing services may be timely and costly (Farrar et al., 2018a; Garrett-Wright et al., 2016; Greksa & Korbin, 1999; Weyer et al., 2003; K. K. Yoder, 1997). Strategic responses could include centrally locating services (Elmlinger, 2014; Graham & Cates, 2006; Miller-Fellows et al., 2018), bringing services into homes (Crawford et al., 2009; Elmlinger, 2014; Fisher, 2002; Lehman, 1994), bundling appointments for an individual’s diverse needs or a family/neighborhood sharing taxi service (Cates, 2005; Elmlinger, 2014), avoiding last-minute cancellations (Cates, 2005), being sensitive to travel patterns during certain times and seasons, and providing a hitching post or bike rack (Graham & Cates, 2006).

Third, Amish have household technology limits, though they vary widely. For communication, many rely either on written letters or phone service outside the home, such as at a neighbor’s or in an outdoor shelter. Patients should be asked whether communications, such as voicemail, are private (Gershenson & Levine, 2016). Providers should allow extra time for making appointments and communicating information (Graham & Cates, 2006; Greksa & Korbin, 1999; Lehman, 1994; Purnell & Fenkl, 2019; Weyer et al., 2003). During emergencies, police may need to visit a home (Brewer & Bonalumi, 1995); however, cell phone ownership has increased among progressive Amish (Miller-Fellows et al., 2018). Amish also have limited sources of electricity, if any, in the home. Consequently, when discharging Amish patients, practitioners should inquire about the ability to use electronic devices at home and the heating/cooling facilities available (Banks & Benchot, 2001; K. K. Yoder, 1997). When service providers make home visits, electric outlets may be unavailable, so equipment should be charged and extra power sources, such as batteries, packed (Elmlinger, 2014).

Fourth, while the immediate family makes any final decisions (Purnell & Fenkl, 2019), community and family opinion leaders hold much sway and could influence a family’s decision to decline controversial treatments. Amish emphasize ascribed statuses—leadership ordained by lot, age, and gender—for determining prestige (i.e. decision-making power) (Waltman, 1996; K. K. Yoder, 1997). Husband and wife usually share equally in decision-making, though in public, the wife may appear retiring (Purnell & Fenkl, 2019). They also value highly the opinions of family and kin, turning to them for health advice (Crawford et al., 2009; Weller, 2017). Prestigious Amishmen may need to be involved early and often, especially through extensive or prolonged treatment (e.g. for mental health, deep burns, or cancer) or in implementing new programs. Whereas practitioners assume medical matters are private, Amish are group-referencing and interested in others’ involvement. Service providers should carefully navigate when and how much information to channel to other Amish, respecting both a patient’s need for privacy and others’ expectations that information is shared (Benedict, 2017; Cates, 2005, 2011, 2014; Dellasega et al., 1999; Gershenson & Levine, 2016; Purnell & Fenkl, 2019; K. K. Yoder, 1997).

Fifth, Amish prefer homecare over institutional care, and culturally tailored institutions over culturally mainstream ones. The home holds an emotional appeal due to the social support there (Banks & Benchot, 2001; Palmer, 1992; Showalter, 2000) and its familiarity for caregivers (Farrar et al., 2018a). Amish prefer dying at home over an institution (Banks & Benchot, 2001). Service providers such as midwives and advanced practice nurses (APNs) have had success dropping in at homes to see families when needed (Dellasega et al., 1999). If institutionalized, an Amish patient will likely have a large support network offering routine visits. Consider the extent to which visiting policies are responsive to constant, sizeable visits (Weller, 2017).

Sixth, Amish hesitate before using modern medicine due cost. Instead, they may explore alternative treatments (Dellasega et al., 1999; Garrett-Wright et al., 2016), travel to Mexican clinics (Graham & Cates, 2006) or simply forgo modern medical services (Antommaria et al., 2015; Finn, 1995; K. K. Yoder, 1997). Providers can reduce costs by limiting expensive tests (Dellasega et al., 1999; Gershenson & Levine, 2016), minimizing hospital stay lengths, moving therapies into homes (Henderson & Anbar, 2009; Weyer et al., 2003), explaining and justifying all cost-incurring steps and laying out all treatment options (Gershenson & Levine, 2016; Horton & Irwin, 2018), subsidizing travel and treatment costs when funding exists for studies, partnering with Amish churches in fundraising efforts such as benefit auctions (Henderson & Anbar, 2009), and offering payment plans matched to household incomes (Rohr et al., 2019). Some independent service providers have even accepted services or goods, such as homemade food, as payment (Finn, 1995). One doctor recommends against offering free services, as the sympathetic doctor-to-patient relationship should still remain professional (Wiggins, 1983).

Service Provider Effectiveness

Healthcare workers have written more about effective practice than any other subject. Among our references, 32 emphasize applied effectiveness. Their quality and depth vary from systematic qualitative analysis to anecdotal best practices lists compiled from one case or personal experience. Standing alone, each seems arbitrary; synthesized, they provide a useful overview of salient service provider issues.

Wenger (1993) provides an illustrative case of the cultural translation process which these studies stress. An Amish mother took herbs to quicken premature labor after falling on ice. She later consulted a Braucher to interpret the newborn infant’s symptoms while also seeing a doctor, who knew nothing of her alternative practices. The doctor attempted to fit her symptoms to existing medical equivalents. Had he worked instead to elicit cultural meaning from the client’s perspective and reconstruct that knowledge, he may have learned about the alternative practices and provided more appropriate treatment.

General Cultural Competency

Service provider publications usually offer a generic culture primer that also stresses the importance of studying Amish culture (Elmlinger, 2014; Wiggins, 1983; K. K. Yoder, 1997). Two key emphases include: one, overarching religious-cultural beliefs and values (Dellasega et al., 1999; Fisher, 2002; Weyer et al., 2003; K. K. Yoder, 1997) and, two, family and community networks (K. K. Yoder, 1997). From there, publications generally encourage hands-on education opportunities, such as: interacting with individuals on a casual basis (Adams & Leverland, 1986); participating in community activities, such as auctions; selectively integrating cultural practices into one’s personal life, such as fascinating folk remedies (Dellasega et al., 1999); and attending meetings that focus on cultural competency (Buccalo & Stevens, 1994). Publications often emphasize that while Amish appear similar, prepare for diversity (Weller, 2017). Each individual differs in his/her conformity to church positions (Dellasega et al., 1999), and variation exists within and across families, churches, communities, and denominations (Crawford et al., 2009; Dellasega et al., 1999; Waltman, 1996).

Establishing Trust and Clarity in Interactions

Amish are sensitive to a service provider’s character. Cultivating desirable traits builds respect; an educated, elitist air repels (K. K. Yoder, 1997). Desirable character traits include trustworthiness, integrity, humility, sympathy, genuineness, warmth, care, patience, engagement, and cooperativeness (Adams & Leverland, 1986; Garrett-Wright et al., 2016; Graham & Cates, 2006; Waltman, 1996; Wiggins, 1983). Once a service provider’s reputation is established, for better or worse, this reputation spreads quickly. If a service provider is trusted, Amish will be less likely to seek help elsewhere (Greksa & Korbin, 1999; Henderson & Anbar, 2009). Trust is built gradually through respect and genuine interest (Fisher, 2002).

Service providers should engage in face-to-face relationships (Weller, 2017). Communication should be honest, friendly, simple, clear, interested, and respectful, and should not be aggressive, bossy, or gushingly affectionate (Beachy et al., 1997; K. K. Yoder, 1997). Maintain an appropriate physical distance—usually no closer than hand-shaking distance—especially across gender lines (Beachy et al., 1997). A polite handshake is acceptable but not further affectionate touch (Purnell & Fenkl, 2019; Waltman, 1996; Weller, 2017). Amish are usually good listeners who have a slower conversational pace. Watch for barely perceptible non-verbal cues passed among themselves, especially during important conversations (Brown, 2017; Graham & Cates, 2006). Amish sometimes avoid eye contact; other times, especially with children, they sustain eye contact; neither are intended as an offense (Purnell & Fenkl, 2019).

The first language of Amish is “Amish”/“Dutch” (a German variant). Depending on the person and conversation subject, their command of English varies. Particularly difficult concepts to express in English include personal matters (Cates, 2005; Weller, 2017; K. K. Yoder, 1997) and some Amish-specific symptom descriptions (Gershenson & Levine, 2016; Purnell & Fenkl, 2019). It is especially important to gauge children’s and elderly’s English comprehension. For children with English difficulties, practitioners should maintain eye contact, use basic language, have short utterances, and give opportunity for caregivers to translate into Amish (Beachy et al., 1997; Elmlinger, 2014; Graham & Cates, 2006). One communication technique is to demonstrate medical procedures on a (faceless) doll (Banks & Benchot, 2001); another is to have patients write the Amish words for symptoms so the provider can research the term and use it (Gershenson & Levine, 2016). A Mennonite doctor could speak Amish and felt it helped his practice (Lehman, 1994); where no staff can speak Amish, bilingual or ESL personnel may have insights into the language situation (K. K. Yoder, 1997).

Though usually appreciative of services, Amish may appear socially distant, possibly as a precaution to protect private matters until trust is established; silence is not consent (Weller, 2017). Similarly, Amish usually internalize pain rather than make a show or complain; consequently, practitioners should ask directly about pain levels (Beachy et al., 1997; Brewer & Bonalumi, 1995; Finn, 1995; Weller, 2017).

At least until trust is established, service providers should not inquire too deeply into personal affairs, especially on subjects that could potentially expose church or family troubles (Graham & Cates, 2006; Wiggins, 1983; Wittmer & Moser, 1974; K. K. Yoder, 1997), though Amish may ask personal questions about family, residence, and beliefs (Weller, 2017). Trust is developed through demonstrating an understanding of the patient’s perspective across several conversations (Y. A. Lee & Ruth-Sahd, 2011). Amish may express appreciation through gifts; accept them as a token of the relationship (Banks & Benchot, 2001).

Limited formal education may impact communication and health literacy. Providers should identify knowledge deficiencies, verify communication is understood, and elicit information using direct, close-ended questions and simple explanations (Beachy et al., 1997; Waltman, 1996). Amish are less likely to just trust the doctor’s advice but want to be involved in the process. Hence, providers should take time to educate, explaining all options and potential outcomes, including treatment progress and timing until discharge. Consider educating in a group setting, so those impacted, especially extended family and community leaders, feel comfortable and have time to confer and raise questions (Henderson & Anbar, 2009; Horton & Irwin, 2018). Amish are sensitive to being singled out, so group conversations should not call too much attention to one person (Brewer & Bonalumi, 1995; Wiggins, 1983; Wittmer & Moser, 1974). By building trust and demonstrating sensitivity, providers have found that Amish are willing to work with tests, services, and medical experiments they otherwise would have rejected (Henderson & Anbar, 2009; Horton & Irwin, 2018).

Additional Recommendations for Cultural Competency

Other practical strategies include these non-exhaustive tips:

• Amish usually limit media consumption, especially with children present. Inquire whether hospital patients would like a television-free room and whether educational videos are acceptable. Consider limiting or removing television from public areas such as waiting rooms (Banks & Benchot, 2001; Garrett-Wright et al., 2016; Purnell & Fenkl, 2019; Weller, 2017).

• Conversations are usually preferred to written communications (Rohr et al., 2019).

• Amish will likely be sensitive to nudity and immodesty. Patients should be kept covered when possible (Weller, 2017). Simple hospital gowns should be offered. Women will often prefer to wear a head covering even while resting (Banks & Benchot, 2001)

• Photographs for medical analysis are generally accepted but face or full body shots should be explained and cleared (Banks & Benchot, 2001).

• The traditional, two-parent family is highly regarded and the norm; at home, the father and mother of nearly all children are present and active (Beachy et al., 1997).

• Children are active and many live in farm settings. During pediatric assessment, discuss the child’s chores at home (Beachy et al., 1997; Purnell & Fenkl, 2019).

• Identification during an emergency can be difficult. Amish may not carry ID and, to those unacquainted with Amish, their similar dress styles may make them appear indistinguishable. Many have similar given names and surnames (Brewer & Bonalumi, 1995).

• By their dress and activities, some adolescents appear to have forsaken their religion. This may just be a phase (Graham & Cates, 2006; Purnell & Fenkl, 2019).

• Should both parents be hospitalized, extended family or the church will usually care for the children (Banks & Benchot, 2001).

• Hospital discharges should be made with enough forewarning that the Amish have time to arrange to be picked up (Farrar et al., 2018a).

• Training materials should be written with cultural sensitivity and have culturally specific illustrations; programs should be experiential (Kraybill & Gilliam, 2012).

• Psychological tests may encounter issues with reliability due to cultural translation (Gershenson & Levine, 2016; Wittmer & Moser, 1974).

Multiculturalist versus Critical Perspectives

The possibility of an infinite competency checklist led Garneau, et al. (2018) to argue for an alternative paradigm, “cultural safety,” a critical perspective responding to the cultural competency paradigm. They argue that the multiculturalist assumptions dominating the cultural competency literature since the 1990s ignore postcolonialism’s call to interrogate power relationships. Multiculturalists, though appearing sensitive, may nevertheless retain positions of power in service provider work, especially by “othering” the served. Cultural safety seeks to equalize power relationships between providers and recipient by calling providers to reflect on assumptions they have about others, as well as reflecting on the historical, political, and social contexts that shape health beliefs and institutions. Cultural dimensions of relationships—values, assumptions, and perspectives—should be identified through critical reflection and power shifted to service recipients. Service providers and recipients should continually work toward equal partnerships through alertness to interpersonal and systemic power imbalances, participation of all parties at all stages, and protection of cultural identities through rejecting stereotypes.

Amish-Specific Health Programming

Amish are usually interested in pragmatic services based on current needs rather than health education and preventive services. An assessment of services for the Scenic Bluffs Community Health Center (Cashton, WI) revealed that both local Amish and non-Amish were interested in walk-in care, dental care, 24-hour access to a provider over the phone, and the bundling of providers including a chiropractor and pharmacist in one place—McBride and Gesink (2018) also reported success with bundling screenings and education at a single day-long health event. Compared to non-Amish, Amish participants were more interested in home health care options, a birthing center, and mental health services, and less interested in preventive care (Dickinson et al., 1996). These findings verify many anecdotal statements across our literature and further suggest that Amish-targeted health services will also serve rural non-Amish health needs.

The 1980s-90s cultural turn in healthcare birthed several programs customized to Amish preferences, which increased Amish access to the medical system.

Birthing Centers:

Amish women often prefer midwife-assisted home births or birthing clinics, though hospitals births are common (Campanella et al., 1993; Deline et al., 2012; Finn, 1995; Kreps & Kreps, 1997; Lehman, 1994; Lemon, 2006; Palmer, 1992; Showalter, 2000). Due to cost, travel commitments, and social influence, Amish pursue relatively few formal prenatal care activities and check-ups. Women visit a doctor primarily to confirm the pregnancy, to check-in before birth, and if serious symptoms arise (Campanella et al., 1993; Finn, 1995; Lehman, 1994), with formal prenatal care sought less and later after each pregnancy (Brensinger & Laxova, 1995). In place of formal care, Amish women pursue health-seeking advice internally and through alternative medicine (Campanella et al., 1993; Thomas et al., 2002).

Responding to these birthing patterns, Amish-focused birthing clinics started as an inexpensive, culturally sensitive service for prenatal care and birth (Kreps & Kreps, 1997; Showalter, 2000). These birthing centers, including Mt. Eaton Care Center (near Holmes County, OH), New Eden Care Center (Northern Indiana), and LaFarge Birthing Center (Cashton, WI), offer modern delivery options and midwife services while maintaining culturally competent practices, providing an ambiance of plainness and avoiding the expense of hospitals (Deline et al., 2012; Kreps & Kreps, 1997; Lemon, 2006; Showalter, 2000). For a flat fee, three days of standard services are offered to low-risk mothers—with fees for additional services—making this a comfortable and accessible environment for patients to receive skilled care outside of a hospital setting (Lemon, 2006). Although Amish women generally maintain their health and seek services when needed, earlier research found that expectant mothers made prenatal doctor visits every 8 weeks or more rather than the recommended 4 weeks. Additionally, Amish tended to withhold expensive care for critically ill infants with low likelihood of survival (Campanella et al., 1993; Waltman, 1996). It is uncertain the extent to which birthing centers have closed these gaps versus met the Amish where they are at. The LaFarge Birthing Center did accept high risk pregnancies—monitoring progress and providing additional care as needed—when they discovered these women were having high-risk home births rather than hospital births (Deline et al., 2012).

Mental Health Facilities:

Amish are generally cautious about mental health services. First, the service necessitates trust and vulnerable conversations with someone who may not sympathize with Amish beliefs. Herein is a chance for mental health service providers to meddle, agitating tensions within the Amish rather than solving problems. A common belief is that mental health services catalyze religious defection, although the impact of services on defection versus the predisposition of patients to defect remains unknown. Second, discrepancies exist between how emotions and life challenges are addressed in Amish culture and how they are addressed through modern mental health treatment. For example, some Amish see mental health services as substituting a root spiritual need—repentance from a moral failing causing distress—with a humanist placebo (Cates, 2005; Greksa & Korbin, 1999; Nolt, 2011; Reiling, 2002a). Where mental health challenges occur, laity are expected to first contact ministers for direction, then seek Amish-sponsored mental health support groups and organizations. If difficulties persist, Amish generally support outside services (Cates & Graham, 2002; DeRue et al., 2002; Greksa & Korbin, 1999; Nolt, 2011; Reiling, 2002b). These steps are hardly clear-cut, as opinions vary widely among individuals and service providers about the kinds and extent of resources that should be within versus outside the group (Egeland & Hostetter, 1983).

Since the late 1990s, three Amish-focused mental health services have grown. First, several existing professionally licensed private mental health facilities provide culturally sensitive onsite housing and services to Amish patients, offering Amish residential staffing and oversight from an Amish board. Second, for moderate, non-psychiatric counseling cases, Amish, often in collaboration with Old Order Mennonites, have established independent counseling centers, including Harmony Haven (Evart, MI), Hofnungsheim (Holmes County, OH), and Whispering Hope (Cumberland County, PA). Amish people’s opinions vary depending on the particular program, especially in the extent to which it is modeled off evangelical Protestant counterparts and the extent to which the Amish church has oversight, with progressive-minded Amish having more favorable views of independent, evangelically-oriented counseling than the conservative-minded (Cates, 2014; Nolt, 2011; Reiling, 2002b). Third, in response to a contracted report (Greksa & Korbin, 1999), Geauga County, OH’s, mental health services worked to increase awareness and access among the Amish, including creating a funding collaboration with the four counties encompassing the Amish settlement, disseminating contact and services information, opening a branch in a central location, and hiring a coordinator who had good rapport. A program assessment found that the usage rate increased 320% in the five years after the changes (Miller-Fellows et al., 2018).

Genomic Clinics:

Geneticists have maintained interest in the Amish since the 1960s, as the Amish have properties that help isolate the effects of genes (Francomano et al., 2003; McKusick et al., 1964). Amish genealogical data are unusually accessible, as Amish have produced meticulous genealogies out of ancestral curiosities—at 522 by 1985 (Luthy, 1985) and well-exceeding this today. These data sources have enabled geneticists to compile ancestral databases helpful in tracking genes (Agarwala et al., 1998; Agarwala et al., 2003; Agarwala et al., 2001; Cross & Crosby, 2008; Francomano et al., 2003; W.-J. Lee et al., 2010). Early data collection strategies—so-called “genetic tourism”—advanced genetic research but with little return to the Amish and without a permanent presence in Amish communities. Since the 1990s, data collection efforts have come increasingly from settlement-specific, genomic clinics (Gura, 2012; M. L. Hunt et al., 2018; Law, 2014; D. H. Morton et al., 2003; Tell, 2012). These clinics are a symbolically congruous physical presence in Amish settlements, allow Amish to maintain agency and direct institutional priorities via Amish advisory boards and local fundraisers, and offer bundled services, including treatments, genetic counseling, screenings, and even on-site lab work (Francomano, 2012; King, 2017; Tell, 2012).

At the dawn of Amish genomic clinics, Brensinger and Laxova (1995) found that Amish parents of children with developmental disabilities tended to have limited knowledge of genetics and genetic screenings. While respondents expressed interest in learning more, they had reservations toward testing, as did a small sample of Amish when asked about cystic fibrosis screenings (S. Miller & Schwartz, 1992). Even with the establishment of genomic clinics, genetic screenings remain a sensitive issue. One genomic clinic deliberately avoids suggesting preconception or prenatal screenings. Occasional patients with histories of certain genetic disease request prenatal screenings but only to prepare and watch for cases after birth (King, 2017).

Adolescent Substance Abuse Intervention Programs:

Adolescents charged with substance abuse may have to take treatment classes, but the social settings are not sensitive to their culture. Then, too, as with mental health programs, some Amish perceive psychiatric (Chupp, 2008) and publicly sponsored programs as intrusive (Reiling & Nusbaumer, 1997). Furthermore, some Amish believe adolescents can discontinue a substance by choice and/or public confession when joining church, which mental health professionals may doubt. As an alternative to public treatment classes, the Amish Youth Vision Project in Northern Indiana used Amish peers in focus groups to educate each other about peer pressure and substance use effects. Amish peers validate the program, orally translate difficult terms and ideas into English, monitor the group mood, and move attention from the individuals sharing to group ownership of ideas (Weber et al., 2010). As a result, participants were more knowledgeable about alcohol, nicotine, and meth (but not marijuana). Furthermore, participants were more comfortable making decisions regarding alcohol, though many reported a low likelihood of ending drinking (Cates & Weber, 2013).

Farm and Road Safety:

To help reduce farm and road injuries, especially among children, scholars and extension agents have developed resources that offer both preventive safety measures and childhood readiness education (Rhodes & Hupcey, 2000). Children commonly chore at their rural home and enter the formal workforce in their mid-teens. Amish adults assign tasks to children based on maturity, strength, age order, and gender, with physical and mechanical tasks preferred for males. In a series of multi-settlement Amish focus groups addressing primary safety concerns for children, respondents identified water, lawnmowers, string trimmers, and chemicals as primary concerns, and confined spaces, skid loaders, and tractors as secondary (Jepsen & Donnermeyer, 2012; Jepsen et al., 2012). These self-reported concerns are inconsistent with the most common causes of injuries aforementioned, raising question about Amish awareness of risks. Furthermore, some researchers are concerned that Amish children are doing tasks above their maturity level (Jones & Field, 2002) while Amish parents may feel unable to teach safety due to not knowing safety procedures for some tasks (Jepsen et al., 2012). The Amish approach to safety was once characterized as “just common sense” and, beyond that, one’s life is in God’s hand. Thus, when injuries and fatalities occur, Amish tend toward prayer and manage grief by resigning to God’s will (Gerdner et al., 2002). More recently, some Amish are showing interest in safety education and research (Jepsen et al., 2012), and in one case, even initiated a collaboration with extension agents to improve visibility markings on low profile horse-drawn vehicles (e.g., children’s pony carts) (Jepsen & Mann, 2015).

Educators have offered teaching programs through schools, safety camps, culturally sensitive workbooks and factsheets, board games, and community workshops. Frequently encountered complications when conducting outreach to the Amish include language use, Amish unfamiliarity with and skepticism about formal research, and challenges building community consensus. While sustained outreach programs have increased safety practices, no research has determined whether actual injuries have declined as a result of Amish adopting these practices (Beaudreault et al., 2009; Burgus & Rademaker, 2007; Eicher et al., 1997; James, 2001; Jepsen et al., 2012). Newer databases now exist to help scholars track Amish injuries (Jones et al., 2013), so long-term effects may eventually be determined.

Physical Health Services:

The ways in which established medical programs have responded to the Amish are many. The literature provides several examples. In Milverton, ON, a collaborative Women’s Health Day was planned with support from local health facilities, church leaders, and university partners. Registered women received complementary bus transportation, two meals, and opportunities for shopping and socializing. The event included screenings and lectures about cancer, healthy eating, mental health, and cardiac health. Most participants were under-screened (85%) and younger than 50. Women received cervical cancer screenings (52%), mammograms (48%), fecal test kits for colon cancer screenings (52%), and blood screenings (88%), especially due to concern about anemia. Feedback was supportive and the program has been repeated, although limitations include a lack of feedback from women who choose not to participate. The events were held in early spring before planting and in mid- to late-autumn after canning (McBride & Gesink, 2018). In Holmes County, OH, a local medical doctor described the cultural strategies his office employs to meet Amish health needs, including management of transportation and appointment concerns, home visits, and speaking Amish (Lehman, 1994). Also in Holmes County, a participatory research project with a hospital emergency ward department resulted in staff incorporating traditional Amish B&W and burdock leaf treatment for burn and wound care. Skilled Amish dressers trained hospital nurses and other staff as a way to provide the preferred care to patients and to permit formal study of the treatment’s efficacy (Amish Burn Study Group et al., 2014; Hess, 2017).

Disagreements and Ethical Conflicts

For healthcare workers to fail navigating a conflict can alienate the Amish from the medical institution. Avoid being aggressive, pushy and litigious when differences arise, as Amish are more likely to passively resist than actively resist or yield (Adams & Leverland, 1986; Waltman, 1996). Service providers who have a history of trust report positive responses when being firm in expecting compliance or in recommending treatments (Adams & Leverland, 1986; Dellasega et al., 1999).

Several areas are particularly sensitive and prone to disagreement. First, providers must remain aware of parallel medical systems among the Amish (Elmlinger, 2014; Purnell & Fenkl, 2019; Wiggins, 1983) and that Amish usually consult this system first (Dellasega et al., 1999; Garrett-Wright et al., 2016; Graham & Cates, 2006; Palmer, 1992). Simultaneous use of CAM with modern medicine may appear to challenge the doctor’s wisdom or prompt concern about negative effects (Dellasega et al., 1999; Sauder, 2020); however, Amish are unlikely to respond well to rebukes (Adams & Leverland, 1986) and are unlikely to discontinue all forms of traditional treatments if no harm is perceived (Fisher, 2002). Due to anticipating controversy, many Amish will not mention CAM usage (Purnell & Fenkl, 2019). Amish respect the advice of service providers who show understanding, interest, and acceptance of CAM (Elmlinger, 2014; Waltman, 1996; K. K. Yoder, 1997). Either way, practitioners should always inquire what home remedies are being used (Banks & Benchot, 2001; King, 2017; Purnell & Fenkl, 2019; Weller, 2017). Of special note, the Amish prefer the B&W Ointment and burdock leaf treatment for burns over skin grafting. This treatment has triggered conflict (Kahn et al., 2013), although doctor-patient collaborations with this treatment—when requested and so long as no harm is done—attracts the Amish to the institution, providing continued opportunities to serve them (Flurry et al., 2017).

Second, because they believe in a heavenly afterlife for the faithful and in God’s involvement in human affairs, including the timing of one’s death, Amish are more willing to accept death when they sense the time approaches, no matter one’s age. Extreme lengths to preserve life such as life support are frequently refused, and particularly invasive measures, such as open -heart surgery, may be viewed as tampering too much with God’s creation. Healthcare providers must be aware of Amish preferences and respect their decision-making autonomy (Huntington, 1993[2003]).

Amish want ownership of their ill, which is especially controversial when dealing with a child or the severely ill. When caregivers must rely on the health care system, they are liable to have concerns, frustrations, confusions, and ambivalences about yielding some control and navigating an unfamiliar system on behalf of the ill (Farrar et al., 2018a). When a practitioner pushes for extensive or invasive treatment, Amish may refuse if the treatments are expensive, do not align with beliefs (Brown, 2017; Kahn et al., 2013) or prolong suffering (Antommaria et al., 2015; Huntington, 1993[2003]). Amish from some groups may object to transferring a patient to another hospital if they feel the transfer causes a loss of control or if the mode is objectionable, such as a helicopter for some (Rohr et al., 2019). At times, they prefer yielding the ill to God’s will, believing in a joyous afterlife for the faithful, while continuing with CAM treatments. If death occurs, at least the family can remain by one’s bedside (Adams & Leverland, 1986; Huntington, 1993[2003]).

Service providers may object when Amish request to take the ill home, but providers must respect an adult patient’s wishes. However, when the patient is a child, a neglect case is potentially triggered. Amish believe children belong to the family, not the state, until they reach the age of accountability (around 16). The Amish will strongly object to any action to gain custody of a child, even when the condition is fatal without further intervention (Garrett-Wright et al., 2016; Huntington, 1993[2003]; Waltman, 1996) and may even be willing to accept imprisonment (Huntington, 1993[2003]). Circumstances justifying a child neglect case are debatable and require weighing the parents’ interests against the state’s obligation to protect children. Professionals should consider that the Amish system tends to emphasize mutual well-being while the Enlightenment-based medical establishment looks at individuals as pursuing personal interests, life being foremost. American ethics tend to respect the parents’ decision when calculations fall into grey areas. Nevertheless, physicians may observe that financial considerations could arise for uninsured parents. Professional codes of ethics preclude financial considerations from entering the equation. However, Amish parents are unlikely calculating whether saving a child is “worth the money.” Rather, they likely view expensive procedures as a ruinous fight against what is actually God’s timing for the child. In the end, when faced with parents rejecting treatment for a child, physicians should investigate all options, including culturally informed education, financial sponsorship of the medical procedure, and ethics committee involvement, before weighing out whether a case of potential child neglect should be reported, for this may alienate an entire Amish church from the institution (Antommaria et al., 2015; Clayton & Kodish, 1999).

Third, contraception is generally prohibited, though the extent and enforcement varies by church from those that do not accept any planning—including natural methods (Finn, 1995), to those discouraging via inference but not enforcing prohibitions on modern contraception. Abortion is universally forbidden. Some women may use contraception in secret (Beachy et al., 1997). However, they are cautious about any treatments that would prevent births, such as for genetic risks (Graham & Cates, 2006). Service providers should approach the subject cautiously and with respect to the woman’s and church’s views (Purnell & Fenkl, 2019; Waltman, 1996).

Fourth, some Amish reject vaccinations, preferring to trust God. This belief is personal, not church policy, and varies widely (Garrett-Wright et al., 2016). Those rejecting immunizations likely distrust the whole modern medical program (Kettunen et al., 2017; J. Yoder & Dworkin, 2006). Other Amish accept immunizations as a way to show care about others (Huntington, 1993[2003]). Controversy may arise when an outbreak occurs, though many Amish are then willing to get immunized (Gastañaduy et al., 2016; Medina-Marino et al., 2013).

Fifth, Amish are generally cautious toward socio-psychological interventions that may change the culture. Counseling is one controversial area; some Amish reject most counseling due to counselors imparting alien ideas to the ill, replacing a role ministers should have, and rejecting the idea that sin could be contributing to illness. Other Amish accept counselors on a case-by-case basis; families with members who have mental illness are more prepared to accept treatment (Greksa & Korbin, 1999). Interventions addressing youth substance abuse also represent potentially controversial programs. Interventions may have to tradeoff an ability to create some changes in order to respect the culture, especially in communities where a teenage “running around” period is accepted (Cates & Weber, 2013).

Discussion

Herein, we have offered an exhaustive review of the Amish health culture literature, synthesizing what is known about Amish health beliefs and practices, Amish interactions with the health care establishment, and the establishment’s response to the Amish. Inasmuch as this review marks a milestone in our aggregate understanding of the Amish health culture, we also advocate several important changes.

We will first address theoretical orientations. Much of the service provider literature is anecdotal, perhaps due to practitioners simply wanting to share what lessons were learned and what works. When encountering other cultures, service providers typically seek quick, practical strategies; the cultural competency paradigm is typically employed to this end. Cultural competency argues that service providers work with cultural groups that approach the medical establishment uniquely; service providers have no homogenous “patients” who need only follow the doctor’s orders. To increase service effectiveness, providers must educate themselves about cultural groups and engage in culturally informed interactions. Without dismissing all insights from the cultural competency paradigm, we believe that “education” is too often a list of anecdotal dos and don’ts, which has several problems.

First, practitioners may ritualize a cultural competency-based interactional repertoire but neglect the frame of mind that enables one to deal ad hoc with each situation (Garneau et al., 2018). This contributes to defining Amish as “other,” where the service provider, working from his/her culturally normative position, is using cultural tricks to unlock secrets of working with “the other.” While cultural competency literature frequently acknowledges that the Amish are diverse, it still cultivates a mindset of Amish as “other,” which is reinforced by the Amish’s theology of “our people” and “the world.” The Amish, though distinct, are hardly isolated, yet the “othering”-separation narrative reinforced by both parties can re/produce marginalization and cultural violence through unaccounted power discrepancies (Good Gingrich, 2016), not just between service provider and Amish patient but also within the Amish as some individuals access institutions and resources outsider their churches.

Second, the cultural competency approach—rooted in multiculturalism—tends to positively evaluate other cultures, which can produce a hyper-functionalist outlook. This perspective invites circular statements—what is, is good for the Amish—and reifications—“the community” is capable of social action because individuals always subject their personal interests to “the community.” For example, a practitioner may approach “the Amish” and hear their justifications, positively appraising it as appropriate for them, but the practitioner fails to consider who is speaking and what forces enable him to speak to you for “the community” and whether it represents everyone or just some. We do not need to devalue other cultures to recognize that cultures have inconsistencies, incoherencies, idiosyncrasies, internal conflicts, and pathogenic dysfunctions. The hyper-functionalist approach risks professional superiority, where being able to explain why certain cultural practices are good makes one a self-appointed representative of the pure Amish perspective to the “outside world” (Anderson et al., 2019; Billig & Zook, 2017; Park, 2017).

Third, cultural competency publications are usually rooted in certain Amish settlements or cases, which make generalizations impossible. By promoting lists of best practices that worked in one place or case, cultural competency researchers risk generalizing Amish behaviors without sufficient grounds. Researchers must engage in comparative studies—across communities, affiliations, and individuals—to determine how monolithic or local a recommendation is. Variation certainly exists for any practice but to what extent? Studies analyzing variation could take the form of a coordinated case series, multi-site studies (e.g.,Jepsen et al., 2012) or longitudinal research (Buccalo, 1997).

Fourth, our theoretical understanding of Amish health culture will stall if the literature remains inundated with dos and don’ts lists. When setting all cultural competency best practices lists side-by-side, their collective theoretical aimlessness is conspicuous. Observations can contribute to social theory’s development through proposition formulation, but when observations only produce best practices, we reach a dead-end. Theory must inform the way practitioners and researchers approach observations, namely, using theory as a basis for hazarding and testing interpretations of our observations, which will then inform further observations so they are no longer standalone ideas.

Finally, while the lists of cultural competency practices seek to promote understanding, they raise few questions about health systems’ organizational and legitimizing structures and about power relations among Amish individuals and between Amish individuals and the health system. Enough evidence exists that structures and power are not marginal forces in Amish health decision making (Ballou, 2004; Garneau et al., 2018; Hartman, 2001; Reiling & Nusbaumer, 1997).

We turn now to questions about access and outreach work. In the cultural competency paradigm’s eagerness to reduce service barriers for all people, the ideal is for everyone to have access without barriers, so he/she has the needed resources to achieve his/her health goal. However, when access is limited by self- and group-imposed socio-religious restrictions, reducing access barriers takes on a new meaning. The contradiction of Amish practices aimed at limiting societal integration by limiting access combined with the practitioner’s goal of making services as freely accessible as possible creates at least three outcomes worth further consideration.

The first is a “double-bind” for Amish, that is, where strategies of necessity in one social space are met with disapproval in another. The religious foundations for the Amish relationship to health care—from institutional distancing to Social Security/Affordable Care Act exemption—are also barriers to taking advantage of health care resources. Thus, extensive involvement with a non-Amish health system risks instigating disapproval from co-religionists or creating unrest in churches as people develop contrasting opinions (Good Gingrich, 2016). As McBride and Gesink (2018) noted in their project limitations, they did not have a good sense as to why non-participants did not participate! This is not trivial and merits further investigation for all outreach.

The second complicated outcome is uncertainty about whether socio-religious group limitations that reduce access are (1) self-imposed as a matter of an individual’s culturally-informed free will or (2) imposed by a ruling elite—be they church leaders, wealthy members who have the most to gain from, say, the Amish-specific aid programs, or other less obvious but significant contours of power. Careful analysis of the Amish culture renders neither explanation satisfactory, but it does present the possibility that some Amish individuals will perceive programs providing better access as an external institution’s gambit toward upsetting their church’s perpetually unsteady peace.

The third addresses resource distribution. We applaud the innovative work of Ontarian health care workers to make health screenings available (McBride & Gesink, 2018). However, we also must consider that to provide free transportation, two meals, time to visit with friends, and shopping time, not to mention free screenings, is a luxury that, for example, low income, urban, minority residents or low income, remote rural residents are unlikely to receive. Nor are such groups likely to have: special legal consideration when the convicted enter culturally tailored rehab programs (Weber et al., 2010); easy access to culturally sensitive clinics that operate on “Amish time”—i.e., time to visit with physicians and quick results from an on-site lab (King, 2017); and legal exemptions to national insurances, which then offer financial advantages and release from contributions toward fellow countrymen’s medical needs (Rohrer & Dundes, 2016). To what extent are these programs models of cultural competency, to be replicated among other groups, and to what extent are culturally-tailored programs privileging a category of people?

We will now raise several cultural questions that constitute conspicuous literature knowledge gaps. First, how do Amish balance their fears of negative impacts incurred from engaging the medical establishment with the medical risks of not engaging it? This question is especially salient when considering their immunization decisions and the potential side-effects of CAM. Second, we have little knowledge of how Amish respond to different institutional-legal medical systems and contexts, notably between American and Canadian systems. Third, are there other theoretical frameworks besides cultural competency (and cultural safety) that could offer competing claims, which can then be empirically tested? “Cultural humility” is one perspective gaining ground outside Amish health research, for example. Fourth, the Amish health care literature is almost entirely blind to gender dynamics, and to a lesser degree, age. Given the Amish culture’s emphasis on age- and gender-specific roles, we argue that age and gender must be more explicitly investigated in Amish health culture research. Fifth, in what ways and to what degree are Amish vulnerable to predatory health care institutions seeking to maximize profit? Are Amish particularly susceptible to being overcharged due to their community support? Or, are Amish particularly vulnerable to incurring additional hospital expenses due to not knowing patient rights?

Our final comments concern changes. While we observe much stability in the Amish health culture, we also notice some changes that researchers should monitor. Among the Amish, service payment systems are shifting, including the structure of Amish financial aid, their increased adoption of insurance, and greater willingness to use government funds. Changes in funding mechanisms are both a product of and contain the power to further change health system access, economic stratification, and religious views. The broader Amish studies literature also provides evidence of changing patterns of caretaking, with the possibility of increased institutionalization (Longhofer, 1994). Underlying changes include industrial/professional occupations, smaller family sizes, larger community sizes, and contemporary Christian religious views. Amish embracing these changes are increasingly accepting leisurely, autonomous retirement.