Health beliefs and practices: The Iowa old order Amish
Gerdner, Linda A
Participants of this study consisted of 41 Old Order Amish living in a community located near Kalona, Iowa. A secondary analysis of data from a series of ethnographic studies was conducted to explore their: 1) perception of the role of faith and prayer in healing, 2) knowledge and use of folk remedies, and 3) use of health care providers. The majority of Old Order Amish respondents believed that faith and prayer played a major role in healing. All of the informants reported detailed knowledge of folk remedies. Minor trauma, commonly associated with farming, was the condition most often treated by folk remedies. All of the informants utilized the services of a physician, but visits were usually limited to serious health conditions and emergencies. Informants also used a variety of alternative health care providers (i. e., chiropractors, reflexologists).
KEY WORDS: Old Order Amish; Folk Remedies; Health Beliefs.
It is important to understand how the adherence to religious beliefs and the resistance toward modernization in the Old Order Amish has affected their health beliefs and practices. An increased understanding of these phenomena is crucial to the provision of culturally competent care.
Theologically, the Old Order Amish are Anabaptists. Major religious beliefs are identified in the Dortrecht Confession of Faith, a document written at Dortrecht, Holland in 1632. The key tenets include: 1) adult, rather than infant, baptism; 2) separation of church and state; 3) refusal to bear arms, take oaths, or hold political office; 4) excommunication or ‘shunning’ of members who break the church’s moral law; and 5) attempting to live life in accordance with the teachings of Christ as described in the Bible (Schwieder & Schwieder, 1975). Nothing in the Amish understanding of the Bible forbids them from using modern medical services (Hostetler, 1993). However, members believe that faith and lifestyle can most effectively be preserved by practicing separation from the world through group solidarity. Members strive to be selfsufficient and avoid relying on outsiders. In addition, reliance on those outside of the church would “destroy dependency on the church and erode its centrality in the lives of members” (Kraybill, 1989, p. 219).
The purpose of this study was to explore Old Order Amish health beliefs and practices including the: 1) role of faith and prayer in healing, 2) knowledge and use of folk remedies, and 3) use of health care providers. This was accomplished by conducting a secondary analysis of qualitative and quantitative data from the Health Heritage Project, a series of ethnographic studies conducted from 1979-1991.
At the beginning of this project there were about 90,000 Old Order Amish living in 20 states (Hostetler, 1980). While the majority of Amish resided in Pennsylvania, Ohio, or Indiana; Iowa ranked fourth in settlement number with a population of about 2280 (Schwieder & Schwieder, 1975). The Iowa population was generally between fifth and seventh generation Americans. The majority of this Old Order Amish community had relatives arriving in the United States in the mid-18th century and migrating to Iowa primarily from Ohio in the mid-19th century.
Informants were recruited from an Old Order Amish community located near Kalona, Iowa. The area contains six Old Order Amish Church districts, each with 21-30 family units. Initial contacts were made with an Amish Bishop who provided a detailed map indicating the names and locations of all members of the Amish community. This was crucial for working in a rural area, among families with common surnames and without telephones. The bishop also personally endorsed the study and explained its purpose and expectations at an annual school meeting.
There was a remarkable willingness to participate in this study. Only three Amish individuals declined to be interviewed. Data were collected using participant observation and semi-structured interviews. Interviews were conducted by a bilingual research assistant who spoke German. In deference to religious preference, rather than taping the interviews, verbatim notes were written on paper by the interviewer.
The sample consisted of 41 Old Order Amish (25 females and 16 males) with a mean age of 56 years. Approximately 75% of the males were solely farmers, the remainder supplemented farming with ministerial work or farm-related activities (e.g., buggy repair, blacksmith). Over 93% of the women did not work outside of the home; when employed they found work compatible with their lifestyle (e.g. teaching students up to the 8th grade, home care for functionally dependent persons). Old Order Amish are endogamous, marrying within their religious group. The majority (85%) were married with a mean of 6 children (range 1-13) per family.
Descriptive statistics were used to analyze the quantitative data related to 1) importance of faith and prayer in healing, 2) folk remedies used, 3) symptoms considered amenable to folk remedies, and 4) use of health care practitioners. Standard content analysis was used to analyze the narrative data. Ten percent of coded interviews were checked by the principal investigator for accuracy.
Faith and Prayer
Initially we examined the role of faith and prayer in healing for the Old Order Amish. Thirty-seven informants believed that faith and prayer played an important role in healing. Interestingly, four were noncommittal about the role of faith but did believe that prayer had an important role in healing.
The majority credited God with the ultimate “power to heal”. This was exemplified in statements such as: “let it up to God”; and “prayer of faith heals the sick…if it’s God’s will, healing can occur”. Informants also acknowledged that the individual has a responsibility toward this goal. One said, “if we ask God to help us and if we give ourselves up to Him, He can help us”. Similarly, another said, “the only way we can get help is through prayer”. One informant believed that “we have to do what we can and then pray for the Lord’s will”. Another said, “God promised to do what you can’t do, but what you can do for yourself, you’re suppose to do”. In addition, the majority believed that it was ultimately God’s decision as to whether or not prayers would be answered. This is reflected in the following statements: “prayer helps, but it’s important to remember that it might not be God’s will”; “God can heal if it’s His will, also it isn’t His will at all times”; and “we have the confidence in Him; if He sees it fit for us to be well, if not, there is a purpose”.
The role of medicine was believed to be dependent on the wishes of God as conveyed in the following comments: “what doctor’s do is because of the blessing of the Lord”, “if it isn’t God’s will the doctor can’t help”.
Eight Amish identified the importance of “anointing”. This procedure is performed by a minister or bishop who consecrates a seriously ill person with holy oil as a means of arresting death. One informant said, “anointing either heals or you die soon, the main thing is healing us from sin – we need prayers for this”.
For the purposes of this study individuals were encouraged to define the concept of “folk remedy” for themselves, promoting an emic rather than an etic perspective. All of the informants had knowledge of folk remedies and 95% reported using them. As a whole the Amish reported 121 condition/treatment units. However, the range in the number of units known per informant was narrow, with the majority reporting knowledge of six or less treatments, none reported more than twelve (Tripp– Reimer & Martin, 1983). Findings are organized by the conditions amendable to folk remedies.
Minor trauma (43%) was the condition most frequently treated by folk remedies. The incidence of minor trauma was commonly associated with farming and was treated with topicals. The folk remedy most frequently used was the application of aloe vera gel for treatment of cuts, burns, bee stings, and insect bites.
In addition, Union Salve was used as a “healing salve” and/or “drawing salve” for sores, cuts, burns and bruises by seven Old Order Amish. Although it was described as a homemade remedy it was later learned that it could also be purchased at a local Amish general store. This product contains: petrolatum, sheep tallow, oil of tar, carbolic acid, castor oil, mineral oil, lanolin, and beeswax. The label informs the consumer that it is effective for relief of minor burns, sunburn, skin irritation, and bites from nonpoisonous insects. Another couple mentioned a homemade salve prepared from similar ingredients (equal parts of tallow, rosin, and beeswax) that was used for “infection”. The recipe had been given to the couple by a grandma in Ohio. Six additional informants used Watkins salve, a similar compound, for cuts, bruises, splinters or infection.
Some participants used kerosene as a disinfectant for cuts. Two of these informants added that if the injury became infected it should be “soaked in Epson salt water or vinegar water”. Little David was also used in the event of an “infection” or for “getting splinters out”. It was reported that this product contained benzoic acid, salicylic acid, benzocaine and chlorothymol and could be purchased in Florida. Treatment for trauma, such as minor burns, included the topical application of vinegar or the contents of a vitamin E capsule. A raw potato poultice was used for “welder’s flash”.
One informant supplemented her husband’s medical care with the oral administration of boneset tea when his “legs were broken, also when his pelvis was broken”. She described the taste as being “bitter, but it’s O.K. if you want to get well”.
The second condition most commonly treated with folk remedies was respiratory problems (24.8%). Four Old Order Amish identified the use of Poho Oil “for colds and earaches”. Poho oil is a remedy containing peppermint oil in a liquid petrolatum base that was also available for purchase at a local Amish general store. The owner of the store provided the first author with written directions for its use. For a common cold, the patient is instructed to gargle several times a day using a preparation of five to ten drops of Poho Oil in a half glass of water. In addition, a small amount of Poho Oil may be applied “to the fingertip and placed up each nostril”. For an earache, the patient is instructed to rub Poho Oil “in back of each ear”. In addition, a cotton swab may be moistened with Poho Oil and gently inserted into the affected ear.
Four Old Order Amish made an onion poultice/plaster as a decongestant for the common cold. One couple described the preparation as follows: “fry grease, put on breast in a cloth as hot as you can stand”. A more contemporary alternative was the use of Vicks VapoRub, by eight informants, as a decongestant for relief of symptoms associated with the common cold. One of the ingredients contained in this product is turpentine oil. The label instructs consumers to “rub on chest and throat” or to “use in steam as an inhalation”.
Several teas were used for relief of symptoms associated with a cold. This included three informants who ingested a tea made from comfrey/boneset. Another couple drank water with honey and lemon for the treatment of a cold. In addition, four Amish stated that sage tea was effective for the relief of a sore throat, two others gargled with vinegar and water.
The Old Order Amish commonly used vitamins and tonics for health promotion. Thirteen informants took vitamins on a regular basis. The combination of vitamins individuals took varied. One woman took a multivitamin daily along with two calcium tablets. In addition, she took an “iron pill” every other day. Another informant admitted to having health problems, but stated that she was “busy all of the time” so she took vitamin E on a daily basis. Another couple took vitamins periodically, but clarified “we discovered if we eat right we don’t need vitamins”. The use of tonics included: Jason Winters Herbal Tea and sage tea.
Old Order Amish used folk remedies for circulatory problems 6.6%. Teas made from chachoral, yellow dock, and white oak bark were used as “blood purifiers”. Dr. Jason Winters herbal tea was also used as a “blood purifier” by two informants. Golden seal and myrrh was used by one informant for treatment of varicose veins. One olderly woman was taking calcium and B complex tablets for control of “high blood pressure” as recommended by a chiropractor.
Amish identified treatments for gastrointestinal distress less than the other three groups of European descendants in the broader study. One informant treated an upset stomach with an ingestion of liquid aloe vera. A variety of remedies were used for a stomachache including three informants who ingested a tea made from comfrey. The topical application of coal oil on the abdomen was also used for a stomachache.
UTILIZATION OF HEALTH CARE PROVIDERS
All of the informants utilized the services of a physician, but visits were usually limited to serious health conditions and emergencies. Informants also used a variety of alternative health care providers. Over 95% Old Order Amish identified the importance of chiropractic care. Four preferred treatment from a chiropractor to that of a physician for conditions such as “high blood pressure”, a “strained back”, or arthritis. One couple was treated by a chiropractor every six weeks, but limited their visits to a medical doctor for annual “checkups” or “when something is wrong”. Similarly, an Amish woman sought treatment from a chiropractor bimonthly for arthritis and weekly for treatment of a foot condition. However, she and her husband only sought the services of a physician when there was a serious, acute problem. Similarly, another female informant saw a chiropractor biannually to “get back in shape”, but sought the advise of a physician only “when needed for a problem”. One Amish man received monthly treatments from a chiropractor for “adjustment of the hip and lower back”. However, he and his wife had not been seen by a physician for “several years”. Another Amish informant was treated simultaneously by a physician and a chiropractor following a “stroke”.
Approximately 3/4 utilized the services of an osteopathic physician (OD). One male informant said an OD “treats the head more than a chiropractor does – some babies have problems with the soft spot”. Another informant had been successfully treated by an OD for epilepsy and concluded “they got it out of me – I took treatments and they reshaped by head, the skull bones were out of line”.
Over 2/3 of the informants used the services of a reflexologist. One female saw a reflexologist every two weeks for “female problems, cramps” but only contacted a physician “if something turns up”. Another informant obtained treatment from a reflexologist “every two weeks” but was seen by a physician “every two to three months”.
Other alternative health providers were used with less frequency. These included: iridologist (7%) and sclerologist (5%).
Approximately 2/3 of Old Order Amish had knowledge of folk practitioners, but only about 1/4 reported using them. Six informants knew of a folk healer in the immediate area who practiced “laying on of hands” or brauche. One local practitioner reportedly claimed he could “take stomachache away from a baby, he gets it and holds the child to his stomach”. The wife of an informant practiced a similar technique “when their baby has stomach pain”. Two informants had deceased relatives (i.e., grandmother, great aunt) who had been folk practitioners. Five informants knew of Amish folk practitioners residing in Ohio, and two knew of folk practitioners living in Oklahoma. In fact, one couple had traveled out-of-state to obtain the services of a Amish folk practitioner because their infant daughter “was puny”, however; they reported that the treatment didn’t help. Four Old Order Amish declared the practice as “out-of-date”.
Payment of Health Care Services
Thirty Old Order Amish were personally able to pay for health care services with cash, eleven needed to supplement personal cash payments with monetary assistance from the church. One informant explained that Old Order Amish do not purchase health insurance, preferring to pay for health care on their own. However, the church will provide financial assistance when needed. For example, “the church helped pay for [my son’s] surgery”.
The Amish belief system “unifies faith and life” (Tripp-Reimer, Sorofman, Lauer, Martin, & Afifi, 1988, p. 186). Therefore, it is not surprising that the majority of Old Order Amish respondents believed that faith and prayer played a major role in healing. There was also recognition that there was a personal responsibility for maintaining health but the role was ultimately dependent on “God’s will”.
The reliance on folk remedies for minor conditions is consistent with the need to be self sufficient. In general, informants were open in their response to questions. However, one notable exception involved an informant who did not hesitate to discuss an herb that had been prescribed by a chiropractor, but when asked about other remedies, replied “I would rather not answer”.
Aloe vera was mentioned by 15 Old Order Amish. The topical application of aloe vera has been credited for its anti-inflammatory, moisturizing, emollient, and antimicrobial action. Its promotion of wound healing has been supported by several studies beginning with el Zawahry, Hegazy, and Helal (1973). A more recent study found that aloe vera gel appeared to stimulate fibroblast and connective tissue formation in addition to epidermal growth (Werbach & Murray, 1994). Another study supports the use of aloe vera in preventing progressive dermal ischemia caused by burns, frostbite, electrical injury, and intra-arterial drug abuse (Heggers, Pelley, & Robson, 1993).
The informants in this study specified the use of Poho Oil “for colds and earaches”. There is limited research to support the use of peppermint (mentha piperita) oil for the use of a “common cold”. A study conducted by Eccles and colleagues (1990) showed that sucking a lozenge containing 11 mg. of L-menthol did result in an increase in nasal sensation airflow that persisted for up to 30 minutes.
Onion was used as a poultice and placed on the chest for respiratory congestion. Several studies support the anti-inflammatory properties of onion. Dorsch and colleagues (1987) found that onion oils counteracted bronchial obstruction caused by the inhalation of plateletactivating factors in guinea pigs. Another study found that onion extracts inhibited in vitro chemically induced chemotaxis of human granulocytes in a dose-dependent manner and were more active than prednisone (Dorsch, Schwieder Bayer, Breu, Wagner, 1990).
It is theorized that Old Order Amish tend to utilize plant remedies because they are considered natural substances. The literature suggests that the Amish may consider prescriptions as being “too strong, foreign, or even toxic” to the body. However the use of plant or herbal remedies does not insure their safety.
In the U.S. herbals are defined as dietary supplements, per the Dietary Supplement, Health and Education Act of 1994. The Act protects them from regulation, as food additives, unless they are proven unsafe. The manufacturers cannot make therapeutic claims unless they can provide evidence that is acceptable by the Food and Drug Administration (FDA). However, companies manufacturing dietary supplements are not regulated by the FDA. Consequently, consumers and health care professionals are left with an unregulated market that has a growing number of available dietary supplements. Without quality control there is no assurance that the herb contained in the bottle is the same as that stated on the label (Klepser & Klepser, 1999; Vickerly, 2001).
In January 2000 the FDA developed the Dietary Supplement Strategy. The objective of this plan is to establish a science based regulatory program by 2010 that provides consumers with a high level of confidence in the safety, composition, and labeling of dietary supplement products (http://www.cfsan.fda.gov retrieved September 9, 2002).
The informants of this study used a variety of herbal based remedies. Six participants used comfrey tea as a remedy primarily for a stomachache or a “cold”. Two other informants identified the use of Boneset tea for a “cold”. Boneset is a synonym for comfrey. The botanical name for this plant is symphytum officinale. The oral ingestion of symphytum officinale is increasingly becoming recognized as a substantial health hazard with hepatic toxicity in humans and carcinogenic potential in rodents (Pearson, 2000; Ridker & McDermont, 1989; Stickel & Seitz, 2000). As a result, the FDA has advised manufacturers to remove comfrey products from the market (http://www.cfsan.fda.gov retrieved September 9, 2002).
An Amish general store in the area had a small section devoted to commercially prepared herbal remedies. Participants in this study identified specific companies from which they purchased herbal products (i.e., Watkins, Jason Winters, Foods Naturally, Shaklee). It is enlightening to review the marketing strategies employed by these manufacturers. A web site selling Watkins products advertise “you have found the best site for all those old time remedies that your grandmother used to treat everyday ailments of the family”. This is accompanied by the silhouette of a traditional horse and buggy with the statement, “the ole peddler is bringing his remedies..to your door” (http://rubsalva.tripod.com/ retrieved on September 1, 2002). Shaklee self identifies as “a company with a conscience” whose philosophy is “living in harmony with nature” (http://www.shaklee.com retrieved on September 1, 2002). Jason Winters proclaims that he has “discovered the herbs mentioned in biblical writings throughout the world”. A patented herbal tea from this same company is claimed to “revitalize the very soul of all who drink” it (http://www.sirjasonwinters.com/ retrieved September 1, 2002).
Ten informants took vitamins on a regular basis to promote personal health. This remedy can be seen as physiologically neutral if dosages are small or moderate. However, there is potential for hypervitaminosis side effects if large amounts of fat soluble vitamins are ingested (e.g., vitamin E) (Goodman & Gilman, 2001).
The religious beliefs of the Old Order Amish also impact the access and utilization of professional health care. Members refuse social security, Medicare and Medicaid benefits. In addition, members do not subscribe to commercial health insurance. Schwieder and Schweider (1975) attribute the origin of this practice to the biblical scripture “be ye not unequally yoked together with unbelievers…” (II Corinthians 6:14). Therefore, personal medical care can be costly. For expensive treatments, the community often provides financial assistance. In addition, those seeking medical services must often travel outside their community. Religious beliefs prohibit the ownership of cars. Rather than traveling per horse and buggy, the usual mode of transportation, the Old Order Amish frequently hire a driver to transport them to medical facilities.
All Old Order Amish used the services of a physician. However, this was usually limited to serious acute illness or emergency situations. Alternative health practitioners such as chiropractors and reflexologists, were routinely used for health promotion, chronic conditions, or less serious conditions. Schwieder and Schwieder (1975, p. 74) recognize that the Iowa Old Order Amish prefer a “natural” approach to health care and believes this philosophy is reflected in their preference of providers. Chiropractic is identified as a holistic form of health care in which spinal manipulation is the primary therapeutic tool. Nutritional counseling is also an important intervention used by chiropractors (Lawrence, 1999). Reflexology is a therapeutic method that applies manual pressure to specific zones of the foot that correspond to areas of the body to relieve stress, promote health and treat physical disorders (Jonas & Levin, 1999). Iridology is a controversial method of diagnosing medical conditions by identifying irregularities in the pigmentation of the iris. These conditions are then treated with vitamins, minerals and herbs (Ernest, 2000). Sclerology is the assessment of the sclera as a means of determining health status. Herbs are one method of treatment employed by the sclerologist (http://sclerology-institute.org/ retrieved September 9, 2002).
Participants reported limited knowledge of folk healers such as those who practiced “laying on of hands” or brauche and several said this was an “outdated practice”. However, it is possible that informants were more reserved in their willingness to share this information. Wiggins (1983) describes brauche as a form of healing which involves ritual acts and quiet recitation of verses, learned from a person of the opposite sex. More specifically, it has been described as a procedure for a “stomachache or headache” in which the “healer” holds his or her hands near the afflicted person’s head or abdomen for the purpose of “pulling out” or “transferring” the discomfort or pain (Wenger 1991, Wenger & Wenger, 1988). It has been said that brauche is a preferred treatment for small children who are unable to verbalize a specific problem (Wenger, 1995). Offner (1998) recognizes that brauchers, or pow-wowers are eclectic and practice a wide variety of techniques. However, the basic practice described by Offner (1998) is very similar to that of therapeutic touch (Krieger, 1979) or healing touch (Hover– Kramer, Mentgen, & Scandrett-Hibdon, 1996).
In summary, the adherence to their community, church and religious beliefs are entwined in the daily life of Old Order Amish. Findings from this study explore the impact of faith and prayer in healing, knowledge and use of folk remedies within the home environment, and the use of health care providers outside of the community. Findings have been integrated in an effort to provide a more holistic perspective of health care beliefs and practices among the Iowa Old Order Amish. An increased understanding is a critical component of culturally competent care.
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Linda A. Gerdner, RAT, PhD
Toni Tripp-Reimer, RN, PhD, FAAN
Bernard Sorofman, RPh, PhD
ACKNOWLEDGMENTS: This study was funded in part by the American Nurses’ Foundation, The University of Iowa-NIH BSRG program, and the National Institute of Nursing Research/NIH (#RO1 NUO1101); Principal Investigator: Toni Tripp-Reimer, RN, PhD, FAAN.
Linda A. Gerdner, RN, PhD, Assistant Professor, University of Minnesota, School of Nursing, Minneapolis, Minnesota; Toni Tripp-Reimer RN, PhD, FAAN, Professor and Associate Dean for Nursing Research, The University of Iowa, College of Nursing, Iowa City, Iowa; Bernard Sorofman PhD, RPh, Professor and Associate Dean for Academic Affairs, The University of Iowa, College of Pharmacy, Iowa City, Iowa.
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