This is an interesting and provocative paper. Lee and her international colleagues 1 clearly challenge other nurses and nurse researchers to take up a global perspective for exploring healthcare issues and join the force to improve the health of people across the nations. The globalization of the world is a reality. It is not a new concept. While nurses form the cornerstone of the healthcare teams, nurses have not taken a leadership role in global healthcare issues or in moving forward with active programs of international collaborative work and research. International collaborations in healthcare research are particularly lacking between Eastern and Western countries. Only a handful of nurse researchers have begun to take an initiative in this venue. Similarities as well as differences in healthcare issues, healthcare delivery systems, environmental, sociocultural, and economical factors, and health behaviors and health policies both at the population and individual levels, for example, can form a rich ground for mutual learning in solving common healthcare problems between the nations. Many healthcare issues are no longer an isolated problem confined to a certain nation or region of the world. As the entire world is within one-day traveling distance, a health problem in one region or nation can quickly spread to the other regions and nations in a very short time period. A recent outbreak of severe acute respiratory syndrome (SARS) is a very good example of such healthcare crises that demand rapid and efficient solutions via active international collaborations. Beyond such unexpected and sporadic outbreaks of illnesses and diseases, a more fundamental issue is how nurses and nurse researchers should think out-ofthe-box and out of the one-locality and one-nation mind set. Nurses need to think beyond the boundaries.
Working together across the nations should be a norm rather than an exception. When and why does a certain healthcare system succeed or fail in a given nation or locality? What lessons can we gain from each other's trials and errors? What are the major factors that may significantly influence public health in a given nation or region, and how can nurses be involved in identifying, overcoming, and correcting any shortcomings to improve public health? What role can nurses and nurse researchers play in improving global health care across the nations? How can we adopt and remodel successful programs of health care from one nation to another to best serve target populations? These are some basic questions nurses and nurse researchers should pursue. Health promotion, disease prevention, and health maintenance and restoration are a common goal for all human beings, regardless of the origin of the race and the nation. Nurses and nurse researchers should take an active role in achieving these goals across the nations. Lee and colleagues 1 have taken an important initial step toward this goal by comparing the healthcare delivery systems and health outcomes between the two countries of Korea and Thailand.
In a conceptual framework for globalization and health, Woodward et al 2 list several major constructs that influence the overall level and equity of health. These constructs include the healthcare system, national and personal economy, health influences and risk factors at the population and individual levels, along with other societal and political factors. Within the health care system, the health care delivery system may drive the health service access, health service quality, and health service price. As indicated in Lee et al's 1 article, the two different healthcare delivery systems of Korea and Thailand with differential structural and resource allocation may lead to considerably different health outcomes. Despite similar demographic characteristics of the population between two countries and despite the fact that the gross national income is nearly 5 times higher for Korea than for Thailand, the maternal and infant mortality rates are much higher in Korea. Such success in Thailand may be attributed to the healthcare delivery system built wisely and appropriately to serve people, while keeping the health service price down. As a clear example demonstrating the linkages between the health care delivery system and subsequent health outcomes, it may be useful to further illustrate the Thailand system in detail.
The majority of people in Thailand reside in rural areas where the traditional healthcare system may not sufficiently cover the cost of healthcare services for the poor. The concept of primary health care was introduced in Thailand over 2 decades ago, interestingly modeled after a successful Korean system developed to revitalize the pride and economy of every rural village in Korea. Under this primary healthcare concept, health care in Thailand starts at the lowest village level. When adequate care cannot be provided at that level, then the sick seek the care at the next higher level of the care system, moving from the village to subdistrict to district to provincial hospital level. At the village level, each village selects village health volunteers who can provide health information and basic care to their neighbors of 15-20 households. These village health volunteers are trained and supervised by the technical nurses at the subdistrict health centers, using the modules and manuals provided by the Ministry of Public Health. These modules and manuals are developed to fit the levels of village health volunteers for easy understanding and allow them to give their neighbors simple health information that is focused on nutrition, sanitation, maternal child health, immunization, mental health, and so on. This system is known as the grass root healthcare system in Thailand. The Ministry of Public Health presents its continuous support by designating an annual "National Village Health Volunteer Day" and giving recognition to excellent village health volunteers. Placement of a midwife at each subdistrict health center is another example of making a difference in maternal and child health outcomes in Thailand.
This example highlights how systematic structures of a healthcare delivery system with specific targets on particular areas of health care can make a difference in health outcomes of the nation. Because the economy is a major interacting factor, the healthcare delivery system needs to be built to increase health service access and quality while keeping the health service price down. The effective mobilization and maintenance of the low cost healthcare system and easy access to healthcare services, supported by the global national policy and structure, might have been the keys to success demonstrated in Thailand in Lee et al.'s article 1 . More active healthcare research can be initiated at international levels by nurse researchers to explore effective means of improving public health across nations. Health out-comes, however, might also have been affected by several other factors beside the healthcare delivery system, which have not been adequately addressed in Lee et al.'s article, 1 perhaps largely due to the limitations in available databases. One such salient factor affecting health outcomes is health behavior.
Health behaviors are a major determinant of health outcomes. In Woodard et al.'s 2 globalization and health conceptualization, health behaviors are conceptualized as an individual health risk factor that also can be influenced by social/cultural health influence at the population level. As clearly illustrated in Lee et al.'s article, 1 the high percentages of men smoking and drinking in Korea are striking. While the percentages of men smoking and drinking in Thailand are not low, the smoking rate is nearly double among Korean men. In contrast, the percentage of men exercising in Korea is a mere 9.9%, approximately one third of the percentage of men exercising in Thailand. Another clear concern is the considerable number of women drinking in Korea. Although health outcome data are limited in specifics, such as for the types of cancer mortality, 1 the extent and duration of certain health behaviors and other confounding factors would have a major impact on various health outcomes. This relationship is partly evidenced by the high mortality rate from cancer and cardiovascular diseases in Koreans.
There is an urgent need of further investigations. Nurses need to better understand the basis of such detrimental health behaviors in a particular sector of the world, Korean men in this case. Through international collaborations and communications, the underlying reasons and potential strategies for interventions can be carefully explored. Detrimental health behaviors must be discouraged systematically, while protective health behaviors need to be adopted at the national and individual levels. Lessons from other nations can ideally facilitate a more effective change process in another nation. Needless to say, the strategies must be adopted to be socioculturally appropriate and economically sound for meeting the particular needs of a given nation. However, increased international collaborations and comparative analyses between and among nations on relevant health issues can substantially increase the efficiency and the likelihood of the success of the adopted programs. Further, adopted programs must be implemented at the multidimensional levels, targeting behavioral changes, not only on the individual but also on the societal levels.
In order for the programs to be successful, it is also essential for nurses and nurse researchers to understand deeply embedded social cultures beforehand. For example, nurses must know that it is customary for a large proportion of Korean men to eat dinner out with friends and colleagues after work nearly every weekday. At the dinner table, men smoke and share drinks. In fact, smoking and drinking are highly encouraged and pressure to conform to this behavior is common among members of the social groups. For instance, it is not polite for a man to refuse a drink or a cigarette when others, particularly someone in higher power or a higher position, offer such. Furthermore, it is expected that those who receive the offer return the favor, thus continuing a vicious cycle of more smoking and more drinking. When such behavior largely constitutes male socialization and bonding, those who do not smoke and drink tend to fall outside the social circle, often feeling left out and isolated. A positive note in such a seemingly destructive social culture is that this is an effective means for Korean men to disperse their daily stress from a highly competitive society. Thus, understanding cultural aspects is a critical step for any international collaboration. In such a social climate, it will be extremely difficult to change individuals' behaviors without concurrent changes in the societal attitude and norm. To this end, national healthcare policy and societal/cultural changes need to be planned over time, using a step-by-step systematic approach, to facilitate the success.
Negative health behaviors can result in direct economic consequences for the society. Kang et al. 3 estimated the economic burden of smoking in Korea using two different approaches: "disease specific" and "all causes" approaches. Based on the major data source of the Korea Medical Insurance Corporation cohort study, the authors estimated the costs of smoking to range from 0.59% to 1.19% of gross domestic product, equivalent to $4.89-$9.86 million per 100,000 people. In addition to being an economic burden, smoking in Korea is found to be a major independent risk factor of cerebrovascular and cardiovascular diseases, even in a population that has relatively low levels of serum cholesterol. 4 Fortunately, however, there is a recent movement for changes in smoking behaviors in Korea. Because of increasing public awareness, national policies are being implemented to curtail smoking in Korea. The smoking areas are clearly designated and separated from non-smoking areas in all public buildings, and more strict regulations are expected in the near future to restrict smoking. In contrast, the rate of drinking, both in men and women, remains high in Korea, despite the high incidence rates of liver malignancies and diseases. Similarly, exercise is another major health behavior that needs to be actively promoted and endorsed for beneficial effects on health outcomes. Although societal attitude has become much more enthusiastic about exercise/physical activity since the Olympics in Seoul, Korea in 1988, the society needs to embrace beneficial health behaviors more quickly and actively. This is a clear national example that demonstrates how culture intersects with societal health behaviors that can have a significant impact on health outcomes.
Seeman and Crimmins 5 discussed the effects of social environment on health. Major health behaviors known to impact various health outcomes, such as smoking, drinking, exercise/ physical activity as well as diet/nutrition, need to be examined and compared across nations. Effective strategies for endorsing beneficial health behaviors can be implemented concurrently at the individual and population levels with adequate allocation of resources and infrastructures. Often, history tends to repeat. History in one nation can be a current reality in another nation. Through active international collaborations, as demonstrated by Lee et al, 1 nurses and nurse researchers can make significant contributions to minimizing unnecessary repetition of an unsuccessful history by facilitating an adoption of effective strate-gies for changing health behaviors that are culturally appropriate.
Nurses and nurse researchers have a major role in public health promotion, disease prevention, and maintenance and restoration of health. In particular, nurses can make a significant impact on health promotion and disease prevention. Health education is an essential, basic means of promoting health and preventing diseases. Through public education, nurses can contribute to changing the health behaviors and self-care practices of the public. The people in the community, for example, can be educated without delay when they need to seek healthcare. Appropriate care-seeking behaviors, participation in screening and preventive measures, and effective utilization of the healthcare system, in turn, are related to healthcare access. As illustrated in Lee et al.'s 1 article, the heathcare system in Thailand seems to have been structured to facilitate easy access to healthcare by people in the community who are most likely underprivileged and poor. By utilizing Village Health Volunteers at the village level, the Thailand system seems to facilitate easy dissemination of basic health information and basic care to people in need, thus making an impact on health promotion and disease prevention at an early stage. In this regard, technical nurses at the subdistrict level have the major responsibility of training these Village Health Volunteers as the workforce in the frontline for health promotion and disease prevention.
In the past, technical nurses at health centers at the subdistrict level in Thailand were graduates from a 2-year school of nursing sponsored by the Ministry of Public Health. Most of these nurses receive scholarships from the Ministry of Public Health and go back to work at health centers. However, more recently, these technical nurses have been highly encouraged to continue their education to obtain a bachelor's degree in nursing. At the same time, the Ministry of Public health is advocating that all of their schools of nursing be "Nursing and Midwifery Colleges" to better prepare nurses at health centers to promote maternal child health and prevent diseases. This bottom-up approach from the lowest healthcare level to the highest coincides with greater emphasis on the nurse's role in health promotion and disease prevention, which can make substantial differences in health outcomes that are evident in low maternal and infant mortality rates in Thailand. 1 Nursing curriculum, at the same time, should be organized to prepare nurses adequately for health promotion and disease prevention.
The use of complementary and alternative medicine (CAM) is common practice, particularly in the Orient, which can affect health outcomes. Certain healing remedies are handed down across many generations as traditional medicine. Although there was a transient movement to discourage the use of CAM, a more recent approach in many nations is to better understand basic mechanisms underlying the anticipated effects of CAM and accept the use of CAM more openly and efficiently in conjunction with Western medicine. For example, the Thai government and the Ministry of Public Health are now trying to incorporate the wisdom of Thai traditional and alternative medicine into health care of Thai people. The Institute of Thai Traditional Medicine was established under the Ministry of Public Health in 1993 (http://www.ittm.or.th/eng/ittm_ history.htm) to further develop Thai Traditional Medicine. Similarly, the use of CAM is prevalent in Korea, and the studies of oriental medicine have been well established in the university setting for decades. Commonly used CAM includes Thai and Korean traditional medicine, herbal medicine, massage, acupuncture, acupressure, and aromatherapy, to name a few. In Western nations, vitamins and dietary supplements are commonly used. Given the frequent use of CAM by the public and their potential impact on health outcomes, future studies should also utilize a more systematic approach for understanding the use of CAM and their impact on health outcomes across nations.
Various factors, such as the healthcare delivery system, healthcare access, quality, cost, and health behaviors, have a major impact on health outcomes. With globalization of the world, nurses and nurse researchers need to take an active leadership role to promote health and prevent diseases across nations. By enhanced international collaborations and comparisons, nurses can make significant contributions to improving global health. Selected strategies for improving health, however, need to be carefully revised to be socioculturally and economically appropriate for the people of the target. Lee et al 1 clearly demonstrate the importance of further international collaborations for a common goal of health. Ⅲ
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