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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Discussion

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

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

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

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

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

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

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

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

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

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

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

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

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