Rural Health Promotion Research Articles

Learning by Doing: The Potential for Experiential Education in Health Promotion

Background: Rural populations face significant health disparities (e.g., high rates of chronic diseases) and unique accessibility barriers (e.g., limited healthcare facilities). Training higher education students to serve as facilitators for chronic disease prevention programs may address rural health promotion needs. Purpose: The purpose of this pilot, exploratory study was to create an experiential learning opportunity for students and examine their experiences. Methodology/Approach: Project leaders completed a Diabetes Prevention Program Lifestyle Coach training and, based on their experiences, created training program goals, content, and schedule. Undergraduate students in health-related programs or courses were recruited to participate. Four students completed a 4-week experiential training program and, at the end of the program, participated in an individual qualitative interview for researchers to understand their experiences. Findings/Conclusions: Data were analyzed through a qualitative-descriptive approach. The main theme, experiential learning, branched into two subthemes: (a) professional development and (b) program implementation and future program directions. Students’ experiential learning influenced their personal and programmatic views of prevention training. Implications: The benefits of experiential learning in prevention will enhance students’ education and future employment experiences. Future studies should improve upon training delivery and examine the acceptability of this method of delivery in the rural population.

Learning afforded to student paramedics in a rural health promotion activity

Learning afforded to student paramedics in a rural health promotion activity

Rural and nonrural racial variation in mentally unhealthy days: Findings from the behavioral risk factor surveillance system in North Carolina, 2015–2019

Rural-nonrural health disparities are well documented, yet researchers rarely consider how mental health is experienced across racial groups in rural areas. Black Americans frequently demonstrate better mental health than White Americans, which is puzzling, given their exposure to interpersonal and structural racism and discrimination. To determine if this paradoxical mental health patterning occurs within the context of rurality, we used zero-inflated negative binomial regression to model 2015–2019 North Carolina Behavioral Risk Factor Surveillance System respondents' self-reported days with stress, depression, and problems with emotions (“mentally unhealthy days”) in the past 30 days. The rate of mentally unhealthy days was 1.10 times as great for rural respondents than nonrural respondents (95% CI 1.04–1.17, p ​= ​0.002), in the negative binomial portion of the model. However, this relationship was moderated by racial identity. Rural White respondents had 1.26 times as many mentally unhealthy days as rural Black, nonrural Black, and nonrural White respondents (95% CI 1.08–1.47, p ​= ​0.003). Probing the interaction of rurality and racial identity indicated that rural residence was associated with more mentally unhealthy days for White respondents and fewer mentally unhealthy days for Black respondents. Because of expectations that are rooted in the social system of whiteness, we posit that White Americans' mental health could be more susceptible to the barriers to mental health that are associated with rural residence. Our findings also suggest that it may be insufficient to examine the association between rurality and mental health without documenting how health is experienced across racial groups. This study enhances understanding of potential social determinants that could underlie Black-White racial patterning in mental health. To advance rural health promotion and health care delivery, future research should investigate which underlying determinants may facilitate mental wellbeing for rural Black Americans and identify which mechanisms influence rural White Americans' relative mental health deficit.

Application of the consolidated framework for implementation research to understand implementation context of a cardiovascular disease risk-reduction intervention in rural churches.

Rural populations in the USA face higher rates of cardiovascular disease (CVD) incidence and mortality relative to non-rural and often lack access to health-promoting evidence-based interventions (EBIs) to support CVD prevention and management. Partnerships with faith organizations offer promise for translating preventative EBIs in rural communities; however, studies demonstrating effective translation of EBIs in these settings are limited. We used the Consolidated Framework for Implementation Research (CFIR) and a multiple case study approach to understand the role of internal organizational context within 12 rural churches in the implementation of a 12-week CVD risk-reduction intervention followed by a 24-month maintenance program implemented in southernmost Illinois. The study involved qualitative analysis of key informant interviews collected before (n = 26) and after (n = 15) the intervention and monthly implementation reports (n = 238) from participating churches using a deductive analysis approach based on the CFIR. Internal context across participating churches varied around organizational climate and culture in four thematic areas: (i) religious basis for health promotion, (ii) history of health activities within the church, (iii) perceived need for the intervention, and (iv) church leader engagement. Faith organizations may be ideal partners in rural health promotion research but may vary in their interest and capacity to collaborate. Identifying contextual factors within community organizations is a first step to facilitating rural, community-based EBI implementation and outcomes.

Qualitative Exploration of Cultural Influence on a Rural Health-Promotion Initiative

ObjectiveTo develop a conceptualization of cultural influence on perceptions of a rural food and physical activity policy, systems, and environmental (PSE) change project to inform public health research and practice. DesignBasic qualitative research design, semistructured phone interviews with community health coalition members. SettingFive rural Southern counties (obesity prevalence > 40%). ParticipantsThirty-nine community coalition members. InterventionThe Centers for Disease Control and Prevention High Obesity Program. PSE initiatives to increase access to healthy food and physical activity opportunities through a community coalition model. Phenomenon of InterestSocial norms and cultural influences surrounding community members’ food preferences, physical activity behavior, and future hopes for community development. AnalysisAbductive content analysis. ResultsMajor categories on food social norms (subcategories: physical health, eating habits, and food preference), race relations, generational factors, physical activity social norms, and hopes for the community (subcategories: increased engagement, health, awareness, cohesion, and inspiration) were discussed in relation to the progress of PSE initiatives. Conclusions and ImplicationsBecause of community member perceptions, PSE initiatives became associated with factors beyond food and fitness, such as race relations, generational differences, and community cohesion. A focus on increased youth and church involvement, community values, relationship building, and input from diverse voices can be foundational to culturally-appropriate PSE efforts in rural settings.

Exploring identity-oriented evaluation for rural community development: A constructivist grounded theory approach

ABSTRACT Many practitioners use culturally responsive approaches for community development; however, identity-oriented frameworks may enhance holistic engagement with communities and foster increased participatory collaboration. The current study identifies components of identity narratives within a community-based health-promotion initiative focused on rural food access through a culturally responsive lens to develop a preliminary theory of identity-oriented evaluation. Data were collected with members of the community coalition in one county participating in the rural health-promotion program. A constructivist grounded theory approach was used to identify themes related to identity construction by participants. Themes included community identity, economic narratives of health, personal identity, descriptions of coalition, cultural food preferences, identity constructions around health, community-first perspective, collaboration across community sectors, slowness of change, and social observations related to behavior change. Looking at the themes in a rural health-promotion context, the authors discuss implications for engaging in community development using identity as an entry point for participatory work.

Off the beaten path: A scoping review of how 'rural' is defined by the U.S. government for rural health promotion.

Background: Given the recognition that the U.S. government lacks a consensus definition of the word rural, the purpose of this scoping review was to uncover how the federal government defines the term and to establish a nuanced understanding of what criterion is used to designate an area as rural. Methods: Arksey and O’Malley’s framework was used to synthesize, analyze, and summarize the existing literature. A multi-system search was conducted, and articles were screened for eligibility by two independent reviewers using pretested forms. Results: Initially, 929 articles were screened that used the search terms rural and some variation of the word definition. After eliminating all ineligble studies, 49 documents were included in the final analysis. These documents revealed 33 federal definitions of rural. The majority of definitions centered on either population, population density, or urban integration provisions. Additionally, the analysis showed that the literature could be separated into two categories: how rural was defined in a particular industry or for a specific population and the multiple adverse effects of having multiple definitions of rural. Conclusion: The discrepancies found in current classification systems reveal the need for a standardized definition of rural. Ultimately, policies centered on securing health care services for rural populations are impacted by whatever definition of rural is used. Failing to establish a gold standard definition of rural could have harmful consequences to the health and wellbeing of the many people living in rural communities across the U.S.

Bridging Allied Health Professional Roles to Improve Patient Outcomes in Rural and Remote Australia: A Descriptive Qualitative Study.

PurposeAustralia’s rural and remote populations experience inequality of access to healthcare, with demand exceeding capacity for delivery of health services, often due to a maldistribution of the health workforce. A strategy which may overcome barriers to accessing adequate healthcare includes implementation of interdisciplinary collaborative teams, identified as a successful method of healthcare delivery. This study thus aimed to explore interdisciplinary allied health collaborative practice in a rural community.MethodsRole theory, as a philosophical perspective, was used to explore role perceptions and the potential for interdisciplinary collaboration between pharmacists and allied health professionals including dieticians/public health nutritionists, speech pathologists, occupational therapists, and physiotherapists, by conducting 29 interviews in a rural community. All interviews were transcribed verbatim, coded, and categorised into emerging themes.ResultsFive constructs of role theory were used to describe the data: role identity, role overload, role sufficiency, role conflict, and role ambiguity. Participants identified as rural generalists and health promoters, who work within innovative and adaptive healthcare settings. Role overload was reported as considerable due to high demand for services and a lack of resources in rural and remote regions, resulting in poor role sufficiency. Overall, there was a low level of role conflict, and participants were highly in favor of interprofessional collaboration; however, uncertainty of the pharmacist’s role (role ambiguity) was a major barrier identified. Health professionals with more years in practice provided few examples of how they would utilise a pharmacist in their practice, although these gave valuable insight into the potential integration of a pharmacist into an interdisciplinary health team, with allied health professionals.ConclusionThis study has applied role theory providing a greater understanding of the enablers and barriers of pharmacists working within interdisciplinary allied health teams and highlighting opportunities to bridge interprofessional roles to improve patient outcomes, especially in rural and remote communities.

12주간의 농어촌 건강증진 운동프로그램 참여가 노인여성의 SFT와 EQ-5D에 미치는 영향

본 연구의 목적은 12주간의 농어촌 건강증진 운동프로그램 참여가 노인여성의 SFT와 EQ-5D에 미치는 영향에 대해 분석하여 농어촌 건강증진 운동프로그램의 효과성을 검증하는 것이다. 이를 위해 3개 보건진료소에서 각각 실험군과 대조군을 각각 34명과 17명씩 모집하였으며 2개 진료소는 농어촌 건강증진 운동프로그램을 운영하고 1개 진료소는 통제 군으로 사전사후검사만 실시하였다. 12주간의 농어촌 건강증진 운동프로그램은 스트레칭, 걷기운동 및 근저항 운동으로 구성하여 12주간 적용하였으며, 측정항목으로는 SFT와 EQ-5D로 하였다. 이에 따른 연구결과는 다음과 같다. 실험군의 SFT 항목인 의자에서 일어섰다 앉기, 2분 제자리 걷기 및 의자앉아 앞으로 굽히기와 EQ-5D에서 사전에 비해 사후에 유의한 차이가 나타났다. 이러한 결과를 볼 때, 농어촌 건강증진 운동프로그램은 하지 근력, 근지구력, 하지 유연성, 삶의 질이 긍정적인 영향을 미친다는 것을 알 수 있었다. 이러한 연구결과에 기반하여 상지 근력, 상지 유연성 등 보다 다양한 효과를 나타낼 수 있도록 농어촌 건강증진 운동프로그램으로 발전이 필요할 것으로 생각된다.

Héctor Abad-Gómez (1921-1987): médico, educador y defensor de los derechos humanos

Héctor Abad-Gómez, Colombian physician, university professor, journalist and human rights defender, was murdered in Medellín in 1987. He was a pioneer public health activist engaged in various fields. While being student his restless and dissatisfied mind, led him to fight for a better and safer water and food. He specialized in the University of Minnesota (USA), at his return to the country he led the establishment of the Rural Medical Service. Forced to exile for several years he was WHO consultant to several countries in the Americas and Asia. In 1956 he founded the Preventive Medicine and Public Health Department of the University of Antioquia. He carried out the first recorded mass community vaccination against polio in the world. He initiated a community health agents program known as “Rural health promoters” that later would be implemented nationally. In 1962 he first proposed the application of epidemiological methods to study violence; he was visiting professor at the University of California; he coined the term “polyiatry” for a specialty dedicated to the health populations; he was director of the Colombian National School of Public Health that currently bears his name. Héctor Abad-Gómez ventured into political life, in accordance with Virchow dictum that “politics is medicine on a large scale”. The lives of both have interesting similarities except for the tragic and premature death of the former that still receives rejection today in social, political and academic levels, both in Colombia and abroad.

Supporting better mental health services for rural Australians: Secondary analysis from the Australian National Social Survey.

People with mental illness experience poorer physical health, less access to physical health care and live shorter lives compared to the general population.1 Managing physical health issues along with mental illness can be difficult, especially for those living in rural locations, given that access to mental health services diminishes as remoteness increases.2 Bridging health service disparities between regional and urban localities must be a national imperative since people with mental illness in rural areas have higher rates of early mortality due to physical illness.3 The aim of the present study was to offer additional evidence for bridging this gap by comparing the prevalence of co-morbid mental and physical illness between urban and rural areas. Participants in the Australian National Social Survey (n = 1265) self-reported demographic, quality of life, chronic disease and health behaviour characteristics. Dichotomous (Yes/No) self-reported chronic disease status including being told by a doctor, they have depression and/or anxiety was recorded. Urban and rural classifications were based on self-report. In this secondary analysis, Chi-square and independent samples t tests were conducted to test differences in proportion of respondents with self-reported depression and/or anxiety in urban and rural areas with co-morbid physical conditions, and the number of co-morbid physical conditions, respectively. Statistical significance was accepted where P < 0.05. Participant characteristics are shown in Table 1. Depression and/or anxiety was reported by n = 216 respondents. Urban residents comprised 74% (n = 159) of the sample. Co-morbid physical illness was reported in n = 109 (69%) and n = 45 (79%) urban and rural residents, respectively (χ2 = 2.215, df = 1, P > .05). Those in urban and rural areas reported 1.6 ± 1.7 (range: 0-9) and 2.1 ± 1.8 (range: 0-7) co-morbid chronic conditions, respectively (t = −1.848, df = 214, P > .05). Participants provided informed consent, and the study was approved by Central Queensland University's Human Research Ethics Committee (Approval No: H14/09-203). There was no difference in the prevalence of at least one other co-morbid chronic condition between people with self-reported depression and/or anxiety who resided in urban versus rural areas. Acknowledging limitations of self-reporting health status, small sample size, and potential confounders such as age, this is a novel finding. Although the prevalence of psychological distress is similar between rural and urban areas, people with mental illness in rural areas have more than 300% greater risk of premature death due to co-morbid physical health conditions, compared to their urban counterparts.3 In part, this can be explained by the reduced access and more barriers to mental health services for people living in rural areas compared to than people living in urban areas.4 Given the common prevalence of co-morbidity, our findings argue strongly for better access to health care services in rural areas that address mental health care but with capacity and capability to address physical health care to reduce disease burden in these communities. Telehealth services may reduce this disparity, but service location remains “urban-centric.” One potential solution may be to develop and implementation multi-skilled practitioners who can provide mental and physical health services simultaneously. Achieving this requires efforts directed at funding, attracting, and retaining medical and allied health professionals to rural communities, especially those who come from and feel connected with rural communities. Recently, the Federal Government announced the Stronger Rural Health Strategy aimed at addressing the higher disease burden and risk of early mortality faced by those in rural areas. However, this strategy has been criticised as being overly focussed on medical professionals, with a relative absence of attention to allied health professionals.5 Together with limited funding for rural health promotion, rural residents may be worse off, thereby widening, rather than bridging, the current disparity in health service provision. Clearly, more needs to be done to develop and support the rural workforce to help communities in need and achieve health service parity with metropolitan areas. The authors have no conflicts of interest to declare.

Cultural Competency and Rural Disorder in PNG Health Promotion

ABSTRACTHealth workers in Papua New Guinea strongly emphasise their duty to provide services to the country’s rural majority. Trained to see rural communities as lacking modern discipline and order, they worry that rural people will resist, perhaps with violence, if health workers fail to ‘show respect for culture’. Examining cultural improvisation among nursing students on a rural experience practicum in the Eastern Highlands, I show how students and teachers tried to craft culturally respectful health education. However, when difficulties emerged, local people were described as unable or unwilling to harim tok (understand, heed or follow instructions). The capacity to follow instructions, cultivated through education and Christian faith, was cast as incompatible with Highlands culture. Rural health promotion activities, when they fail to foment major transformation, can help reproduce the ideological construction of the people of the hauslain (village, hamlet) as emotionally volatile and ungovernable.

Avoiding Failure for Australia's Digital Health Record: The Findings from a Rural E-Health Participatory Research Project.

Low adoption and use of Australia's digital health record has driven the Australian Government to trial 'opt-out' registration from mid-June 2016. The assumption that automatic registration will increase use and thereby deliver benefit requires further investigation especially amongst those sections of the population in rural, regional, remote Australia living with complex chronic conditions. This paper reports on findings from a community based participatory e-health research project based on an initiative where people with complex chronic conditions and their carers attended a rural health promotion and lifestyle modification program. Through co-operative enquiry, health promotion officers and their clients were actively supported to adopt and use Australia's digital health record as an intervention. Simultaneously they were encouraged to reflect on its design and their perceptions of its overall impact on their individual ability to self-manage complex chronic conditions. The findings, ultimately contributing to a conceptual implementation and evaluation framework for Australia's digital health record that could directly avoid failure of the new 'opt-out' approach being adopted.

New Evaluation Vector through the Stanford Mobile Inquiry-Based Learning Environment (SMILE) for Participatory Action Research.

ObjectivesThis article reviews an evaluation vector model driven from a participatory action research leveraging a collective inquiry system named SMILE (Stanford Mobile Inquiry-based Learning Environment).MethodsSMILE has been implemented in a diverse set of collective inquiry generation and analysis scenarios including community health care-specific professional development sessions and community-based participatory action research projects. In each scenario, participants are given opportunities to construct inquiries around physical and emotional health-related phenomena in their own community.ResultsParticipants formulated inquiries as well as potential clinical treatments and hypothetical scenarios to address health concerns or clarify misunderstandings or misdiagnoses often found in their community practices. From medical universities to rural village health promotion organizations, all participatory inquiries and potential solutions can be collected and analyzed. The inquiry and solution sets represent an evaluation vector which helps educators better understand community health issues at a much deeper level.ConclusionsSMILE helps collect problems that are most important and central to their community health concerns. The evaluation vector, consisting participatory and collective inquiries and potential solutions, helps the researchers assess the participants' level of understanding on issues around health concerns and practices while helping the community adequately formulate follow-up action plans. The method used in SMILE requires much further enhancement with machine learning and advanced data visualization.

Papshop: Not a ‘melon’choly Pap smear workshop!

As Head of Undergraduate Education in the Department of Obstetrics and Gynaecology at the University of Cape Town, South Africa, I have a particular interest in the competencies needed to perform primary care gynaecological procedures, one of which is the Pap smear. I was approached by a group of keen volunteer students to assist with Pap smear training to roll out a pilot screening programme at student-run after-hours clinics in Cape Town and at volunteer rural health promotion clinics. This article describes a novel approach to teaching the Pap smear technique, using fruit and toilet rolls, which can easily be replicated in resource-constrained areas. Students branded the workshops as ‘Papshops’, and the name has stuck. Increasing numbers of students are now taught by peers already trained in prior Papshops, thereby expanding the teaching workforce. To date, during 2013 - 2014, Papshop students have performed almost 300 Pap smears for eligible women in under-resourced areas.

Psychosocial, physical, and autonomic correlates of depression in korean adults: results from a county-based depression screening study.

ObjectiveWe aimed to investigate the prevalence and psychosocial and neurophysiological correlates of depression in a large county-based cohort of Korean adults.MethodsWe recruited 2355 adults from a rural county-based health promotion program. The following psychometric scales were used: the Center for Epidemiologic Studies Depression scale (CES-D) was used to assess depression, the General Health Questionnaire (GHQ) was used to evaluate stress, and the Medical Outcome Study Social Support Survey (MOS-SSS) was used to determine perceived social support. Heart rate variability (HRV) was used to assess neurophysiological properties. The psychosocial and neurophysiological variables of adults with depression (CES-D score ≥25) and without depression (CES-D score <25) were statistically compared. A logistic regression model was constructed to identify factors independently associated with depression.ResultsWe estimated that 17.7% of the subjects had depression, which was associated with old age, being female, being single, less religious affiliation, high education, low body mass index (BMI), low levels of aerobic exercise, low social support, and a low HRV triangular index. The explanatory factors of depression included high education, less religious affiliation, low levels of current aerobic exercise, low BMI, and low social support.ConclusionGiven the relatively high prevalence of overall depression, subsyndromal depression should also be regarded as an important issue in screening. The independent factors associated with depression suggest that practical psychosocial intervention, including brief psychotherapy, aerobic exercise, and other self-help methods should be considered. In addition, the HRV results suggest that further depression screening accompanied by neurophysiological features would require fine methodological modifications with proactive efforts to prevent depressive symptoms.

A Conceptual Sustainability Strategy for a Rurally-Based Community Health Promotion Initiative

Sustaining grant-funded rural community health promotion initiatives following expiration of active funding cycles is usually challenging. Rural communities are described as periphery to cities and somewhat isolated with all larger communities located more than 30 miles away and are perceived as lacking in essential resources that create and nurture businesses [1,2]. Statistics show that rural residents are comparatively poorer than urban and metropolitan residents. For instance in 2005, 17% of rural residents lived below poverty line whereas in metropolitan areas it was 13% [3]. Furthermore, as funding sources and grant making agencies limit, restrict, prioritize, and restructure funding because of current national economic downturn, it is imperative that rurally-based community healthcare promotion projects become familiar with a locally-dependent strategy that fosters sustenance of life-saving community health initiatives. This article describes a practical strategy for securing local resources to sustain rurally-based grant-funded community health promotion programs. It provides a step by step guide for identifying, recruiting, and engaging suitable local collaborators to secure resources that continue to meet goals and objectives of funded programs following expiration of external funding thereby ensuring that rural residents continue to receive benefits of useful health promotion initiatives. During these times of severe national economic hardship, program administrators will find this strategy very informative and helpful. However, there is need for further testing to properly evaluate the usefulness of this sustainability strategy.

The contribution of social work in promoting rural health: a case from the grassroots

Promotion of rural health has become a high priority of policy makers in many third world countries. Numerous NGOs are working to improve health quality in rural India. By describing a rural health promotion project in which a social worker played a key role, this article illustrates how social work practitioners can bring their many skills to bear in efforts to promote health. This commentary seeks to share the experience of an NGO in specific health promotion project in Rural Karnataka State (India).

Promotion of Rural Health: Experience of an Indian NGO

Promotion of rural health has become a major agenda of policy makers. Health can be more properly viewed as an index of human adaptation to a micro ecological niche. From this point of view, health management can mean the full visualization of the minimal requirements of clinical–curative inputs in health planning and management. A variety of factors have promoted increasing interest in prevention as a health care practice in the country. Numerous non‐government organizations (NGOs) are working to improve the health quality of rural India. In describing a rural health promotion project, in which a social worker played a key role, this article illustrates how social work practitioners can bring their many skills to bear in efforts to promote health. In this paper an effort has been made to share the experience of an NGO in health related project.

Child care in China: lessons for the west?

Helen Warner DipHE Nursing (Child), SRN is early intervention nurse, East Kent Hospitals Trust China – the word itself evokes thoughts of the exotic and a culture many thousands of years old. Yet since the 1990s China has undergone continuous and rapid development during what has been the most peaceful decade in the whole of Chinese history. Although still officially a communist country, the old structure has gone and a new one is emerging. In the words of our Chinese tour guide, ‘three centuries of growth and change have been experienced over the last 30 years’. In spite of this China remains a third world country and people living in western parts of China still have to walk three to five kilometres just to fetch water. Some of the population still live in caves. It is a land of huge contrasts and there is the biggest divide between the ‘haves’ and the ‘have nots’ than anywhere else in the world. There is also the largest generation gap when you consider that the older generation lived under strict communism and the younger generation do not even know who Chairman Mao was. As part of a paediatric health study tour organised by Master Travel Ltd (www.mastertravel.co.uk), I joined a group of 18 paediatricians, GPs and paediatric nurses who wanted to see for themselves how their profession is practised in this fascinating country. Tours are accompanied by a British tour leader, in this case a retired paediatrician and an experienced Chinese national guide. Our Chinese guide was a mine of information, having specialised for 12 years leading health study tours, and his local knowledge and contacts opened doors to places not readily accessible to the typical tourist. In addition his knowledge of China’s culture, history, health and social care helped provide real insight into everyday life in modern China. Among the places we visited were the Shanghai Paediatric Hospital, a neighbourhood paediatric and family planning centre, and a state Chinese kindergarten. In Beijing we saw the Beijing Children’s Hospital, the largest hospital of Traditional Chinese Medicine (TCM) in the world, the Xi Yuan, a medicine market, the Care for Children Foster Project, the Xian Orphanage for Children with Special Needs, and visited a traditional ‘barefoot doctor’ to learn about rural health promotion and immunisation. My particular interest was in how TCM and western medicine are used in combination for children with disabilities, and how western medicine can learn from this. This article gives an overview of the visit and aims to increase readers’ understanding of China’s progress in the health care of its children, including the place of nursing. The photographs illustrate some key issues: we were careful to request parental permission before taking photographs in spite of being informed that in a communist country this was not necessary as long as permission is sought from the doctor in charge.