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Journal of Nursing and Researchers
Review Article
Amish Literature Review *Corresponding author
*
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 | 66as 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 | 67contact 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 | 68some 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 | 69as 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 | 70there 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 | 71who 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 | 72frequently 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].
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