Discuss the cultural development of the African American and Amish heritage in the United States.

1.  Discuss the cultural development of the African American and Amish heritage in the United States.

2.  What are the cultural beliefs of the African American and Amish heritage related to health care and how they influence the delivery of evidence-based healthcare?

Transcultural Health Care: A Culturally Competent Approach, 4th Edition
African Americans
Larry Purnell, PhD, RN, FAAN
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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”.
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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.
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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.
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Afrocentric Framework
Nguzo Sabo
▪
▪
▪
▪
▪
▪
▪
Umojo—unity
Kujichagula—self-determination
Ujimaa—cooperative economics
Ujima—collective work and responsibility
Kuumba—creativity
Nia—purpose
Imani—faith
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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”.
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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.
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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.
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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.
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Transcultural Health Care: A Culturally Competent Approach, 4th Edition
Amish
Larry Purnell, PhD, RN, FAAN
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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