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 Praise for Healthy Places, Healthy People, Third Edition

“The third edition of Healthy Places, Healthy People begins with the principle that the health
of people begins with the health of their community. This text takes providers out of hospi-
tals and clinics and into the culture of communities—into workplaces, schools, homes, and
neighborhoods—where health is both created and compromised. The authors assume that to
work with communities, you have to know how communities work, their political and eco-
nomic realities, their strengths, their frailties, and their capacity for mobilizing citizens for
action. This how-to book, grounded in an understanding of culture and all its complexity,
provides realistic strategies and practical advice for achieving health equity.”

–Bechara Choucair, MD
Senior Vice President Safety Net & Community Health
Trinity Health

“Healthy Places, Healthy People is a masterfully written text for nursing students learning
about community health nursing. The art of nursing includes understanding the communities
where people live their lives. This text exposes the learner to the importance of understanding
the patient in the larger context of community through a culturally informed lens. Nursing
professionals in all areas of nursing practice would benefit from reading the third edition of
Healthy Places, Healthy People to fully understand what scope of care means along the entire
healthcare continuum.”

–Monica Dillon, RN
Community/Public Health Nurse
Loyola University Community Nursing Center

“This book is a well-designed text that identifies community as keeper of culture, dynamic,
and defined from the inside, while setting out the different skills and competencies that pro-
mote leading change and social justice. It includes concrete examples and materials that can
be used in completing a community culture assessment, a theoretical model that can guide a
culturally focused community practice of nursing. Integral is a well-defined understanding
that culture is not about ethnicity and that the meaning of community entails how space and
time is used. The meaning of community is found in lifeways and manners in which people
are organized and interact. A must-read for any practitioner interested in true community
engagement and change.”

–P. Ann Solari-Twadell, PhD, RN, MPA, FAAN

Associate Professor and Director, Global Health Experiences and International Studies
Marcella Niehoff School of Nursing, Loyola University Chicago

HPHP3.indb 1 4/25/16 3:58 PM

 “This book weaves together public health nursing practice, culture, and social justice, embold-
ening nurses to place values into practice. Its thoughtful organization allows for concise yet
visionary descriptions of strength-based and community-based theoretical approaches, prac-
tice examples, and case studies. This edition brings to life a holistic public health nursing
care that will inform undergraduate students’ practice for years to come.”

–Angela Kueny, PhD, RN

Assistant Professor, Luther College

“The authors of Healthy Places, Healthy People are pioneers in the practice of culturally
informed healthcare, and this book serves to capture their enormous practitioner experience
in a refreshingly new academic framework. As a person who has been using this model for
many years, I can say with confidence that this book fills a much-needed gap and will be
very useful for practitioners and students around the world.”

–R. Balasubramaniam, MD, MPhil, MPA

Founder, Swami Vivekananda Youth Movement, India
Former Frank Rhodes Professor, Cornell University

“The third edition of Healthy Places, Healthy People provides the reader with practical strate-
gies to lead change and promote social justice in healthcare. This handbook is applicable to
more than just nursing. Individuals in all healthcare settings striving to promote a healthy
society can benefit from reading this guide. As a nurse scientist, I have used the culturally
informed strategies outlined in this text in recruitment and will continue to reference this
guide when engaging in communities.”

–Fayron Epps, PhD, RN

National Hartford Center of Gerontological Nursing Excellence
Claire M. Fagin Fellow 2013–2015

“Healthy Places, Healthy People provides a groundbreaking, very adaptable framework for
community/public nurses at any stage of their career. This edition is even more streamlined
and is an excellent resource for classroom instruction, research studies, and practice projects.
This handbook has had an enormous influence on my professional practice as a nurse practi-
tioner in the care of individuals and communities.”

–Mandy Peacock, DNP, AGPCNP-C

HPHP3.indb 2 4/25/16 3:58 PM

 “Healthy Places, Healthy People provides a theoretical guide and practical strategies to incor-
porate culture as a critical element of assessment, intervention, and evaluation in community
and public health nursing. This book places culture at the center of nursing activities that
enhance learning, promote cultural awareness, and contribute to cultural competence.”

–Melissa Lehan Mackin, PhD, RN

Assistant Professor, College of Nursing, University of Iowa

“Skemp, Dreher, and Lehmann have hit the ball out of the park with this third edition of their
book, Healthy Places, Healthy People. The text is well-researched and full of information.
Two new areas stand out: the authors’ detailed explanation of how nurses use ethnography
and ethnographic research to examine whole communities and the Practice Project, which
provides readers with tools and activities to facilitate the application of theory with clinical
practice in the community. The authors discuss the need for sensitivity in eliminating stigma-
tizing language and avoiding reference to terms such as vulnerable populations, which may
connote weakness or dependence. This book sets the standard for culturally informed com-
munity nursing practice. I highly recommend it.”

–Mary P. Westerman, MSN, RN

Assistant Professor of Nursing
Saint Anthony College of Nursing

HPHP3.indb 3 4/25/16 3:58 PM

HPHP3.indb 4 4/25/16 3:58 PM
 Healthy Places,
Healthy People
THIRD EDITION

A Handbook for Culturally Informed Community

Nursing Practice

Lisa Elaine Skemp, PhD, RN, FGSA, FAAN

Melanie Creagan Dreher, PhD, RN, FAAN
Susan Primm Lehmann, MSN, RN

HPHP3.indb 5 4/25/16 3:58 PM

 Sigma Theta Tau International
Copyright © 2016 by Sigma Theta Tau International

All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmit-
ted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from
the publisher.
Any trademarks, service marks, design rights, or similar rights that are mentioned, used, or cited in this book are the property of
their respective owners. Their use here does not imply that you may use them for similar or any other purposes.
The Honor Society of Nursing, Sigma Theta Tau International (STTI), is a nonprofit organization founded in 1922 whose
mission is to support the learning, knowledge, and professional development of nurses committed to making a difference in
health worldwide. Members include practicing nurses, instructors, researchers, policymakers, entrepreneurs, and others. STTI
has more than 500 chapters located at more than 700 institutions of higher education throughout Armenia, Australia,
Botswana, Brazil, Canada, Colombia, England, Ghana, Hong Kong, Japan, Kenya, Lebanon, Malawi, Mexico, the Nether-
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To order additional books, buy in bulk, or order for corporate use, contact Nursing Knowledge International at 888.NKI.4YOU
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ISBN: 9781940446660
EPUB: 9781940446677
PDF: 9781940446684
Mobi: 9781940446691
__________________________________________________________________________________________________________________
Library of Congress Cataloging-in-Publication Data

Names: Dreher, Melanie Creagan, author. | Skemp, Lisa Elaine, 1955- , author. | Lehmann, Susan Primm, author.
Title: Healthy places, healthy people : a handbook for culturally informed community nursing practice / Lisa Elaine Skemp,
Melanie Creagan Dreher, Susan Primm Lehmann.
Description: Third edition. | Indianapolis, IN : Sigma Theta Tau International, [2016] | Melanie Creagan Dreher's name appears
first in the previous editions.
Identifiers: LCCN 2016013154 (print) | LCCN 2016015817 (ebook) | ISBN 9781940446660 (print : alk. paper) | ISBN
9781940446677 (epub) | ISBN 9781940446684 (pdf) | ISBN 9781940446691 (mobi) | ISBN 9781940446677
(Epub) | ISBN 9781940446684 (Pdf) | ISBN 9781940446691 ( Mobi)
Subjects: | MESH: Community Health Nursing | Culturally Competent Care | Transcultural Nursing--methods
Classification: LCC RT98 (print) | LCC RT98 (ebook) | NLM WY 106 | DDC 610.73/43--dc23
LC record available at https://lccn.loc.gov/2016013154

First Printing, 2016

Publisher: Dustin Sullivan Principal Editor: Carla Hall

Acquisitions Editor: Emily Hatch Project and Development Editor: Kezia Endsley
Editorial Coordinator: Paula Jeffers Copy Editor: Heather Wilcox
Proofreader: Todd Lothery Indexer: Larry D. Sweazy
Interior Design and Page Composition: Rebecca Batchelor Cover Design: Rebecca Batchelor

HPHP3.indb 6 4/25/16 3:58 PM

 Dedication
This book is dedicated to the citizens and students who have shared with us the
joy and struggle of building sustainable, healthy communities and promoting
social justice and health equity.

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 Acknowledgments
We are deeply indebted to the communities in which we work and the people and
groups that have opened their doors and hearts to students from the University of
Massachusetts, University of Iowa, Rush University, and Loyola University–
Chicago, who have embraced a new way to nurse and enthusiastically set about
working with community members in creating healthier places for people to have
healthier lives.

The treatise of this text is easily traced to Columbia University Teachers College
and the Department of Anthropology, where Professors Lambros Comitas and
Conrad Arensberg helped us understand how communities work and how to
work with communities. We are indebted to Kathy Pryzynski, Maureen Groden,
and Ken Culp for their thoughtful comments on the earlier editions and to Glenn
Blalock and Amanda Peacock for their thoughtful guidance on this, the third edi-
tion. We are especially grateful for the contributions of Dolores Shapiro and
Michelene Asselin, the original co-authors of Healthy Places, Healthy People.
Finally, we thank our families, friends, and colleagues for their unrelenting
patience and support.
–Lisa Elaine Skemp, PhD, RN, FGSA, FAAN
–Melanie Creagan Dreher, PhD, RN, FAAN
–Susan Primm Lehmann, MSN, RN

HPHP3.indb 8 4/25/16 3:58 PM

 About the Authors
Lisa Elaine Skemp, PhD, RN, FGSA, FAAN
Lisa Skemp is Professor and Chair, Department of Health Systems, Leadership,
and Policy at Loyola University–Chicago. Skemp taught community health at the
University of Iowa College of Nursing and was the Director of the Global Health
Initiative at the Iowa Hartford Center of Geriatric Nursing Excellence. Skemp
held an Endowed Chair in Gerontological Nursing at Our Lady of the Lake Col-
lege. In 2000, Skemp received the American Public Health Association New
Investigator’s Award for her cross-cultural research in the Caribbean, and in 2003
she became a Claire M. Fagin Fellow for her work in rural community healthy
aging. After receiving her BSN from Viterbo University, Skemp obtained her mas-
ter’s degree in community health nursing and education and then her doctorate in
nursing at the University of Iowa with an emphasis in community capacity build-
ing for healthy aging. In 2015, Skemp became a fellow in the Gerontological
Society of America and the American Academy of Nursing. Skemp integrates her
role as an educator in community health nursing, global health, and gerontology
with her research and practice in diverse cultures and communities. Her extensive
ethnographic research has included community studies in St. Lucia, the West
Indies, rural American Midwest farming communities, Mexican immigrant popu-
lations, Sudanese refugee groups, and South India villages. Skemp’s contributions
to global health include two study-abroad programs in interprofessional commu-
nity capacity building for healthy aging in St. Lucia and South India.

Melanie Creagan Dreher, PhD, RN, FAAN

Melanie Dreher is the Dean Emeritus of Rush University College of Nursing. An
educator for more than 40 years, Dreher has championed nursing as a profession
with enormous potential to improve the health and well-being of people in com-
munities. She has taught community assessment, analysis, and intervention at
Columbia University, University of Miami, University of Massachusetts, Univer-
sity of Iowa, and Rush University. Dreher earned her bachelor’s degree in nursing
at Long Island University and her doctorate in anthropology at Columbia

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 x Healthy Places, Healthy People, Third Edition

University and Teachers’ College. Her extensive ethnographic research in the

Caribbean has focused on communities as powerful determinants of the health
and welfare of children and adults. As a member of the charter Council of Public
Representatives, Dreher brought the realities of people living in communities to
the National Institutes of Health. She is a member of the Chicago Board of
Health, a trustee at Loyola University–Chicago, and a director on the boards of
Trinity Health and Wellmark, Inc., Blue Cross Blue Shield of Iowa and South
Dakota. Dreher has received many awards for her contributions to the health of
communities, including a citation from the U.S. ambassador for her community
development work in Jamaica, where she held a visiting professorship at the Uni-
versity of West Indies. Finally, she has published extensively on culture as an
organizing concept in nursing education and practice.

Susan Primm Lehmann, MSN, RN

Susan Primm Lehmann received her BSN and MSN from Loyola University Mar-
cella Niehoff School of Nursing in Chicago and has engaged in nursing practice
with adult, geriatric, and pediatric populations in acute care and community set-
tings. An Assistant Professor (Clinical) at the University of Iowa College of Nurs-
ing, Lehmann has expertise in BSN nursing education focusing on Community
and Public Health Nursing (CPHN) with more than 20 years of experience,
including BSN curriculum development, mentorship of colleagues new to nursing
education, and practicum teaching. She is recognized for her knowledge of and
advocacy for the healthcare needs of persons who are homeless, and she has
given presentations regionally and nationally on curriculum development for
CPHN education. Lehmann is the creator and Director of the Young Community
Nurse Clinician Program, an extracurricular mentorship program for talented
nursing students who are considering a career in community and public health
nursing. Lehmann’s areas of research and practice interest include people who
experience mental illness in the community, people who are homeless or experi-
ence other vulnerabilities, and health promotion across the lifespan. Being an
early adopter of the culturally informed community health model of nursing
practice, Lehmann is thrilled to be a contributor to this latest edition of Healthy
Places, Healthy People.

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 Table of Contents
About the Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

1 The Cultural Framework of Community

Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Culturally Informed Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Communities and Populations: Partner Concepts . . . . . . . . . . . . . . . . . . . . . . . 7
Moral Imperatives of Health and Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2 Culturally Informed Community Health

Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
What Is Community/Public Health Nursing?. . . . . . . . . . . . . . . . . . . . . . . . . . 22
The Community Health Legacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
The Community Practice Paradigm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
The Nurse Community Presence: Building Relationships . . . . . . . . . . . . . . . . . 34
Community/Public Health Nursing Values . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

3 Learning the Culture and Health of

Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Learning About the Community’s Culture and Health . . . . . . . . . . . . . . . . . . . 40
Informing Public Health Practice Through Ethnography . . . . . . . . . . . . . . . . . . 41
Gathering Community Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Community Health Field Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Informing Community/Public Health Practice Through Epidemiology and
Bio-Statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Epidemiological Studies of Population Health. . . . . . . . . . . . . . . . . . . . . . . . . 60
Accessing Public Health Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Culturally Informed Community Health Analysis . . . . . . . . . . . . . . . . . . . . . . . 72

4 The Practice Project . . . . . . . . . . . . . . . . . . . . . . . 75

Entering and Engaging: New Roles, New Relationships . . . . . . . . . . . . . . . . . 76
Considering Demeanor and Deportment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Engaging in Effective Team Member Relationships . . . . . . . . . . . . . . . . . . . . . 79

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 xii Healthy Places, Healthy People, Third Edition

Organizing and Managing the Community Information. . . . . . . . . . . . . . . . . . 80

Understanding the Community Information. . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Framing the Culturally Informed Nursing Practice Project Process . . . . . . . . . . . 91
Situations to Help Assess a Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

5 Discovering the Culture of Your Community . . 105

Community Culture Inquiry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
The Physical Environment of a Community . . . . . . . . . . . . . . . . . . . . . . . . . . 107
The Population of a Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
The Social Organization of a Community . . . . . . . . . . . . . . . . . . . . . . . . . . 139

6 Determining the Health of Your Community. . . 163

Community Health Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Environmental Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Population Health Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Healthcare Organization Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

7 Laying the Foundation for a Healthy

Community Agenda . . . . . . . . . . . . . . . . . . . . . . . . 229
The Future Is Now. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Why Is Planning So Important in Community Health Practice? . . . . . . . . . . . . 231
Health Planning: As It Was, Is, and Can Be. . . . . . . . . . . . . . . . . . . . . . . . . 232
Developing a Culturally Informed Healthy Community Agenda. . . . . . . . . . . . 241
Building a Constituency for Culture-Based Action: Do We Need It?
Who Should Be on It?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

8 Leading Culturally Informed Community

Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Building Capacity Through Citizen Engagement. . . . . . . . . . . . . . . . . . . . . . 258
Guiding Change: A Culturally Preservative Approach. . . . . . . . . . . . . . . . . . 258
Models for Community Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
The Role of the Nurse in Community Action. . . . . . . . . . . . . . . . . . . . . . . . . 264

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 Table of Contents xiii

Creating a Community Action Plan for a Healthy Community Agenda. . . . . . . 266

The MAP-IT Framework: Mobilize, Assess, Plan, Implement, and Track . . . . . . 273
Formulating a Culturally Effective Community Case Statement. . . . . . . . . . . . . 287

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

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 Introduction
This is the third edition of a book designed to help students of community/public
health nursing learn how to lead change and promote social justice in healthcare
locally and globally. Using the concept of culture, they learn how to work with
residents by first listening to and observing how communities work and compar-
ing them to other communities. Then, with community partners, students learn to
ensure change through programming and public policy. Like the first two edi-
tions, this is not your standard textbook. Our goal is not a comprehensive survey
of community/public health nursing. Our objective is to guide students in acquir-
ing the core public health leadership competencies of community relationship
building, inquiry, assessment, analysis, planning, action, evaluation, and persua-
sion that transcend the categorical public health concerns, such as infectious dis-
eases, maternal-child health, environment monitoring, terrorism, and disaster pre-
paredness. We strive to keep this a small handbook with realistic strategies and
practical advice on how to be more effective in mobilizing citizen action for pub-
lic health. It contains useful tools for preparing, gathering, organizing, and ana-
lyzing community information to facilitate work with citizens and groups to build
capacity for a healthy future and health equity. In many ways, it is a “how-to”
book—a public health improvement strategy that can be applied to any commu-
nity, at any time, to get the jobs of public health and social justice accomplished.

The organizing theme of this edition remains the same: Healthy places are the
building blocks for healthy people. That means that the capacity of communities
to ensure a robust physical and social environment will promote and protect the
health of their citizens. In this paradigm, we make the distinction between creat-
ing health and treating health problems—a notion that often is not easily grasped
by students who come to their course in public health fresh from the clinical
imperatives of the acute care setting. Although access to quality clinical services
and illness care is critically important (and disparities in access are symptomatic
of an unhealthy community), we do not equate health with healthcare. It is in the
cultural context of the community, stretching well beyond its clinics and hospi-
tals, where the impact of social and environmental determinants is most keenly
felt. Obvious examples include clean air, water, and land; safe highways; and

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 Introduction xv

uncontaminated food. But they also include the socioeconomic dislocations that
place some members of a community on unequal footing—creating local “hot
spots” that, left unattended, compromise the health of the whole community.

In this edition, we continue our emphasis on the powerful influence of place on

health and the role of nurses in leading change. Beginning, perhaps, with the
Alameda County study in which human relationships took precedence over health
behaviors as the number-one predictor of mortality, research continues to reveal
the impact of residential community culture on health. In addition to the work of
Roberts et al. cited in the first edition (and revisited here), Bender, Clune, &
Guruge, 2009; Carolan, Andrews, & Hodnett, 2006; Cummins, Curtis, Diez-
Roux, & Macintyre, 2007; Cummins, Stafford, Macintyre, Marmot, & Ellaway,
2005; Drevdahl, 2002; Kerker et al., 2011; Marmot, 2005a and 2005b; Pobutsky,
Baker, & Reyes-Salvail, 2015; Stafford & Marmot, 2003; Szwarcwald, da Mota,
Damacena, & Pereira, 2011; and Tarlier, Browne, & Johnson, 2007, offer com-
pelling evidence and justification for extending the examination of social and
environmental determinants of health beyond the correlation of variables and into
the situational realities of community context.

Nursing is defined by orientation rather than by setting. The nurse who is

employed in the cardiology clinic of a tertiary-care setting and who sits on local
and national policy boards for cardiac prevention, who speaks to women’s groups
throughout the community to educate them about the risks for heart disease in
women, who establishes self-help programs for women with heart disease, and
who links the families of women with cardiac pathology seen in the hospital to
community services has a strong community health orientation. In contrast, the
nurse who is employed in a neighborhood-based prenatal clinic but whose prac-
tice is limited to assessing and counseling expectant mothers—ignoring the obvi-
ous disparities in birth weight, the burden of parenthood, the lack of day care
programs, food and nutrition, transportation to the clinic, and existing regula-
tions and housing policies that compromise the mothers’ capacity to raise their
children in a healthy and safe environment—may be working in a community set-
ting but does not have a community orientation.

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 xvi Healthy Places, Healthy People, Third Edition

Furthermore, the commonly made distinction between acute care and community
care is spurious and diverts our attention from our true mission. Essentially, the
presence of a sufficient and well-integrated acute care system falls within the
“assurance” responsibility of public health. Hospitals are simply another commu-
nity institution, not unlike churches, schools, clinics, businesses, and factories,
with an important role to play in promoting the health of the public. As public-
health providers, our goal is to offer a perspective that prepares all students for
beginning practice in community health and to fulfill their responsibility for
active citizenry. We do not distinguish between “community health nurse” and
“public health nurse” and use the term community/public health nurse through-
out the book.

We continue to use the title Healthy Places, Healthy People: A Handbook for
Culturally Informed Community Nursing Practice and are delighted to see trends
for an increase in the use of “culturally informed” and a decrease in the use of
“cultural competence” in the literature. This reinforces the notion that nurses’
work with communities—each partner bringing unique strengths through sharing
cultural information.

Healthy People 2020 is referenced heavily. Students then learn how their commu-
nities compare with others nationally and that public health is an interprofession-
al, community-wide responsibility. Healthy People 2020 is guided by two critical
questions: (1) What makes some people healthy and others unhealthy? and (2)
How can we create a society in which everyone has a chance to live long, healthy
lives? At a time when it is easy to be distracted by categorical problems, initia-
tives, and funding, we believe effective responses to these two great big societal
questions require a comprehensive and unrelenting focus on the health of the
whole community and its culture.

Healthy People 2020 provides strategies for achieving overarching goals and a
project management model, called MAP-IT. With only three categories of inter-
ventions and a widely used logic model for planning and implementation, build-
ing capacity for community action would seem relatively straightforward. But
inspiring communities to take action goes beyond just formulating policies about
the sale of cigarettes to minors, educating the public about the dangers of obesity,

HPHP3.indb 16 4/25/16 3:58 PM

 Introduction xvii

or cleaning up a polluted river. When we start moving initiatives, such as sex edu-
cation or improved emission standards, into the cultural realities of community
life, things get much more complicated. Mobilizing specific action with a specific
community in a specific place requires an understanding of the complexities of
community culture, with all its diverse citizens, groups, interests, goals, and
values.

So what is different about this edition? First of all, no community desires to be

“problematized.” We contend that community strengths are the “glue” that holds
a community together and that it is within nurses’ purview to discover these
strengths. In this edition, a strengths-based assessment is emphasized. We have
avoided many references to “vulnerable populations” and “socioeconomic deter-
minants,” as such terms suggest a kind of unassailable dependency and weakness
that deter us from seeing the opportunities that are waiting to be discovered and
activated in a strengths-based, “culturally informed” community health practice.

We took the advice of our readers to better explain how nurses use ethnography
and epidemiology to understand the health and the culture of their communities.
These concepts are best comprehended not only by explaining what they are and
are not but also by emphasizing how they are complementary or “partner” con-
cepts. Beginning in Chapter 1, we juxtapose ethnography and epidemiology and
their respective units of analysis—communities and populations—to illustrate the
differences and the complementarities between the two scientific orientations in
community/public health nursing.

Responding to faculty and student requests, we have added an additional chapter,

entitled “The Practice Project.” Chapter 4 is a transition chapter that provides
practical steps, tools, and activities to help students bridge the concepts from
Chapters 1–3 to the applied Chapters 5–6, where they conduct the culturally
informed community assessment, and then to Chapters 7–8, where students move
into the action and evaluation phases of community/public health nursing.

The passage of the Patient Protection and Affordable Care Act in 2010 has
expanded healthcare access to 30 million formerly uninsured Americans and pro-
vides unprecedented opportunities for nurses to fulfill their mandate not only to

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 xviii Healthy Places, Healthy People, Third Edition

care for the health of the public but also to lead the redesign of healthcare (Glied
& Ma, 2015; Institute of Medicine, 2010). Community/public health nurses will
lead this change by working with communities to realize their strengths and build
the capacity necessary to shape the future of health and healthcare. Finally, we
remain committed to the moral imperative for nurses to lead in promoting social
justice, equity, and the health of all people as enduring values. We embrace the
promise of health reform not just for universal access to health services but for
universal engagement in making communities healthy, open environments in
which people are welcome to work, play, raise families, and experience long and
healthy lives.
–Lisa Skemp, PhD, RN, FGSA, FAAN
–Melanie Dreher, PhD, RN, FAAN
–Susan Lehmann, MSN, RN

HPHP3.indb 18 4/25/16 3:58 PM

 The Cultural
C h a p t e r
1
Framework of
Community Health
Beginning with culture and how it informs nursing practice,
this chapter explores the concepts essential to becoming an
effective community/public health nurse. It goes on to dis-
cuss communities and populations—two very different but
necessary concepts in public health that prompt the need for
nurses to incorporate ethnographic as well as epidemiologi-
cal inquiries into their practice. The chapter ends with an
introduction to the moral imperatives that frame commu-
nity/public health practice and a discussion of the role of
nursing in promoting social justice and leading change in
public health.

Chapter 1 Objectives

■ Describe the significance of culture as an organizing

concept in community/public health nursing practice
and the ecological fallacy that has inhibited its applica-
tion in clinical practice.

■ Understand the difference between communities and

populations, their usefulness in community/public health
practice, and the ways in which they frame public health
science.

■ Know the difference between equality and equity in ethi-

cal community/public health practice and the role of
nursing in promoting social justice and leading change
in public health.

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 2 Healthy Places, Healthy People, Third Edition

Culturally Informed Nursing Practice

Culture is not a new concept in public health. The importance of knowing a com-
munity’s culture to determine patterns of illness, health, and the use of health ser-
vices was documented in the 1950s in a landmark collection titled Health, Culture,
and Community: Case Studies of Public Reactions to Health Programs (Paul,
1955):

If you wish to help a community improve its health, you must learn
to think like the people…. To assume new health habits, it is wise
to ascertain the existing habits, how these habits are linked to one
another, what functions they perform, and what they mean to those
who practice them. (p. 1)

Nor is culture a new concept for community/public health nurses. More than 60
years ago, George Rosen (1954) advised:

First and foremost comes a knowledge of the community and its

people. This knowledge must be acquired and is just as important
for successful public health work as is a knowledge of epidemiology
or medicine…. The community/health nurse … should be conscious-
ly aware of the way of life of the people, their goals in life, the
motivations that make them do the things they do, [and] the things
in life that mean much or little to them. (Rosen, 1954, p. 15)

Using cultural information in practice is a distinguishing feature of the profession

of nursing (Dreher, 1996; Leininger, 1988). According to the American Nurses
Association (2015):

Nursing is the protection, promotion, and optimization of health

and abilities, prevention of illness and injury, alleviation of suffering
through the diagnosis and treatment of human responses, and advo-
cacy in the care of individuals, families, communities, and popula-
tions.

HPHP3.indb 2 4/25/16 3:58 PM

 1 The Cultural Framework of Community Health 3

Unlike medical practice, in which a streptococcal infection is treated pretty much

the same way in Bangkok at it is in London and an appendectomy is fundamen-
tally the same procedure in Kenya as in Canada, nursing practice anticipates and
accommodates the wide variation in culturally embedded human responses to
health, illness, and treatment. To be effective, nurses must know more about their
patients than just the biological variables of disease, age, and sex. They must
incorporate knowledge of their lifestyles, values, education, occupation, social sta-
tus, and the ways they interpret illness and treatment.

To improve the health of the public, community nurses need to know more than
the rate of HIV infection, the prevalence of diabetes, or the incidence of low-
birth-weight babies. They also need to know the community’s religious institu-
tions, educational resources, political economy, commonly held values, social
norms, and cultural interpretations of health and healthcare. In other words, in
public health, just as in personal health services, nurses must use cultural knowl-
edge to inform their practice and optimize the outcomes.

Cultural Competence and Clinical Practice

Culturally competent care has become a mantra of contemporary healthcare prac-
tice (Andrews & Boyle, 2008; Betancourt, Green, Carrillo, & Ananeh-Firempong,
2003; Campinha-Bacote & Munoz, 2001; Fahrenwald, Boysen, Fischer, & Mau-
rer, 2001; Leininger, 1988, 1997; University of Kansas, 2015; U.S. Department of
Health & Human Services, 2010). According to cultural competence advocates,
when care is consistent with traditional beliefs and practices, patients will be
more engaged in the plan of care, care will be safer and more appropriate, and
clinical outcomes will be improved. Unfortunately, despite nationwide leadership
from experts in nursing and medicine, professional organizations, and certifying
bodies, routine incorporation of cultural information in patient treatment plans
has not been widely achieved (Benkert, Tanner, Guthrie, Oakley, & Pohl, 2005;
Fisher, Burnet, Huang, Chin, & Cagney, 2007; Omeri & Malcolm, 2004; Wil-
liamson & Harrison, 2010). With the important exception of language transla-
tion, most nurses, physicians, and other care providers continue to work in a cul-
tural vacuum when planning the care of their patients, and patient charts seldom
include references to cultural information.

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 4 Healthy Places, Healthy People, Third Edition

These disappointing outcomes do not reflect a lack of will or interest on the part of
caregivers but rather a fundamental misunderstanding of culture that leads to con-
fusion and frustration in its application. Culture is a social construction that per-
tains to groups. Within any group, some members may embrace all its rules and
traditions, while others may embrace only some, and still others may apply them
according to the situation. When information that pertains to groups (cultures) is
used to make decisions about individuals (patients), an ecological fallacy has
occurred (Bernard, 2011; Clancy, Berger, & Magliozzi, 2003; Dreher & Mac-
Naughton, 2002). To illustrate the ecological fallacy inherent in the application of
cultural information in a clinical context, we could use the opposition of the Cath-
olic Church to birth control, based on its ethical religious directives. As an institu-
tion, the Catholic Church formally opposes birth control, but it is widely known
that many Catholics are critical of the directive, support the use of birth control,
use or desire to use birth control, and yet still consider themselves devout Catho-
lics.

In the attempt to be culturally sensitive and acknowledge the faiths of our patients,
we could wrongly assume that a particular woman of Catholic faith would have no
interest in learning about birth control and fail to discuss the range of options
available to her. This would be a misapplication of cultural knowledge. Just know-
ing a patient’s ethnicity, national origin, or religion is not sufficient to inform care.
Achieving cultural competence in a clinical practice requires soliciting each patient’s
interpretation of his or her illness episode and expectation of treatment by asking
the right questions and listening carefully to the responses, which must then be
included and implemented in a culturally informed plan of care (Kleinman, 1980).
Cultures are not monolithic and unchanging, and patients are not frozen in cultural
traditions, unable to modify their behavior or learn new ways.

Although the cultural competence movement emerged and accelerated in response

to an increasingly multiethnic, global society, understanding health and illness from
the perspective of the patient is not a new concept. It is, in fact, the foundation for
patient-centered care. The goal of the cultural competence movement was to pre-
pare us for an increasingly diverse world, but it also raised our sensitivity to the
cultural factors that affect the care of all patients and that likely were taken for
granted when patients and providers looked much more alike. Real culture-

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 1 The Cultural Framework of Community Health 5

informed practice begins with acknowledging that all patients (not just those of a
different ethnicity, national origin, or language group) are influenced by their
cultures and deserve culturally informed courses of treatment. And further,
patients and providers bring “cultural baggage,” of which they are likely to be
unaware, to every healthcare encounter.

Cultural Capital and Public Health

In public health practice, culture is a potent and highly applicable concept.
Because information about groups (cultures) (Edelson, 2008; Fahrenwald et al.,
2001; Kreuter & McClure, 2004; Racher & Annis, 2007) is used to understand
and manage the health of groups (communities and populations), an ecological
fallacy does not occur. The most successful public health initiatives and commu-
nity-based programs target culturally relevant community groups, engage com-
munity leaders, work with and through local institutions, and establish culturally
prescribed channels of communication (Tripp-Reimer, Choi, Skemp Kelley, &
Enslein, 2001). This culturally informed approach to public health begins with
an inquiry and analysis of (a) how and why a particular public health problem is
embedded in the cultural context of community life, and (b) the cultural capital
available to fix it. Cultural capital is the arsenal of community institutions, lead-
ers, customs, knowledge, and values that can be invested to promote healthy
communities and the well-being of all their citizens (Hopkins & Mehanna, 2000,
2003).

The recent epidemic of childhood obesity provides a useful example of the poten-
tial of cultural information to inform community/public health practice. As a
serious public health problem with a significant impact on community resources
over time, childhood obesity is more than an individual nutritional problem or
eating disorder to be treated in a clinical setting. Examining childhood obesity in
the context of community life reveals the cultural norms, values, and behaviors
that pertain to physical activity, body-image preferences, parent-child relation-
ships, and food preparation and consumption. It expands the breadth and depth
of interventions and enlists the community’s cultural capital (e.g., teachers,
coaches, local athletes, grocers, fast-food restaurants, parks and playgrounds,

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 6 Healthy Places, Healthy People, Third Edition

churches, grandmothers, schools, grocery stores, policymakers, and community

celebrations) to increase the effectiveness of the intervention and reduce the costs.
Cultural information about where, when, and what children eat and the social
meaning of food consumption both for children and caregivers provide guidance
for social marketing, public education, community coalitions, and the organiza-
tion of system-level services.

This approach to the resolution of a public health epidemic of a personal health

problem stands in marked contrast to the usual “deficit” analysis of a commu-
nity’s health, focused almost exclusively on what is “wrong” with communities—
what they lack or need to become healthy places that will generate healthy popu-
lations. Creating healthy communities by investing in actual and potential cultural
capital lessens the reliance on expensive clinical resources needed for treating each
child separately and focuses on more enduring and far-reaching changes in society
and the built environment to ameliorate and prevent the epidemic level of child-
hood obesity in the community. Mobilizing community strengths around a public
health issue also models community self-determination and self-help that can be
mobilized for other human service problems ranging from traffic safety and clean
air and water to HIV/AIDS and elder support.

Cultural Barriers? Not Really

It is never acceptable to cite a patient’s “culture” as the reason a provider’s care
plan has not been followed, and it is equally unacceptable to attribute the lack of
success in public health initiatives to “culture barriers” rooted in the community.
Such outcomes almost always reflect the difficulties and frustrations encountered
by the public health team in effectively acquiring and interpreting the community’s
cultural perspective and adjusting the plan of care accordingly. This process
requires practice and patience, and it is not uncommon for providers of the domi-
nant group to assume that cultural barriers are minimized and partnerships for
community action are optimized only when healthcare providers and community
residents are of the same ethnic and language groups. Although having greater
diversity in the provider community is highly desirable, ample evidence suggests
that cultural barriers in clinical and public health practice are attributable not so
much to the lack of community-provider sameness as they are to the failure of

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 1 The Cultural Framework of Community Health 7

providers to establish meaningful relationships with persons and groups (Epps,

Skemp, & Specht, 2015). Knowing the community, its people, and its culture is
the responsibility of all members of the healthcare team—not just those who bear
cultural similarities to community members. Cultural understanding is the key to
effective provider-community relationships, without which it is impossible to for-
mulate and execute a healthy community agenda (Drevdahl, 1995).

In the H1N1 flu epidemic of 2010, when it was important first to immunize
those most at risk (children and pregnant women), health departments did
not have to go from house to house to ensure that immunizations were car-
ried out effectively and efficiently. Instead, they deployed the communities’
cultural capital (radio, newspapers, Internet, primary schools, faith institu-
tions, after-school programs, neighborhood pharmacies, city colleges, hospi-
tal emergency rooms, teachers, volunteers, obstetricians, and primary-care
physicians) to ensure that women and children would be protected first.

During the African Ebola crisis of 2014, conventional means of communica-

tion (newspapers, TV, and radio) were used to disseminate accurate infor-
mation about the virus in rural and isolated areas. In densely populated cit-
ies, where more educated persons had access to cell phones and the
Internet, social media was an effective means of acquiring and sharing
health information. Social media users were recognized as some of the most
influential people in society who helped spread the word about the dangers
of Ebola (Putic, 2014).

Communities and Populations: Partner

Concepts
The terms community and population often are used interchangeably in public
health practice. They are interrelated but different in important ways that make
them effective “partner concepts” in advancing the health of the public.

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 8 Healthy Places, Healthy People, Third Edition

Communities
In its broadest use, the term community can be applied to almost any configura-
tion of people whose values, characteristics, and/or interests unite them in some
way (for example, a religious community, a retirement community, or a university
community). In public health practice, we ordinarily define community as the unit
in which the cultural impact on health and illness is most observable: a place (envi-
ronment) where people (populations) live and interact with each other in routine
and predictable ways (social organization). But communities are not just collec-
tions of people occupying the same space at the same time. Rather, they are com-
posed of institutions (religion, commerce, government, music, recreation, art and
architecture, education, domestic patterns) and regular cycles of human activity
that bring people together in socially organized ways to learn, work, play, and par-
ticipate in family activities. Community members may attend the same schools,
work for the same employers, live in the same apartment buildings, or exercise at
the same gyms. It is not necessary for all members of the community to know all
the other members of the community or to hold the same beliefs, share the same
values, or engage in the same behavior, but ordinarily, overarching community val-
ues and rules and sets of exchanges—formal and informal—guide the ways in
which community residents behave and interact with one another.

As the keepers of culture, communities have lives of their own. Individuals may
enter and leave a community over time with varying degrees of impact—if any—on
its culture. On the other hand, communities and the cultures that perpetuate them
are not static. They are constantly refreshed (and disrupted) by new persons, new
knowledge, and new circumstances. Although we tend to think of communities as
harmonious places, guided by established cultural rules, their dynamic nature
makes conflict inevitable as traditional values are challenged. The presence of con-
flict within a community is a normal vehicle for culture change and, although it
can be unsettling, does not necessarily challenge the integrity of the community.

Finally, a community is defined from the inside—a continuing saga, a society with
a history and a future, constantly changing the way in which it uses “place” (time

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 1 The Cultural Framework of Community Health 9

and space) and is being changed by it. Some communities look very much like
they did 50 years ago, while others have changed dramatically. In the late 19th
century, American communities grew and flourished at each stop of a burgeoning
railway system, creating residential areas and “downtown” centers. With the
introduction of automobile transportation in the 1920s, however, families moved
to new and larger homes on the outskirts of towns, creating suburbs. Schools,
hospitals, and businesses followed. Shopping centers replaced the small shops and
services that had once served to bring people together in villages and town cen-
ters. These transformative changes in where and how people live, work, and play
are simultaneously the genesis and the outcome of human communities over time.
Today, the Internet and social media have created virtual interactions, transac-
tions, and communities, heralding an unparalleled global interconnectivity among
humans that transcends their physical environments. But even residential commu-
nities are a subjective reality, with no designated geo-political boundaries and
often defined differently by members of the same community.

Populations
Populations, in comparison to communities, are somewhat easier to comprehend,
because they are objective realities, exactly equal to the sum of their parts. Broad-
ly defined, a population is simply a category of humans that has at least one char-
acteristic in common (e.g., residence, eye color, religion, etc.). Traditionally, how-
ever, we think of populations as the number of people who reside in a specific
geo-political unit at a specific time (e.g., the population of Louisiana in 2015 or
the population of Franklin County in 2012). This practical definition is consistent
with the goals of public health administration. It reflects the responsibilities of
boards of health or health departments to make rules that promote and protect
the health and safety of the people of a corresponding geo-political unit (e.g.,
municipality, incorporated village, county, state, country, etc.) through the enact-
ment of laws and policies. Examples include regulations prohibiting smoking in
public places and car-seat laws to protect infants and small children. Populations
also are important in public health research as the units of analysis we examine
and correlate statistically to identify health risks (e.g., the population of cigarette
smokers is “at risk” for lung cancer, children living in old homes or on busy

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 10 Healthy Places, Healthy People, Third Edition

streets are at greater risk for lead poisoning). When categories of persons within a
community are singled out for a public health intervention and/or research, they
often are referred to as target populations.

Populations are snapshots of a category of people in a specific place at a specific

time, taken from the outside, for specific and important purposes—the adminis-
tration of services or medical research. They do not constitute a group in which
members necessarily interact with each other. There is no reason, for example, for
all the persons diagnosed with asthma in the city of Spokane to know each other
and convene socially. On the other hand, if nurse practitioners determine that
their patients with asthma have much to gain from each other and decide to bring
them together for learning and mutual support, they are potentially transforming
a health population into a therapeutic community, which has a life of its own.
The size and characteristics of populations change as individuals are born, die, or
migrate in or out of an area. From 2000 to 2013, for example, the ethnic compo-
sition of the population of Cloudcroft, New Mexico, first saw an increase in the
Hispanic or Latino composition and then a decrease in Hispanic or Latino com-
position from 15.5% to 10.3% of the population (City-Data.com, n.d.). The
community of Cloudcroft, however, has continued to exist, incorporating these
changes in ethnic composition within its ever-changing community culture.

Although population and community are not the same, they are related in impor-
tant ways in public health practice. All communities have constituent populations,
but not all populations have or are communities. Sometimes, populations and
communities are conterminous. In the tiny village of Shelburne Falls, Massachu-
setts, for example, the population and the community are composed of the same
people, all of whom benefit from the services provided by the Town of Shelburne
Board of Health. When a family moves away from Shelburne Falls, it alters the
population, but its departure may or may not affect the community, depending on
the role and position of that family in community life. Even a small place like
Shelburne Falls contains several populations—elders, schoolchildren, persons with
diabetes, business owners, Baptists—and some of these categories may create sub-
communities that extend beyond the borders of Shelburne Falls. In comparison,
the very large municipality of Chicago has a population of roughly 3 million

HPHP3.indb 10 4/25/16 3:58 PM

Another random document with
no related content on Scribd:
 Can you not see that these would have been too frail to work their
way uninjured through the earth?
But by crooking its stout stem the plant opened quite easily a path
for itself and for its leaves, and no harm was done anywhere (Figs.
106, 107). Was not this a clever thought? But really every step in the
life of the plant is full of interest, if we watch it with sharp eyes and a
brain in good order.
 Part III—Roots and Stems

ROOT HAIRS

C AREFULLY pull up one of your bean plants and look at its root
(Fig. 108).
You see that the root grows downward from the lower part of the
stem.

Fig. 108

This bean root looks not unlike a bunch of dirty threads, some
quite thick, others very thin. If you look at these thread-like roots in a
good light, perhaps you may be able to see growing from them a
quantity of tiny hairs.
Now, what is the use of such a root as this?
 Surely some of you are able to guess at the object of this root, and
I will help the others to the answer.
Give a firm though gentle tug to one of the larger plants,—one of
those that are growing in the pot of earth.
Does it come out easily in your fingers?
Not at all. Unless you have been really rough, and used quite a
good deal of strength, the little plant has kept its hold.
What holds it down, do you suppose?
Ah! Now you know what I am trying to get at. Its root is what holds
it in place; and this holding of the plant in place is one of its uses.
Its thread-like branches are so many fingers that are laying hold of
the earth. Each little thread makes it just so much the more difficult
to uproot the plant.
I think you know already that another use of the root is to obtain
nourishment for the plant.
These thread-like roots, you notice, creep out on every side in
their search for food and drink. The water they are able to suck in
easily by means of tiny mouths, which we cannot see. But the plant
needs a certain amount of earth food, which in its solid state could
not slip down these root throats any more easily than a young baby
could swallow a lump of sugar.
Now, how is the plant to get this food, which it needs if it is to grow
big and hearty?
Suppose the doctor should tell your mother that a lump of sugar
was necessary to the health of your tiny baby brother, what would
she do about it?
Would she put the great lump into the baby’s mouth?
You laugh at the very idea. Such a performance might choke the
baby to death, you know quite well.
Perhaps you think she would break the lump into small pieces,
and try to make the baby swallow these; but even these small pieces
might prove very dangerous to the little throat that had never held a
solid morsel.
“She would melt the sugar in water, then the baby could swallow
it,” one of you exclaims.
That is exactly what she would do. She would melt, or dissolve as
we say, this sugar in water. Then there would be no difficulty in its
slipping down the little throat; for you know when anything is
thoroughly melted or dissolved, it breaks up into such tiny pieces that
the eye cannot see them. When you melt a lump of sugar in a glass
of water, the sugar is all there as much as it ever was, although its
little grains no longer cling together in one big lump.
And so when the plant needs some food that the little root hairs
are not able to swallow, it does just what the mother does. It melts or
dissolves the solid food so that this is able to slip quite easily down
the root throats.
But how does it manage this?
No wonder you ask. A root cannot fill a glass with water, as your
mother did. Even if it could, much of this solid food which is needed
by the plant would not melt in water, or in anything but certain acids;
for you know that not everything will dissolve, like sugar, in water.
If I place a copper cent in a glass of water, it will remain a copper
cent, will it not? But if I go into a drug shop and buy a certain acid,
and place in this the copper cent, it will dissolve almost immediately;
that is, it will break up into so many tiny pieces that you will no longer
see anything that looks at all like a cent.
And as much of this earth food, like the copper cent, can only be
dissolved in certain acids, how is the plant to obtain them? Certainly
it is not able to go to the drug shop for the purpose, any more than it
was able to fill a glass with water.
Fortunately it does not need to do either of these things.
If you will look closely at the root of a plant that has been raised in
water, you will see that it is rough with a quantity of tiny hairs. These
little hairs hold the acid which can dissolve the solid earth food.
When they touch this food, they send out some of the acid, and in
this it is soon dissolved. Then the little mouths suck it in, and it is
carried up through the root into the rest of the plant.
Would you have guessed that plants were able to prepare their
food in any such wonderful way as this? It surprised me very much, I
remember, to learn that a root could give out acids, and so dissolve
the earth food it needed.
 ROOTS AND UNDERGROUND STEMS

I N the last chapter you learned that the root of the bean plant has
two uses.
It holds the plant in place, and it provides it with food and drink.
Such a root as this of the bean plant—one that is made up of what
looks like a bunch of threads—is called a “fibrous” root.
The next picture shows you the root of a beet plant (Fig. 109).
Such a thick, fat root as this of the beet is called a “fleshy” root.
The carrot, turnip, radish, and sweet potato, all have fleshy roots.
This beet root, like that of the bean, is useful both in holding the
plant in place and in providing it with food and drink.
But the fleshy root of the beet does something else,—something
that is not attempted by the fibrous root of the bean.
Here we must stop for a moment and look into the life of the beet
plant.
During its first year, the beet puts out leaves; it neither flowers nor
fruits, but it eats and drinks a great deal. And as it does not use up
any of this food in flowering or fruiting, it is able to lay by much of it in
its root, which grows large and heavy in consequence. When the
next spring comes on, the beet plant is not obliged, like so many of
its brothers and sisters, to set out to earn its living. This is provided
already. And so it bursts into flower without delay, its food lying close
at hand in its great root.
 Fig. 109

So you see that a fleshy root, like that of the beet, does three
things:—
1. It holds the plant in place.
2. It provides it with food and drink.
3. It acts as a storehouse.
These plants that lay by food for another year are useful as food
for man. Their well-stocked roots are taken out of the ground and
eaten by us before the plant has had the chance to use up its food in
fulfilling its object in life, that of fruiting. Of course, when it is not
allowed to live long enough to flower and fruit, it brings forth no
young plants. So a habit which at first was of use to the plant
becomes the cause of its destruction.
Perhaps you think that the white potato (Fig. 110) is a plant with a
fleshy root.
 Fig. 110

If so, you will be surprised to learn that this potato is not a root at
all, but a stem.
You think it looks quite unlike any other stem that you have ever
seen. Probably you do not know that many stems grow underneath
the ground, instead of straight up in the air.

Fig. 111

Fig. 112

If you find something in the earth that you take to be a root, you
can feel pretty sure that it really is a stem, if it bears anything like
either buds or leaves. A true root bears only root branches and root
hairs. But in this white potato we find what we call “eyes.” These
eyes are buds from which new potato plants will grow. Close to these
are little scales which really are leaves. So we know that the potato
is a stem, not a root. But this you could not have found out for
yourselves, even with the sharpest of eyes.
 Fig. 111 shows you the thick, fat, underground stem of the
cyclamen. From its lower part grow the true roots.
Next you have that of the crocus (Fig. 112), while here to the right
is that of the wood lily (Fig. 113). This is covered with underground
leaves.

Fig. 113

All these stems are usually called roots. In the botanies such an
underground stem as that of the Jack-in-the-pulpit (Fig. 114) is
named a “corm,” while one like that of the crocus is called a “bulb”
(Fig. 112). All have a somewhat rounded shape.

Fig. 114

Fig. 115

During our walks in the woods last fall, often we found the
Solomon’s seal, and stopped to admire its curved stem, hung with
blue berries. I hope one of you boys whipped out your pocketknife
and dug into the earth till you found its underground stem (Fig. 115).
This was laid lengthwise, its roots growing from its lower side. From
its upper side, close to one end, sprang the growing plant. But what
causes those round, curious-looking scars?
These scars are what give the plant its name of “Solomon’s seal.”
They are supposed to look like the mark left by a seal upon wax.
They show where the underground stem has budded in past
years, sending up plants which in turn withered away. Each plant has
left a scar which shows one year in the life of the underground stem.
Next spring when you find in the woods the little yellow bells of the
Solomon’s seal, I think you will have the curiosity to dig down and
find out the age of some of these plants.
Another plant with an underground stem is the beautiful bloodroot.
As its name tells you, this so-called root contains a juice that looks
something like blood. Such underground stems as those of the
Solomon’s seal and bloodroot are called “rootstocks.” Rootstocks,
corms, and bulbs are all storehouses of plant food, and make
possible an early flowering the following spring.
 ABOVE-GROUND ROOTS

B UT before we finished talking about roots we were led away by

underground stems. This does not matter much, however, for
these underground stems are still called roots by many people.
Just as stems sometimes grow under ground, roots sometimes
grow above ground.
Many of you know the English ivy. This is one of the few plants
which city children know quite as well as, if not better than, country
children; for in our cities it nearly covers the walls of the churches. In
England it grows so luxuriantly that some of the old buildings are
hidden beneath masses of its dark leaves.
This ivy plant springs from a root in the earth; but as it makes its
way upward, it clings to the stone wall by means of the many air
roots which it puts forth (Fig. 116).
Our own poison ivy is another plant with air roots used for climbing
purposes. Often these roots make its stem look as though it were
covered with a heavy growth of coarse hair.

Fig. 116

There are some plants which take root in the branches of trees.
Many members of the Orchid family perch themselves aloft in this
fashion. But the roots which provide these plants with the greater
part of their nourishment are those which hang loosely in the air. One
of these orchids you see in the picture (Fig. 117). It is found in warm
countries. The orchids of our part of the world grow in the ground in
everyday fashion, and look much like other plants.

Fig. 117

These hanging roots which you see in the picture are covered with
a sponge-like material, by means of which they suck in from the air
water and gases.
In summer, while hunting berries or wild flowers by the stream that
runs through the pasture, you have noticed that certain plants
seemed to be caught in a tangle of golden threads. If you stopped to
look at this tangle, you found little clusters of white flowers scattered
along the thread-like stems (Fig. 118); then, to your surprise, you
discovered that nowhere was this odd-looking stem fastened to the
ground.
It began and ended high above the earth, among the plants which
crowded along the brook’s edge.
 Fig. 118

Perhaps you broke off one of these plants about which the golden
threads were twining. If so, you found that these threads were
fastened firmly to the plant by means of little roots which grew into its
stem, just as ordinary roots grow into the earth.
This strange plant is called the “dodder.” When it was still a baby
plant, it lay within its seed upon the ground, just like other baby
plants; and when it burst its seed shell, like other plants it sent its
roots down into the earth.
But unlike any other plant I know of, it did not send up into the air
any seed leaves. The dodder never bears a leaf.
It sent upward a slender golden stem. Soon the stem began to
sweep slowly through the air in circles, as if searching for something.
Its movements were like those of a blind man who is feeling with his
hands for support. And this is just what the plant was doing: it was
feeling for support. And it kept up its slow motion till it found the plant
which was fitted to give it what it needed.
Having made this discovery, it put out a little root. This root it sent
into the juicy stem of its new-found support. And thereafter, from its
private store, the unfortunate plant which had been chosen as the
dodder’s victim was obliged to give food and drink to its greedy
visitor.
 And now what does this dodder do, do you suppose? Perhaps you
think that at least it has the grace to do a little something for a living,
and that it makes its earth root supply it with part of its food.
Nothing of the sort. Once it finds itself firmly rooted in the stem of
its victim, it begins to grow vigorously. With every few inches of its
growth it sends new roots deep into this stem. And when it feels
quite at home, and perfectly sure of its board, it begins to wither
away below, where it is joined to its earth root. Soon it breaks off
entirely from this, and draws every bit of its nourishment from the
plant or plants in which it is rooted.
Now stop a moment and think of the almost wicked intelligence
this plant has seemed to show,—how it keeps its hold of the earth till
its stem has found the plant which will be compelled to feed it, and
how it gives up all pretense of self-support, once it has captured its
prey.
You have heard of men and women who do this sort of thing,—
who shirk all trouble, and try to live on the work of others; and I fear
you know some boys and girls who are not altogether unlike the
dodder,—boys and girls who never take any pains if they can
possibly help it, who try to have all of the fun and none of the work;
but did you ever suppose you would come across a plant that would
conduct itself in such a fashion?
Of course, when the dodder happens to fasten itself upon some
wild plant, little harm is done. But unfortunately it is very partial to
plants that are useful to men, and then we must look upon it as an
enemy.
Linen is made from the flax plant, and this flax plant is one of the
favorite victims of the dodder. Sometimes it will attack and starve to
death whole fields of flax.
But do not let us forget that we happen to be talking about the
dodder because it is one of the plants which put out roots above
ground.
 Fig. 119

There is one plant which many of you have seen, that never, at
any time of its life, is rooted in the earth, but which feeds always
upon the branches of the trees in which it lives.
This plant (Fig. 119) is one of which perhaps you hear and see a
good deal at Christmas time. It is an old English custom, at this
season, to hang somewhere about the house a mistletoe bough (for
the mistletoe is the plant I mean) with the understanding that one is
free to steal a kiss from any maiden caught beneath it. And as
mistletoe boughs are sold on our street corners and in our shops at
Christmas, there has been no difficulty in bringing one to school to-
day.
The greenish mistletoe berries are eaten by birds. Often their
seeds are dropped by these birds upon the branches of trees. There
they hold fast by means of the sticky material with which they are
covered. Soon they send out roots which pierce the bark, and, like
the roots of the dodder, suck up the juices of the tree, and supply the
plant with nourishment.
Then there are water roots as well as earth roots. Some of these
water roots are put forth by plants which are nowhere attached to the
earth. These are plants which you would not be likely to know about.
One of them, the duckweed, is very common in ponds; but it is so
tiny that when you have seen a quantity of these duckweeds,
perhaps you have never supposed them to be true plants, but rather
a green scum floating on the top of the water.
But the duckweed is truly a plant. It has both flower and fruit,
although without a distinct stem and leaves; and it sends down into
the water its long, hanging roots, which yet do not reach the ground.
There are other plants which have at the same time underground
roots and water roots.
Rooted in the earth on the borders of a stream sometimes you see
a willow tree which has put out above-ground roots. These hang
over the bank and float in the water, apparently with great
enjoyment; for roots not only seem to seek the water, but to like it,
and to flourish in it.
If you break off at the ground one of your bean plants, and place
the slip in a glass of water, you will see for yourselves how readily it
sends out new roots.
I have read of a village tree the roots of which had made their way
into a water pipe. Here they grew so abundantly that soon the pipe
was entirely choked. This rapid, luxuriant growth was supposed to
have been caused by the water within the pipe.
So you see there are underground roots and above-ground roots
and water roots. Usually, as you know, the underground roots get
their food from the earth; but sometimes, as with the Indian pipe,
they feed on dead plants, and sometimes, as with the yellow false
foxglove, on other living roots.
 WHAT FEW CHILDREN KNOW

T O-DAY we must take another look at the plants in the

schoolroom garden.
By this time some of them have grown quite tall. Others are just
appearing above the earth.
Here is a young morning-glory (Fig. 120). We see that its stem,
like that of the bean, was the first thing to come out of the seed. This
stem has turned downward into the earth. From its lower end grows
the root, which buries itself deeper and deeper.
An older plant shows us that the upper part of the stem straightens
itself out and grows upward, bearing with it a pair of leaves (Fig.
121).

Fig. 120

From between these starts a tiny bud, that soon unfolds into a
fresh leaf, which is carried upward by a new piece of stem.
On the tip of this new piece of stem grows another bud, which also
enlarges into a leaf, and in the same way as before is borne upward
(Fig. 122).
 Fig. 121

In this fashion the plant keeps growing bigger and bigger. Soon
branches start from the sides of the stem, and later flowers and
fruits.
So we see that it is the stem which bears all the other parts of the
plant.
Most people think that the plant springs from the root; but you
children know better. With your own eyes, here in the schoolroom,
you have seen that instead of the stem growing from the root, the
root grows from the stem.

Fig. 122

That more people have not found this out, is because they do not
use their eyes rightly.
Every spring hundreds and thousands of baby plants make their
way out of the seed shell into the world, just as you saw the baby
bean plant do, sending out first its little stem, which pointed
downward into the earth and started a root. And every spring there
are hundreds of thousands of men and women, and boys and girls,
who go through the woods and fields, and across the parks and
along the streets, as though they were blind, taking no notice of the
wonders all about them.
 PLANTS THAT CANNOT STAND ALONE

A LREADY we have learned that some stems grow under ground,

and that by most people these are called roots.
And among those which grow above the ground we see many
different kinds.
The stem of Indian corn grows straight up in the air, and needs no
help in standing erect.
Fig. 123 shows you the morning-glory plant, the stem of which is
unable to hold itself upright without assistance. A great many plants
seem to need this same sort of help; and it is very interesting to
watch their behavior.