cultural practices

Definition of Health and Health Promotion BehaviorsAmong Midwestern Old Order Amish Families

Jane M.Armer, PhD, RNM. Elise Radina, PhD

OBJECTIVES: To investigate health beliefs andbehaviors among Old Order Amish. METHODS.- 87Old Order Amish adults. Open-ended questions andquantitative measures - Health Promoting LifestyleProfile (HPLP), Multidimensional Health Locus ofControl (MHLC), and Perceived Social Support (PSS)scales. Hermeneutic analysis of qualitative data.Comparison of means of quantitative measures acrossgender and generation using ANOVA. RESULTS.-Support for multidimensional concept of health, 2)Dominance across generations of exercise/physicalactivity and nutrition as health-maintaining behavior,3) Definition of health as ability to continue working toprovide for family, 4) Work-related physical activitymost frequent health-maintaining behavior; 5)Internal-HLOC consistently scored most highly; 6)

Chance-HLOC scores were higher than powerful oth-ers-HLOC scores; 7) HPLP - nutrition ranked amonghighest and exercise ranked lowest; and 8) PSS-familyscores were higher than PSS-friends scores. CON-CLUSIONS: Strong Amish family support systemmakes family involvement in health maintenance essen-tial, 2) Findings important for clinicians working withpersons who prefer natural remedies to complex scien-tific options, 3) Evidence that health/illness of cultural-ly-diverse rural persons may be unique, and 4) Needfor further examination of cultural appropriateness ofmeasures in research with diverse groups.

KEY WORDS: Health Behaviors; Internal-External Control; Lifestyle; Religious Beliefs;Social Support.

T he aim of this multi-generational, ethno-reli-gious minority research project was toexplore health promotion and well-beingamong three generations of one ethnically-ACKNOWLEDGMENTS: This research was sup-ported in part by the University of Missouri ResearchBoard (#93-053) and the University of Iowa Centeron Aging, National Institute on Aging PostdoctoralFellowship (NIH AG00214).

Jane M. Armer, PhD, RN, Sinclair School ofNursing, and M. Elise Radina, PhD, Department ofFamily and Community Medicine, both are at theUniversity of Missouri, Columbia.

diverse group - Old Order Amish. Although manystudies document health promotion activities amongthe general population (e.g., Collins, et al. 2001;Kaufman, 1996; Miller, 1991), relatively few investi-gators have focused on such behaviors among mem-bers of diverse subgroups (DeSantis, 1989; 1993). Thediscrepancies in life expectancy, morbidity, and mortal-ity among different ethnic groups (Arnold, 1993; Ma &Henderson, 1999) may relate to differences in lifestyleor health-promoting behaviors (Foster, 1992;Geronimus, 2000). Indeed, as an ethnic and religiousminority group, the Amish experience of health in theU.S. may be quite different from that of the majoritypopulation and other population subgroups.

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 12:3 FALL 2006 44

The overall goal of the larger research projectwas to examine factors influencing the health, well-being, and health promotion practices of community-based, ethnically-diverse rural older adults. The specif-ic aims of the reported research were to: 1) examineand compare open-ended responses to health definitionand health maintenance practices among three genera-tions of Old Order Amish, and 2) compare and contrastthe variables of health locus of control, health-promot-ing lifestyle, and perceived social support among thethree generations.

AMISH HERITAGE

The Old Order Amish are descendants of the16 century Swiss Anabaptists, a group that espousedbaptism of adult believers and opposed infant baptism.In the early 1700's, to escape religious persecution, theAmish broke away from the Mennonites and immigrat-ed to the U.S., settling in Pennsylvania. Today, theAmish seek to maintain a separateness from the worldby maintaining a simple lifestyle without material lux-uries, a distinctive style of dress that is similar to the16"^ century European peasants, an agricultural way oflife, travel by horse and buggy, and absolute pacifism(Bomar, 1989; Fuchs, Levinson, Stoddard, Mullet, &Jones, 1990; Hostetler, 1993; Kraybill, 1989; Pahner,1992). Not opposed to technology per se, they areopposed to "becoming worldly," and carefully maintaintheir separateness by keeping technology at a lessaccessible distance (Hostetler, 1993). For example, useof a telephone belonging to a neighbor or business, orlocated in a covered shelter at the end of a lane andshared by more than on family, might not be prohibitedin the Amish community.

The religious and cultural beliefs of the Amishresult in many health perceptions and behaviors thatdiffer significantly from the dominate American culture(Adams & Leverland, 1986; Brubaker & Michael,1987; Buccalo, 1997; Palmer, 1992; Schweider &Schweider, 1975; Wiggins, 1983). For example, theAmish voluntarily abstain from participation in thegovernment social security system, choosing to main-tain separateness from the world by relying on a casheconomy and "self-insurance" through community sup-port in case of natural disaster or major health crisis(Glenn, 2001).

This rarely-studied group has approximately150,000 believers in 20 states and Canada today and astrong presence in the Midwest (Harden, 1996).Communities of Amish exist in every state with a major

agricultural base. Birth control measures are not rou-tinely practice, resulting in large families and rapidgrowth of the Amish population (Brubaker & Micheal,1987; Smith, 1961). The Amish represent a young andextremely fast-growing population subgroup, thefastest growing rural group in the U.S. As an ethnicsubgroup within the vulnerable rural U.S., it is impor-tant that researchers and practitioners better understandAmish health perceptions and health promotion prac-tices to help them optimize health and health careaccess.

Because formal education is limited by reli-gious beliefs, the Amish rely on non-Amish, knows asthe "English," for health care needs not met by self-care practices (Hostetler, 1993). Folk medicine such asthe use of liniments, vitarnins, reflexology, mid wives,and therapeutic touch are routinely practiced (Hostetler,1980; Trier, 1991). "Pow wowing," a practice of sym-pathy curing or faith healing using words, charms, andphysical manipulations, to heal is common (Hostetler,1980,p.274; 1993).

Although the use of modem medical technolo-gy is not prohibited by religious beliefs, the Amish arecautious and conservative in action (Hostetler, 1993)and may refuse health services if approval has not beengranted by the community leaders (Wenger, 1991). Forexample, Amish families and communities vary inreceptivity to the practice of immunization for commu-nicable diseases, leading to increased vulnerability toepidemics (Trier, 1991). The Amish are at risk becausethey travel into the non-Anlish community for periodicshopping and visits to relatives in distant Amish com-munities. Although the Amish account for less that0.5% of the national population, they experienced near-ly all rubella reported in the U.S. in 1991 (Briss, Fehrs,Hutcheson, & Schaffner, 1992), a clear example oftheir unique vulnerability.

With scant data (e.g., Troyer, 1988) on inci-dence, prevalence, mortality, and morbidity specific tothe Amish population, Ami$h health risks related to car-diovascular disease, diabetes, cancer, and other dis-eases prevalent in the dominant population are largelyunspecified. The unique combination of Amish lifestyleand genetic factors may lessen or increase the impact ofcertain risk factors.

METHODS

Cultural Beliefs

Cultural beliefs of individuals define health

45 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 12:3 FALL 2006

Table 1. Demographic and Historical Summary of Participants by Generation

Variable

Age (years)

Education (years)MalesFemales

TotalChronic Conditions

MalesFemales

Total

% female^ Generations: Young

Total (N=86)

X

46.41

8.048.128.09

1.842.312.08

59%= 18-39 years,

Young(n=43)X (range)

25.67 (18-39)

8.25 (8-9)8.27 (8-9)8.26

0.751.040.90

63% (n=27)Middle = 40-59 years,

Generation ^

Middle (n=29)X (range)

45.14 (40-57)

8.16 (7-9)8.38 (7-9)8.29

1.922.322.12

61% (n=17)Older = 60+ years

Older(n=14)X (range)

68.43 (60-78)

7.71 (7-8)7.71 (7-8)7.71

2.863.573.22

50% (n=7)

and illness and when and how they will seek access tohealth care (Tripp-Reimer, Johnson, & Rios, 1995). Forinstance, cultural groups within the U.S. do not alwaysview health as a primary value. Group members expe-rience conflicts between their own particular culturalvalues and those of the larger society (Yeatts, Crow, &Folts, 1992). The significance or meaning of health andhealth care for individuals and families of varyingbackgrounds must be understood if health care profes-sionals are to help these clients to optimize their health(Lask, 1991). Understanding the viewpoint of theminority elderly is particularly important so that theircultural heritage and beliefs be maintained while theirhealth and independence are maximized.

Participant Recruitment and Characteristics

Participants were Midwestern conservative OldOrder Amish adults who were voluntarily participatingin a health screening program offered in a local AmishschooUiouse. After initial contact via the health screen-ing program, family members were invited to partici-pate in the present study. Additional recruitment wasconducted through snowball sampling. Potential partic-ipants were given letters of information about the pres-ent study via mail or personal delivery at health screen-ing sites. Potential participants were screened to ensurethey met inclusion criteria: over age 18, verbally facile,and membership in the Amish community. Upon con-senting to participate, interviews were scheduled.

As demonstrated in Table 1, participants aver-aged eight years of formal education (range = 6 to 9years) in the one-room schoolhouses where lessonswere taught in both English and German. This level ofeducation is consistent with what is widely expected inAmish communities (Kachel, 1989). The age range ofall participants was 18 to 78 years with a median age of40 years. Although 73% of the respondents of all ageswere married, 100% of respondents over the age of 60years were married. Fifty-two percent of the partici-pants were female. Respondents over age 60 reportedan average of 3.3 chronic health conditions. For com-parison purposes, participants were classified into threegenerations: young (18-39 years), middle (40-59years), and older (60+ years).Ensuring Culturally Appropriate Measurement

When approaching research with non-main-stream populations (i.e., non-European American, mid-dle-class, Christian-oriented), it is essential to considerthe cultural appropriateness of data collection proce-dures including choice of instruments and method forcollecting data from participants. Sedlacek (1994)argues that there is often a belief among researchersthat what is good for one must be good for all. Becausehumans are inherently diverse, it is impossible forevery research instrument to provide unbiased meas-urement of all people. Related to this is the use of tra-ditional approaches to data collection and analysis that


urement of all people. Related to this is the use of tra-ditional approaches to data collection and analysis thatmay be biased toward mainstream interpersonal normsof interaction. For example. Land and Hudson (1997)found that face-to-face interviewing was a more effec-tive method of data collection for studying Hispaniccultures than mailed surveys that are often perceived asmore impersonal. Although this method was moretime-consuming and costly than mailed surveys, thecultural value of personalismo of the participant popu-lation warranted this modification in methodology.

In consideration of these issues regarding mul-ticultural research, the primary author made severalefforts to incorporate-culturally appropriate proceduresinto data collection. First, the entire interview tool wasreviewed by professional caregivers from agenciesserving this Amish community. Second, pilot work wascompleted with an elderly Amish couple who assessedand evaluated the cultural appropriateness and sensitiv-ity of the interview tool. Third, because some membersof the Amish community may be uncomfortable withthe use of modem technology, the use of audio-tapingwas not included in the present procedures. Rather,interviewers took detailed notes during the interviewsand followed each interview with written fieldnotes.

Instruments and Interview Protocol

All participants took part in a face-to-faceinterview lasting between one and two hours on aver-age. The interview was conducted by trained graduatenursing research assistants who read the items to partic-ipants who were unable to read or who had apparentdifficulty completing the forms. Some participantshowever, preferred to complete the interview on theirown with face-to-face verification by a research teammember. Because several tools were checklists, andmost were designed specifically for use with older par-ticipants, interview fatigue was minimal. Data werecollected using completed quantitative measures, notestaken during the interviews, and post-interview field-notes. Up to three generations were interviewed in thefirst wave of data collection due to the extended familynetworks and geographical proximity of multiple gen-erations of family members.

The interview was composed of open-endedand semi-structured questions dealing with affectiveexperiences (Lawton, 1988), health practices, andhealth perceptions; and scales measuring psychologicalvariables of perceived control (Reid & Ziegler, 1981),health locus of control (Wallston, Wallston, & DeVellis,1978), health-promoting lifestyle (Pender, Walker,

Sechrist, & Stromberg, 1988), perceived social supportfrom family and friends (Procidano & Heller, 1983),self-rated health, and morale (Lawton, 1975).Descriptive data in the areas of health care practicesand self-rated well-being were collected using twoLikert-scale items, and open-ended questions focusingon the type and frequency of health-promoting behav-iors (i.e., "Tell me about five things you do to stayhealthy. For each of these things you listed, tell me howoften you do it.") and on health definition (i.e., "Tell mewhat being healthy means to you?"). For the presentstudy, analyses were focused on responses to the open-ended questions and the measures of health locus ofcontrol, health-promoting lifestyle, and perceived sup-port from family and friends.

Health locus of control was measured usingWallston and Wallston's (1981; Wallston et al., 1978)18-item Multidimensional Health Locus of Control(MHLC) Form A. This measure contains three 6-itemscales measuring dimensions of health locus of control:intemal (IHLC) , powerful others (PHLC), and chanceextemality (CHLC). The IHLC consists of questionsconceming how strongly individuals feel they are incontrol of their health status (e.g., "If I take care ofmyself, I can avoid illness"). The alpha coefficient forthis scale has been reported as .767 for Form A. ThePHLC scale includes questions assessing individuals'perceptions of powerful others' (i.e., doctors, nurses,etc.) control over their health (e.g., health professionalscontrol my health). The alpha coefficient for this scalehas been reported as .673 for Form A. The CHLCmeasures individuals' beliefs that their health status islargely based on chance or fate and that they or anyoneelse has little control over whether they will get sick orbecome well again (e.g., "No matter what I do, if I amgoing to get sick, I will get sick"). The alpha coeffi-cient for this scale has beeti reported as .753 for FormA (Wallston et al., 1978). The MHLC has been fre-quently used with older (e.g.. Fried, van Doom,O'Leary, Tinetti, & Drickamer, 2000; Johansson,Grant, Plomin, & Pederserl, 2001), multicultural (e.g.,Barroso et al., 2000) and rural populations (e.g.,Winstead-Fry et al., 1999).

Health-promoting lifestyle was measured usingPender and colleagues' (Pender et al., 1988; 1990) 48-item Health Promoting Lifestyle Profile (HPLP). TheHPLP is composed of six subscales: stress management(a= .702), interpersonal relationships (a = .800), healthresponsibility (a = .814), self actualization (a = .904),nutrition (a = .757), and exercise (a = .809). The alphareliability for the complete HPLP has been reported as.922 (Walker, Sechrist, & Pender, 1987). The HPLP has


been frequently used with older (e.g.. Conn, 1998;Pullen, Walker, & Fiandt, 2001), multicultural (e.g.,Duffy, Rossow, & Hernandez, 1996; Nies, Bluffington,Cowan, & Hepworth, 1998; Peltzer, 2002) and ruralpopulations (e.g., Pullen et al., 2001).

Perceived social support was measured usingProcidano and Heller's (1983) Perceived SocialSupport-Family (PSS-Fa) and -Friends (PSS-Fr) 20-item scales. The PSS-Fa assesses perceptions of actual,available support from one's family members (e.g., myfamily is sensitive to my personal needs; my familygives me the moral support I need). The alpha coeffi-cient for this scale has been reported as .90. The PSS-Fr evaluates perceptions of actual, available supportfrom friends (e.g., "My friends are sensitive to my per-sonal needs;" "My friends gives me the moral supportI need"). The alpha coefficient for this scale has beenreported as .88 (Procidano & Heller, 1983). The PSSsub-scales have been used with multicultural popula-tions (e.g.. Way, Coal, Gungold, Pahl, & Bissessar,2001).

DATA ANALYSES

Hermeneutic analyses (Packer, 1985) wereused with qualitative data from the open-ended ques-tions regarding definition of health and health promo-tion practices. Initial coding of responses to the open-ended questions were organized into categories fol-lowed by thematic analysis (Lincoln & Guba, 1985).The unit of analysis was the complete thought deter-mine by both a natural pause in the individual's train ofthought and the identification of ideas and topics thatcould stand alone as independent entities. For example,if a participant said, "I walk each day, eat good food,and try to take vitamins," the concepts of walking, eat-ing, and vitamins were coded as three separate units ofanalysis. Coding in this fashion is consistent with qual-itative content analysis described by Germain (1993).

Means were calculated for the quantitativevariables and subscales of interest. Due to potentialproblems with dependence of responses secondary tomultiple familial relationships (41 of the 87 partici-pants were related to one or mother other participants),ANOVA and MANOVA were used to compare meansacross generation.

FINDINGS

Results and Discussion of Qualitative Analyses

The results of the content analysis of qualita-

tive data included responses to questions regardingindividuals' definitions of health and health mainte-nance behaviors. The brevity of participants' responsesto these open-ended questions may refiect a more par-simonious worldview or this brevity may possibly berelated to responding to questions in a non-native lan-guage - German is the first language spoken among theAmish. This brevity of words may have implicationsfor patient teaching and printed patient education mate-rials. The emergent themes for both questions are pre-sented below.

Definition of Health

In the categorization of the data on definitionof health, six themes emerged: the importance of beinghealthy, the ability to work hard, a sense of freedom toenjoy life, family responsibility, physical well-being,and spiritual well-being. These themes were consistentacross the age groups and validated in a letter by onemiddle-aged male participant who chose to respond tothe research team in writing instead of in a formal inter-view (Appendix A).

The first theme, the ability to work hard, wasconsistently expressed by both young and old respon-dents. One reason for the prevalence of this belief maybe that older adults in Amish communities are expect-ed to and do maintain their functional roles throughouttheir life courses, even despite possible disabling con-ditions (Hewner, 1997; Roth, 1997). Another reason forthis belief may be that in Amish communities all indi-viduals over the age of five years who are in goodhealth are expected to work (Roth, 1997). Specificservice to the community as an indicator of beinghealthy, beyond simply the ability to work hard, wasuniquely reported by two respondents. Thus, being ableto work appears to be highly valued as a definition ofindividual health status among these Amish.

The second theme, the importance of beinghealthy, was apparent in responses such as: "veryimportant" or "everything." One respondent equatedgood health to "life itself." Often there was a one-to-two-word global response. For example, one briefresponse to the definition of health question was simplytwo words: "feeling good." One possible explanationfor this response may be the importance of being ableto work among the Amish. Being in poor health andunable to work may be stigmatized and therefore avoid-ed.

The third theme, a sense of freedom to enjoylife, was evident when several respondents noted thatbeing healthy meant "being able to do whatever you


want." The concept of freedom may run contrary to tra-ditional understandings of Amish communities as high-ly structured and rule driven. Rather, Kraybill (1989)argues such structure provides boundaries that allowfor the development of a sense of meaning, belonging,and identity among the Amish. Statements such asthese about personal freedom as an indicator of one'shealth status may reflect individuals' perceptions thatthey are not hindered by their health to fulfill their fam-ily and community obligations. That is, a woman's abil-ity to clean her family's clothes, which she wants to doto fulfill her family role, is an indicator of her personalfreedom and thus her health status. One individualwrote that being healthy meant being able to "enjoy thebeauty of nature." The ability to enjoy the outdoors andnature may be indicative of the agrarian-based lifestyleof the Amish (Roth, 1997). Another individual spoke ofbeing able to travel to visit family because she washealthy. This sentiment may be a result of the salienceof family among the Amish discussed below.

A fourth theme, family responsibility, dealtwith being able to raise a family and to be able to pro-vide for them. The central importance of the familyhas its origins with the religious beliefs of the Amishwhere the entire society is based around the family.Churches measure the size of their congregation bynumber of families rather than individuals and worshipservices are held in families' homes or bams (Bachman,1942; Kraybill, 1989). Most Amish adults marry andhave families. The mainstream U.S. concepts ofdivorce and remarriage are forbidden (Roth, 1997). Allof these factors work together to establish the salienceof the family among the Amish. Thus, being able toprovide for one's family as an indicator of beinghealthy should be expected.

The fifth theme, physical well-being, was char-acterized by participants' mentioning of having energyor feeling good. This theme may be related to othersdiscussed above including being able to work and pro-vide for one's family. Quite simply, having the energyand feeling as though one is not ill are important toone's abilities to be a contributor to the community andfamily. Thus, it appears that not only is individual abil-ity important to health status but individuals' percep-tions of being physically able to contribute are alsoimportant.

A sixth theme, spiritual well-being, was evi-dent when participants spoke of being healthy as beingspiritually healthy. This occurred across the groups, asmany spoke of worshipping in a simple setting such asa home in the community. Because of the centrality ofspirituality and religion among the Amish (Hostetler,

1980), the mentioning of the concept of spiritual healthamong these participants is to be expected.

Health Maintenance Behaviors

Participants were asked to report activitiesdone regularly to stay healthy. The analysis of the self-reported health maintenance behaviors supports thenotion of a multidimensional concept of health outlinedin the MHLC. Mental, physical, psychological, andspiritual components of health behaviors were cited.This is consistent with findings among the other diversegroups of community-dwelling respondents (Armer &Conn, 2001; Huck & Armer, 1996).

Behaviors categorized as exercise/physicalactivity and nutrition dominated the responses. Work-related physical activity was the most frequent health-maintaining behavior cited by both males and females.In tum, health was frequently defined by the ability tocontinue working to provide for the needs of the fami-ly. One respondent listed five activities carried out reg-ularly to maintain health - all of which were related tostrenuous out-of-doors activities, such as haulingmanure, milking cows, and doing shop work.

QUANTITATIVE ANALYSES

Quantitative findings were derived from partic-ipants' responses on the Multidimensional HealthLocus of Control scale (MHLC: Wallston & Wallston,1981; Wallston, et al 1978), Health Promoting LifestyleProfile (HPLP: Pender et al., 1988; 1990), andPerceived Social Support (PSS) -Family and -Friendsscales (Procidano & Heller^ 1983). Table 2 includes themeans and standard deviations for the three generationson each of these scales.

The mean responses of the MHLC was statisti-cally similar across the generations. Intemal healthlocus of control (IHLC), the tendency to perceiveresponsibility for one's health to lie with the individual,was consistently scored most highly by all generations.Respondents scored higher on the chance HLC scale,related to the perception of one's state of health beingstrongly affected by chance or fate (i.e., forces outsideone's control), than the PHLC scale, related to the ten-dency to perceive one's health to be related to actionsof powerful others such as doctors, nurses, and family.Statistically, there were no significant differencesacross the generations on the MHLC scales.

On the HPLP, the nutrition subscale rankedamong the highest and the exercise subscale consistent-ly ranked the lowest of the six subscales. The three gen-


erational groups ranked nutrition behaviors as first ofsix health-promoting behavior subscales. Exercise wasranked sixth by the young and middle generations andfifth among those over age 60. In contrast, nutrition andexercise behaviors were consistently the most frequent-ly reported health maintenance behaviors in response tothe open-ended question, and the most frequent behav-iors carried out by respondents, across generation. Incross-generational comparisons of HPLP subscalescores, means were stable.

Perceived Social Support scores were consis-tent across generations. The three generations allscored higher on the PSS-Fa scale than the PSS-Frscale. A statistically significant difference betweengroup means was found. T-test revealed that this differ-ence was marginal (p

nance activities chosen by Old Order Amish. The diver-sity of the range of health promotional activities report-ed supports the concept of a multidimensional defini-tion of health by these persons. The importance of theability to work and provide for family was clearly com-municated by participants of all ages. Findings support-ing the notion that health and illness experiences of cul-turally-diverse rural persons, such as the Amish, mayindeed differ from other rural cultural groups as well asthe dominant white, middle-class perspective.

Consideration of the cultural and generationalappropriateness of tools designed to measure healthpromotion behaviors and perception is essential to thedesign and conduct of research aimed at increasingunderstanding of and guiding interventions for vulner-able groups. For example, the discrepancy between theHPLP rankings and the open-ended responses suggests

aspects of exercise perceived by elders to infiuencehealth status may not be captured by the standardizedHPLP subscale. The inversion of the powerful othersand chance HLC scores has implications for under-standing Amish perceptions of health and illness andwhat may be considered appropriate interventions fordisease prevention and cure. These findings suggest theneed to further examine factors influencing health andwell-being among these diverse groups.

Further comparative analysis of definitions ofhealth and health promotion behaviors among otherdiverse groups (e.g., urban/rural African American,Catholic nuns) is in progress (Armer & Radina, inreview). These preliminary research findings increaseunderstanding of health-promoting and health-main-taining behaviors among members of these culturallydiverse rural groups.

APPENDIX A

Letter from Participant

We eat 3 full meals a day. Most of our food ishome grown which includes a lot of whole wheat fiour.We don't watch our cholesterol but we do watchrefined sugar and salt some.

We do have one day a week (Sunday) to relaxfrom earthly work. Which we also attend church regu-larly and also is a day to sometimes visit friends orolder people, sick, etc.

Most weekdays are about the same. We get upin the morning - 4:30 -5:00 an go to bed from 9:00-10:30. we try to keep us busy with some kind of work- for two reasons. There is always something that

should be done to provide for the family and it's betterfor us if we have some kind of work to keep our mindson. Of course we also take some time off to rest andrelax like over the noon hour, etc. Sometimes, we alsotake an evening off to get together with our friends orparents and family members. Sometimes we also takethe day off to go to a public sale, bam raising, quiltingor the likes.

There is hardly ever that we see a Physicianunless for a broken bone or something that we can'thandle at home. We don't depend on drugs to keep ushealthy.

We don't take any special exercise. We don'tuse any alcohol, tobacco, or illegal drugs.

REFERENCESAdams, C. E., & Leverland, M. B. (1986). The effects of reli-

gious beliefs on the health care practices of the Amish.Nurse Practitioner, 77, 58, 63, 67.

Armer, J. M., & Conn, V. S. (2001). Exploration of spiritual-ity & health among diverse rural elderly individuals.Journal of Gerontological Nursing, 27,28-37.

Armer, J.M., & Radina, M.E. (In review). Perceptions ofhealth among multiple culturally diverse groups.

Arnold, C. B. (1993). Heart disease mortality: Internationalcomparisons. Statistical Bulletin, 74,19-26.

Bachman, C. G. (1942). The Old Order Amish of LancasterCounty, Pennsylvania. Norristown, PA; German Society.

Barroso, J., McMillan, S., Casey, L., Gibson, W., Kaninski,G., & Meyer, J. (2000). Comparison between African-American and white women in their beliefs about breastcancer and their health locus of control. Cancer Nursing,

23,268-276.Bomar, P. J. (1989). Nurse and family health promotion:

Concepts, assessment, and interventions. Philadelphia,PA: Saunders.

Briss, P.A., Fehrs, L. J., Hutcheson, R. H., & Schaffner, W.(1992). Rubella among the Amish:

Resurgent disease in a highly susceptible community.Pediatric Infectious Disease Journal, 11, 955-959.

Brubaker, T. H., & Michael, C. M. (1987). Amish families inlater life. D. E. Gelfand & C. M. Barresi (Eds.), Ethnicdimensions of aging (pp. 110-116). New York: Springer

Buccalo, S. (1997). Window on another world: An "English"nurse looks at the Amish culture and their health carebeliefs. Journal of Multicultural Nursing & Health, 3,53-58.

Collins, R. L., Kanouse, D. E., Gifford, A. L., Senterfitt, J. W.,


Schuster, M. A., McCaffrey, D. F., Shapiro, M. F., Wenger,N.S. (2001). Changes in health-promoting behavior fol-lowing diagnosis with HIV: prevalence and correlates ina national probability sample. Health Psychology, 20,351-60,2001.

Conn, V. S. (1998). Older adults and exercise - Path analysisof self-efficacy related constructs. Nursing Research,47,180-189.

DeSantis, L. (1989). Health care orientations of Cuban andHaitian immigrant mothers: Implications for health careprofessionals. Medical Anthropology, 12, 69-89.

DeSantis, L. (1993). Haitian immigrant concepts of health.Health Issues, 17, 3-\6.

Duffy, M. E., Rossow, R., & Hernandez, M. (1996).Correlates of health-promotion activities in employedMexican American women. Nursing Research, 45, 18-24.

Fried, T. R., van Doom, C , O'Leary, J. R., Tinetti, M. E., &Drickamer, M. A. (2000). Older persons' preferences forhome vs. hospital care in the treatment of acute illness.Archives of Internal Medicine, 160, 1501-1506.

Foster, M. F. (1992). Health promotion and life satisfactionin elderly black adults. Western Journal of NursingResearch, 14,444-463.

Fuchs, J. A., Levinson, R. M., Stoddard, R., Mullet, M. E., &Jones, D. H. (1990). Risk behaviors among Amish:Results of a survey. Health Education Quarterly, 17,197-211.

Germain, C. P. (1993). Ethnography: The method. In P. L.Munhall & C. O. Boyd (Eds.),Nursing research: A qual-itative perspective (pp. 237-267). New York: NationalLeague for Nursing Press.

Geronimus, A. T. (2000). To mitigate, resist, or undo:addressing structural influences on the health of urbanpopulations. American Journal of Public Health, 90,867-72.

Glenn, B. J. (2001). Collective precommitment from tempta-tion: The Amish and social security. Rationality andSociety, 13, IS5-204.

Harden, M. (1996). From plows to profits. The Marketplace:A Magazine for Christian Businessmen, May-June, 6-7.

Hewner, S. J. (1997). Biocultural approaches to health andmortality in the Old Order Amish community.Collegium Antropologicum, 21,67-82.

Hostetler, J. A. (1980). Amish society. Baltimore, MD: TheJohns Hopkins University Press.

Hostetler, J. A. (1993). Amish society (3^^ edition).Baltimore, MD: The Johns Hopkins University Press.

Huck, D. M., & Armer, J. M. (1996). Health perceptions andhealth promoting behaviors among elderly Catholicnuns. Family and Community Health, 7S, 81-91.

Johansson, B., Grant, J. D., Plomin, R., & Pedersen, N. L.(2001). Health locus of control in late life: A study ofgenetic and environmental influences in twins aged 80years and older. Health Psychology, 20, 33-40.

Kachel, D. (1989). How the Amish educate their children:

Can we leam from them? Educational Horizons, 67,93-97.

Kaufman, J. E. (1996). Personal definitions of health amongelderly people: A link to effective health promotion.Family & Community Health, 19, 58-68.

Kraybill, D. B. (1989). The riddle of Amish culture.Baltimore, MD: The Johns Hopkins University Press.

Land, H. & Hudson, S. (1997). Methodological considera-tions in surveying Latina AIDS caregivers: Issues insampling and measurement. Social Work Research, 21,233-246.

Lask, M. E. (1991). Community health nursing in a minoritysetting. In B. W. Spradley (Ed.), Readings in communityhealth nursing (4* edition) (pp. 512-520). New York: J.B. Lippincott.

Lawton, M. P. (1975). The Philadelphia Geriatric CenterMorale scale: A revision. Journal of Gerontology, 30,85-89.

Lawton, M. P. (1988). Environmental proactivity and affectin older people. Paper presented at the Fifth AnnualSymposium on Applied Social Psychology, Pomona,CA: The Claremont Colleges.

Lincoln, Y, & Guba, E. (1985). Naturalistic inquiry. BeverlyHills, CA: Sage.

Ma, G. X., & Henderson, G. (1999). Ethnicity and healthcare. In G. X. Ma & G. Henderson, Rethinking ethnicityand health care: A sociocultural perspective.Springfield, IL: Charles C. Thomas publisher.

Miller, M. P. (1991). Factors promoting wellness in the agedperson: An ethnographic study. Advances in NursingScience, 13, 3%-5\.

Nies, M.A., Bluffington,C., Cowan, G.,& Hepworth, J.T.(1998). Comparison of lifestyles among obese and non-obese African American and European Americanwomen in the community. Nursing Research, 47, 251-257.

Packer, M. J. (1985). Hermeneutic inquiry in the study ofhuman conduct. American Psychologist, 40, 1081-1093.

Palmer, C. V. (1992). The health beliefs and practices of anOld Order Amish family. Journal of the AmericanAcademy of Nurse Practitioners, 4, 117-122.

Peltzer, K. (2002). Health-promoting lifestyles and personal-ity among black South African students. Social Behaviorand Personality, 30, All-All.

Pender, N. J., Walker, S. N., Sechrist, K. R., & Stromberg, M.F. (1990). Predicting health-promoting lifestyles in theworkplace. Nursing Research, 39, 326-332.

Pender,N. J., Walker, S. N., Sechrist, K. R., & Stromberg,M.F. (1988). Development and testing of the health promo-tion model. Cardiovascular Nursing, 24, 41-43.

Procidano, M. E., & Heller, K. (1983). Measures of per-ceived social support form friends and from family:Three validation studies. American Journal ofCommunity Psychology, 11, 1-24.

Pullen, C , Walker, S. N., & Fiandt, K. (2001). Determinantsof health-promoting behaviors in rural older women.Family and with the locus of control construct


Community Health, 24,49-72.Reid, D. W., & Ziegler, M. (1981). The desired control meas-

ure and adjustment among the elderly. In H. Lefcourt(Ed.), Research (Vol. 1). New York: Academic Press.

Roth, D. E. (1997). The journal of life: Aspects of olderadulthood among the Old Order Amish. Journal ofAging and Identity, 2, 59-78.

Schweider, E. W., & Schweider, D. (1975). A peculiar peo-ple: Iowa's Old Older Amish. Ames, IA: The Iowa StateUniversity Press.

Sedlacek, W. E. (1994). Issues in advancing diversitythrough assessment. Journal of Counseling andDevelopment, 72,549-553.

Smith, E. L. (1961). The Amish today. Allentown, PA:Schlechters.

Trier, K. K. (1991). Assessment of health needs in ruralAmerica: A comparison of Amish and non-Amish fami-lies. Sociological Practice, 9, 153-169.

Tripp-Reimer, T., Johnson, R., & Rios, H. (1995). Culturaldimensions in gerontological nursing. In M. Stanley &J. Baer (Eds.), Gerontological Nursing. Philadelphia,PA: F. A. Davis.

Tripp-Reimer, T., & Martin, M. (1988). Knowledge and useof folk remedies among ethnic aged. In G. Felton & IAlpears (Eds.), Nursing research: A monography fornon-nurse researchers (pp. 100-113).

Troyer, H. (1988). Review of cancer among 4 religious sects:Evidence that life-styles are distinctive sets of risk fac-

tors. Social Science & Medicine, 26, 1007-1017.Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The

Health-I'romoting Lifestyle Profile: Development andpsychometric characteristics. Nursing Research, 36, 76-81.

Wallston, K. A., Walston, B. S., & DeVellis, R. (1978).Development of the Multidimensional Health Locus ofControl (MHLC) scales. Health EducationMonographs, 6, 164-165.

Way, N., Cowal, K., Gungld, R., Pahl, K., & Bissessar, N.(2001). Friendship patterns among African American,Asian American, & Latino adolescents from low-income families. Journal of Social and PersonalRelationships, 18, 29-53.

Wenger, A. F. Z. (1991). Culture-specific care and the OldOrder Amish. Imprint, 38, 80-82, 84, 87.

Wiggins, L. R. (1983). Health and illness beliefs and prac-tices among Old Order Amish. Health Values, 7,24-29.

Winstead-Fry, P., Hernandez, C. G., Colgan, G. M., Cook, C.M., DeSalva, K. L., LaBelle, E., & Perry, E. (1999).The relationship of rural persons' multidimensionalhealth locus of control to knowledge of cancer, can-cer myths, and cancer danger signs. Nursing, 22,456-462.

Yeatts, D., Crow, T., & Folts, E. (1992). Service use amonglow-income minority elderly: Strategies for overcomingbarriers. Gerontologist, 32, 24-32.


cultural practices

Documents

definition of health

frequent health

lifestyleor health

amish experience of

toexplore health promotion

health beliefs andbehaviors

health maintenance essential

old order amish adults