Transcultural Health Care: A Culturally Competent Approach, 4th Edition Amish Larry Purnell, PhD, RN, FAAN Copyright © 2013 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview ▪ Came to the United States in 1693 for the same reason many other groups came to America—persecution and to practice their lifestyle as they so chose. ▪ No reference group in other parts of the world. ▪ Adapt to dominant society slowly and selectively Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ Mutuality and sharing rather than individual achievement and competition ▪ All speak English and are taught English in school, but most speak Deitsch and various dialects (Pennsylvania German) at home ▪ Healthcare providers by definition are outsiders Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ Majority of men work on farms or in carpentry ▪ If women work outside the home, they work in restaurants, sewing, and teach in their schools ▪ If they work far away from home, prefer to live with another Amish family. ▪ Shared finances are the norm. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ A few have telephones, including cell phones for business but do not let it ring in the house. ▪ Some are using communally shared computers because of the necessity of ordering online instead of mail order catalogues. ▪ A few may drive cars but only out of necessity for work and never on the Sabbath. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ Some illnesses and symptom expression do not have direct translations into English ▪ Highly contexted culture ▪ What is common knowledge regarding health matters to most are not to the Amish due to no TV, major newspapers, etc. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ New communities are being formed in the United States due to lack of land in immediate community ▪ New communities in Kentucky, Tennessee, and Belize, Central America Transcultural Health Care: A Culturally Competent Approach, 4th Edition Overview Continued ▪ Demut—humility and demureness ▪ Gelassenheit—quiet acceptance, reassurance, and resignation ▪ Temporality is grounded into present time and guided by natural rhythms ▪ Seek health care from afar when needed Transcultural Health Care: A Culturally Competent Approach, 4th Edition Myths ▪ They do ride in cars and may even own a car out of necessity but severe restrictions as to when and where it can be driven. ▪ Do use the telephone but do not have them in the home. May be located in a neighborhood grocery or deli. ▪ Kerosene refrigerators and gas hot water heaters—no electricity—generators instead Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Roles ▪ Man is head of the family. ▪ Women are accorded high respect and status. In private they are partners, in public, women assume a retiring role. ▪ Freindschaft—three-generation families. Grandparents live in separate house or separate quarters of the home. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Alternative Lifestyles ▪ Singleness is not stigmatized ▪ Same-sex couple may live together out of necessity when away from home. ▪ Pregnancy before marriage is rare, couple encouraged to marry, or the child can be adopted. Abortion is unacceptable. ▪ Gays/Lesbians remain closeted and can cause concern for healthcare provider. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Genetic Diseases ▪ ▪ ▪ ▪ ▪ ▪ ▪ High rates because of a closed gene pool Ellis-van Creveld Syndrome Cartilage hair hypoplasia Pyruvate kinase anemia Hemophilia B Phenylketonuria Glucaric aciduria Transcultural Health Care: A Culturally Competent Approach, 4th Edition Genetic Diseases Continued ▪ Manic-depressive illness ▪ Bipolar effective disorders are higher than general population ▪ Low rates of alcoholism, drug/alcohol abuse Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ ▪ ▪ ▪ Mostly home-grown foods Local storage lockers Increasing trend for junk/snack food Diet is high in fat and carbohydrates leading to obesity, especially in women. ▪ Food has a significant social meaning during visiting. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Practices ▪ Children are a gift from God and large families are an asset usually ▪ Start families early to mid to late 20s ▪ Have lay-midwives but use allopathic practitioners if necessary ▪ Some women are interested in birth control—as are men, but rarely talked about Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Practices Continued ▪ Will attend live prenatal classes ▪ May use herbs, blue cohosh pills to enhance labor ▪ Grandmothers provide much assistance ▪ Older children help care for younger children Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Exceptionally rare to be in a long-term care facility ▪ If at all possible, prefer to die at home ▪ If family member is caring for the ill at home, neighbors may do the cooking and farm chores ▪ Do use visiting nurses and therapists when needed Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Visiting during illness and after death is an obligation ▪ Neighbors take care of family and friends coming from afar ▪ “Wakelike” sitting up all night is not uncommon ▪ Plain wooden coffin for burial Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals Continued ▪ Burial in home cemetery or in community church cemetery ▪ Death is a normal transition of life ▪ May present as stoic—although loss is keenly felt Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ No regional or national church ▪ Districts divided into 30 to 50 families or 200 to 300 people ▪ All religious leaders are male, volunteered, and untrained ▪ National committee may be used for some decisions affecting other communities Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality Continued ▪ Corporate worship is the norm with faith-related behavior, not individual wishes. ▪ Salvation is ultimately individual. ▪ If engaged in sinful activity, can rejoin the church after proper penitence. ▪ Church officials may be sought in healthcare matters. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ Healthcare decisions are ultimately an individual matter ▪ Want to have a decision in healthcare matters— just ask me/us ▪ Health promotion is a family/individual affair Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ Healthcare knowledge is passed among and between families by the women ▪ No health insurance but communities share and have the Amish Aid Society ▪ Some places give a discount because of cash payment ▪ Cost of procedures may be a deciding factor to have the procedure done Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ ▪ ▪ ▪ Herbal treatments Self-medication Abwaarde—minister by being present Achtgewwe—helping others and is many times gender- and age-related Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Brauche or sympathy curing, laying on of warm hands, or powwowing and is similar to Native American practices ▪ Abnemme—failure to thrive and child is taken to a healer who may perform incantations ▪ Aagwachse or livergrown, grown together caused by jostling buggy rides Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Usually stoical with pain and physical discomfort ▪ “Physically or mentally different” are fully accepted into the community without stigma. ▪ Time off for illness is acceptable. Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practitioners ▪ Braucher or traditional healer first and may be men or women ▪ Use reflexology and massage as well as herbal therapies ▪ Western healthcare practitioners, nurses, physicians, dentists are outsiders, but use them when needed and trusted Transcultural Health Care: A Culturally Competent Approach, 4th Edition African Americans Larry Purnell, PhD, RN, FAAN Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition African American ▪ Second largest “minority” group in the United States. ▪ Negro, black, Black American, person of color, and colored: Depends on the individual. ▪ African American does not necessarily mean you have black skin—it is a term to denote that the person has pride in both the African and American heritage Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition African American ▪ Much diversity among this group in terms of the variant cultural characteristics. ▪ Half live in the Southern United States with large numbers living in large cities in the North. ▪ Most came to the United States involuntarily with the slave trade from Africa. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Education and Occupation ▪ Great inequities in educational opportunities in the past, and this still continues in some areas of the United States with inferior schools and lack of economic and human resources. ▪ High drop-out rates from school due to pregnancy, socioeconomics, and family responsibilities. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Education and Occupation Continued ▪ Less well represented in managerial and professional occupations. ▪ High employment in “blue collar” positions and factories increase risks for cancer and poorer health status—steel and tire industries and other hazardous occupations. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications ▪ Black English dialect where the “th” is pronounced like “de” = dese for these. ▪ Gullah, a Creole language spoken by African Americans who come from the Georgia Coast and South Carolina. A dialect originating from Africa and is really a combination of two other languages. ▪ Spoken in other places in the world. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Highly verbal and expressive with family and trusted friends. ▪ Do not air your dirty laundry. ▪ Dynamic loud speech pattern may be perceived as aggression or anger. ▪ Touch easily among family and trusted friends. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ Expressive nonverbal communications. ▪ Comfortable with close physical distance between conversants. ▪ Direct eye contact can be seen as aggression, especially by elders and lower socioeconomic persons—can be a way of protection, especially in times past. ▪ Culture of “being in becoming” and relaxed with time and have a linear sense of time and are polychronic. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Communications Continued ▪ ▪ ▪ ▪ More formal with names in the beginning. Use appropriate titles. Family name is highly respected. People respected by community may be called aunt, uncle, cousin, mother, etc. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family ▪ Traditionally matriarchal out of necessity during times of slavery. Now more egalitarian but great variation. ▪ Single parenting creates more matriarchal families. ▪ Gender roles are easily inter-changeable. ▪ Cooperative teamwork is valued and the “norm”. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Continued ▪ Value self-reliance and education. ▪ Families try to protect their children from street violence, but society prevails during teen years and attempts may be seen as futile. ▪ Employment at an early age is encouraged to develop self-survival and self-reliance skills— also help with chores. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Continued ▪ Many see the future as having limited opportunities if from the lower educational and socioeconomic levels. ▪ Value the Afrocentric Framework—although some do not know them by name. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Afrocentric Framework Nguzo Sabo ▪ ▪ ▪ ▪ ▪ ▪ ▪ Umojo—unity Kujichagula—self-determination Ujimaa—cooperative economics Ujima—collective work and responsibility Kuumba—creativity Nia—purpose Imani—faith Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Continued ▪ Elders, especially grandmothers, are respected. ▪ Not uncommon for grandparents to assist with and/or raise grandchildren. ▪ Extended family is important and cousins and nephews, etc. are considered nuclear family— so are “non-blood relatives”. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Family Continued ▪ Minimal to no stigma for single parenting. ▪ High HIV and AIDS occurrence due to IV drug use and sexual activity. ▪ Lesbians and gays accepted but not talked about for fear of increased stigma and rejection. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology ▪ Different assessment techniques required to detect cyanosis, pallor, rashes, and jaundice. ▪ Overgrowth of connective tissue leading to keloids. ▪ Long bones are longer, bone density is greater than that of Asians, Hispanics, and EuropeanAmericans. ▪ Greater incidence of birthmarks. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Leading cause of death among males is homicide. ▪ Violence in inner city neighborhoods. ▪ High morbidity and mortality due to hypertension —renin-angiotensin syndrome. ▪ Cirrhosis and diabetes rates are also high. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ Sickle cell anemia ▪ Glucose-6-phosphate-dehydrogenase deficiency ▪ Lactose deficiency ▪ Prostate cancer due to enzyme level detection ▪ Colon tumors are deeper within the colon Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Biocultural Ecology Continued ▪ ▪ ▪ ▪ ▪ ▪ Less responsive to beta-blockers More responsive to monotherapy Less responsive to mydriatic dilation High frequency for psychosis and low frequency for depression Higher doses of neuroleptics Higher incidence of side effects for psychotropics and tricyclics Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition ▪ Symbol for health and wealth ▪ Accept food; otherwise you reject the person ▪ Food considered important for controlling high blood and low blood ▪ Soul food is high in fat and sodium with fatback used frequently Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Nutrition Continued ▪ Children introduced to solid food early ▪ Milk, vegetables, and meat are strength foods ▪ Diet frequently low in Vitamins A and C and iron ▪ High-carbohydrate diet leads to obesity ▪ Overweight is seen as positive Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Practices ▪ Oral contraceptives is the most common method of birth control ▪ Mother and grandmother are the primary advisors for pregnancy and childbearing practices ▪ Consume your craving during pregnancy or the baby will be marked Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Practices Continued ▪ Geophagia, eating non food substances, can lead to iron and potassium deficiency ▪ A few believe that a pregnant woman should not have her picture taken because it will capture the baby’s soul ▪ Do not take pictures while pregnant because it can cause a stillbirth Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Childbearing Practices Continued ▪ After delivery avoid cold air and get plenty of rest ▪ Umbilicus may be wrapped or have a coin placed on it to prevent protruding outward— for some it is a means of protection from evil. Practice is rare but still occurs among some. Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Death does not end the connection between people, can communicate with the dead person’s spirit ▪ Some believe in voodoo death in that death or illness can come to a person through supernatural forces ▪ Voodoo is also known as root work, mojo, spell, fix, or black magic Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Death Rituals ▪ Body must be kept intact after death—I came into this world with all of my body parts and I intend to leave this world with all of my body parts ▪ Falling out due to extreme emotional response. However the person can still hear and understand ▪ Express grief openly and publicly with eulogies at funerals is common Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality ▪ The Black Church is the Black Community ▪ Religion is taken seriously; expect to receive a message in church ▪ Group singing and public testimonials ▪ Most are Baptist or Methodist although they belong to all religious groups including Nation of Islam and Seventh Day Adventist Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Spirituality Continued ▪ Use prayer for all situations ▪ Many believe in laying on of hands while praying—power of being able to heal ▪ May speak in tongues ▪ Inner strength comes from faith in God—it is “God’s Will” —fatalism Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Health-Seeking Behaviors ▪ The world is a very hostile and dangerous place to live ▪ The individual is open to attack from external forces ▪ The individual is considered to be a helpless person who has no internal resources to combat such an attack and therefore needs outside assistance Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices ▪ May be suspicious of outsider healthcare professionals and therefore see a physician or nurse only when absolutely necessary ▪ Natural and unnatural illnesses ▪ May receive care from a “root doctor” simultaneously with biomedical practitioners Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Have a tendency to take medicine on an “asneeded” basis ▪ Barriers to health care include affordability, accessibility, acceptability, adaptability, and past discrimination ▪ Some believe “no pain, no illness” ▪ Able to enter the sick role with ease Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practices Continued ▪ Illness brings the family together ▪ Low rates of organ donation due to lack of information, racism, religion, distrust, and fear of organ being taken prematurely ▪ Blood transfusion acceptable unless religion forbids it Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practitioners ▪ Folk practitioners can be grandmothers, respected women or elders in the community, church leaders, root doctors, or voodoo priests and priestesses, who remove hexes ▪ Some may prefer a care provider of the same gender Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company Transcultural Health Care: A Culturally Competent Approach, 4th Edition Healthcare Practitioners Continued ▪ Folk practitioners are held in high esteem and used by all socioeconomic levels of African Americans ▪ Prefer Western healthcare providers who are known to the family or community ▪ Must establish trust to be effective in return visits Copyright © F.A. Davis Company Copyright ©2013 2008 F.A. Davis Company
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