For a number of years now, banks have been going through enormous changes in organization and structure. New technology and new ways of structuring the operation have left their mark on the working conditions and daily lives of employees. Deregulation of labor markets, emerging technologies and new types of jobs have significantly reshaping working lives by continuous changes on employment and working conditions. Such a scenario has a relevant impact not only on companies' organization but also on working population's health. The banking sector is particularly well-deserved of a specific and thorough analysis, in view of the recent increase in psycho-social disorders of employees. This may be related to the major organizational changes affecting this sector and, in particular, to the restructuring processes resulting from the global economic crisis. Our aim is to assess the scale of the phenomenon and how far it relates specifically to the processes of bank organization. With this in mind, through a review of the literature, we selected the main studies dealing with work-related stress in banking, so that we could reach a better understanding of the phenomenon as it relates specifically to this set of workers. The search took place on the MEDLINE® database; in total 20 articles were chosen. There was uniform agreement among the studies that stress in the banking workplace is now at critical levels, and that it can have deleterious psychological effects on workers, and on their physical health, and that organizations, too, are affected. Most studies showed that mental health problems had increased in the banking sector, and that they were stress-related. Examples began with anxiety and depression, carried on through maladaptive behaviors, and ended in job burnout. The reviewed studies' limitations were then discussed, and possible ways forward considered. In recent decades, moves to a global economy and deregulated markets have led to a series of large changes in the way financial services work and are sold, and this is particularly true of the organization and execution of work in the sector , mainly due to strategic reasons rather than to financial failures  already from the beginning 2000 and prevented a proper response to economic shocks, both from the effects of the 2007 international financial crisis and the sovereign debt crisis of 2011   ranked occupations for stress levels, with some of the 130 occupations found to be more stressful. What these stressful occupations had in common was that the employee had insufficient control over the work, with employees feeling that they were trapped in jobs where they were regarded as quasi-machines rather than as people. The dozen most stressful positions were managerial, administrative and supervisory roles; if we extend the 12 most stressful occupations to 28, bank tellers feature in the list  as it relates specifically to this set of workers.To find recent date scientific literature on the subject of work-related stress in the banking sector, we conducted a review following the MOOSE Group's guidelines  , they had to be published in English and their full-text had to be available online (based on both the subscriptions of the University of Florence and of the European University of Rome). No temporal filter has been adopted. MEDLINE® was last accessed on 31 July 2017.Fist, the articles were selected on the basis of title and abstract, then on the basis of the full-text. The references of the selected articles were then examined to identify other suitable studies.The quality of the selected studies, included in the final synthesis, was assessed according to the study design: Table Longitudinal studies are those that follow a cohort of workers for an extended period, permitting changes in the incidence of pathological facets of banking sector work-related stress to be assessed while taking into account observed changes in both physical and psychological working conditions. There is no doubt that such longitudinal studies, as opposed to cross-sectional, studies, would produce more accurate results. Subjective (self-perceived) parameters could lead to social desirability bias, which could result in misclassification or in bias in the interpretation of objective parameters. Moreover, studies with data collected three or more times were considered more accurate and so with higher quality.About 600 citations (565 articles) were identified thought the search strategy. The selection by title and abstract led to the exclusion of 530 studies not related specifically to the topic or not in agreement with the inclusion criteria . The selection by full text led to the exclusion of 20 papers. By consulting the reference lists of the selected articles, five papers were identified. So, the procedure set out above, led to the selection of 20 articles, of which five were European , nine were Asian , four came from Brazil, and two were African .Table Considering the study design, no studies are classified in the first, completely satisfactory, quality category Table , becauseThe oldest study included in this review was published in 1996; the other researches are quite recent, and 17 (85%) were published in the last 10 years.Five of the articles examined ways in which stress at work might give rise to various negative mental health and physical results. These included anxiety and depression, together with such maladaptive behaviors such as smoking and drinking  predictors of visual complaints:- Social support;- Self-esteem;- Work satisfaction;and- Group conflict; - The underuse of skillsSocial support could also act to mitigate the stress and strain model which was responsible for 30% of the variance. Although they could have a significant correlation with asthenopia, subjective environmental factors did not show up strongly as predictors of the symptoms. The authors' conclusion was that complaints about visual health by VDT workers probably reflect in part a psychological discomfort attributable to conditions of work. Discussing the limitations of their work, the researchers observed that they had evaluated environmental discomfort on the basis of self-reporting only, that the same caveat applied to occupational stressors and visual discomfort, and that using self-reports of both job stressors and strains made for a greater likelihood of conceptual overlap.Michailidis and Georgiou  studied Silva and Barreto  took as Silva and Barreto  examinedThe subject of study for Snorradóttir et al.  was psycp < 0.001); cynicism (p < 0.001); and professional efficacy (p < 0.001). Branch office workers returned higher scores for emotional exhaustion and cynicism and lower scores for professional efficacy. This high incidence of BS was higher even than that shown by other studies where the professions involved are associated with BS  in the “passive” quadrant; the drawback to passive jobs lies in their combination of low psychological distress and low control, possibly leading to a gradual decrease in learning and skill development. The greatest risk of occupational stress lay with the quadrant that had the lowest number of employees. These results were not those expected, given the factors in today's banking activities—demanding targets, fierce competition, fewer available jobs, a constant demand to increase qualifications, intensified and overloaded tasks, and increased control and pressure on workers—that could increase the occupational stress risk. The control-demand model concentrates on processes of workforce organization to assess the risk of stress  ,psychological (job dissatisfaction complaints),behavioral (intention to quit) elements.47.2% of changes in workplace stress levels were shown to be due to alterations in posture and other health matters. Factors relating to ergonomic workstations included the effect of posture which correlated significantly with workplace stress levels. Health was shown on analysis to have a stronger relationship than any other factor with workplace stress due to the hours of input work demanded in the department. Dissatisfaction with the job, somatic illnesses and a decision to leave were all fueled by postural weaknesses due to ergonomic considerations related to the workstation and health factors.Fernandes et al.  conductePreshita and Pramod  set out The study by Imam et al.  looked aThe study by Mughal et al.  also looOccupational stress, conflicting demands of family and work, and their effect on symptoms of depression were studied by Kan and Yu , who alsIn South African banks, Mutsvunguma and Gwandure  comparedDevi and Sharma  used a rOginni et al.  investigMost of the selected studies were published in the last 10 years: the work-related stress in the banking sector is a rather recent issue, and this could be the result of the enormous changes in organization and structure that have been occurred in the last decade.Five studies were conducted in Europe, nine in Asia, four in America and two in Africa. Many differences occurred between countries and ethnicities as regards to cultural characteristics and the approach to work-related stress, that result in different risk perception and evaluation (Zoni and Lucchini, All studies in this review show that workplace stress is a critical banking sector issue with potentially negative effects on workers' and organizations' psychological and physical health. Most of the studies showed increases in mental health problems in the sector which were closely related to stress at work. Authors have used a number of different parameters to investigate banking sector job stress: some (Silva and Barreto, Petarli et al.  saw sociMichailidis and Georgiou  looked fPreshita and Pramod  researchAssociations between occupational stress and job burnout were investigated (Mutsvunguma and Gwandure, There was analysis from some authors of how work-related stress impacted specific conditions (Seegers and van Elderen, Other researchers looked closely at role stressors in the banking sector (Fernandes et al., Some authors concentrated on organizational stress's role in development of specific symptoms. Makhbul et al.  sought tMost studies agreed that social support could provide protection against occupational stress thus be important in reducing perceived stress levels. Social support was shown to tend to mitigate negative effect of stressors and to reduce the volume of stress reactions, and could be considered the best-established anti-occupational situational variable (Seegers and van Elderen, Several studies investigated what effect demographic characteristics had on workplace stress. Looking at age, Silva and Barreto  found thOn years of service, Petarli et al.  found thResults with regard to the level of education variable conflicted with each other. Michailidis and Georgiou  showed mSeveral authors looked for gender differences. Snorradóttir et al.  reportedFinally, some researchers researched which work characteristics were most associated with stress. Petarli et al.  said thaThe relationship between work-related stress and mental disorders were confirmed also in other sectors, as described in a recent systematic meta-review of work-related risk factors for common mental health problems (Harvey et al., This review was conducted according to scientific criteria and explored the main stress-related aspects in a changing productive sector such as credit industry. This is a strength, but there are also some limitations, which may affect the results. First, this is not a systematic review, so it has not been designed to provide a complete and exhaustive summary of current literature relevant to the research question. Second, studies overviewed in this paper are all cross-sectional, none used objective parameters, and all were self-reporting. One may add to that the fact that only studies in which the keywords appeared in the abstract or title were included. Moreover, only MEDLINE® was explored to give this first description of work-related stress in the banking sector. All these aspects may have led to not including all the articles related to the investigated topic, so limiting the extent of knowledge of the effects and features of work-related stress in the banking sector. Future systematic reviews, including other databases as well, will be performed to deeply describe the state of the art of this phenomenon according to specific issues, such as risk factors or health outcomes.Finally, the overview was restricted to studies published in the English language, so limiting the extent of knowledge of the effects and features of work-related stress in the banking sector.In conclusion, occupational stress has clearly become a significant cause of ill health and is a serious risk factor for bank workers' psychological and social well-being. This literature review has demonstrated an increasing diffusion of adverse health outcomes from work-related stress in this sector.There is a need for further studies to provide a better analysis of the relationship between work- related stress and health in the banking sector. It would be particularly interesting to carry out longitudinal studies to identify changes in the level and incidence of health problems and to map variations in economic, organizational, and social conditions. Future research should couple longitudinal designs with both objective and subjective measurements of stressors from a number of sources to increase understanding of organizational stress. Future research should also evaluate changes in the different groups of bank employees resulting from actions taken in organizations.GG, GA, AD, and NM conceived and designed the review; MP, CL, and JF-P performed the literature research; GG, NM, and AA-M analyzed the data; GG and NM wrote the paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


As the available therapies for diabetes and obesity are not effective enough, diabetologists and educators search for new methods to collaborate with patients in order to support their health behaviors. The aim of this review is to discuss perspectives for the development of new empowerment-type therapies in the treatment of diabetes/obesity. Empowerment is a process whereby patients gain the necessary knowledge to influence their own behavior to improve the quality of their lives. It is carried out in five stages: (1) identify the problem, (2) explain the feelings and meanings, (3) build a plan, (4) act, and (5) experience and assess the execution. Although many years have passed since the advent and popularization of the concept of empowerment, the area remains controversial, mainly with regard to the methodology of therapy. Some previous studies have confirmed the positive effect of empowerment on body weight, metabolic control, and quality of life of patients with type 2 diabetes; however, few studies have been conducted in patients with type 1 diabetes. There is still a need to confirm the effectiveness of empowerment in accordance with Evidence Based Medicine by performing long-term observational studies in a large group of patients. In future, empowerment may become part of the standard of care for patients with diabetes and/or obesity. Diabetes is one of the most threatening diseases of the 21st century, with epidemiological data indicating that its incidence is increasing [In both type 1 and 2 diabetes, taking medication, a healthy lifestyle, diet, and exercise are essential parts of therapy that affect patients' quality of life. Traditionally, the treatment success in patients with diabetes was measured by adherence to medical recommendations. The plan of self-control was adjusted to the patients' illness and not to their priorities, objectives, possibilities, and lifestyle. It is very difficult for patients with diabetes to comply with all medical recommendations and maintain constant normoglycemia [Another issue in diabetes treatment is that implementing complex diabetes therapy requires training of the patient and/or the caregiver. The educational programs currently used to train patients and caregivers in diabetes management are diverse, despite the similar topics and issues . It is aFunnell et al. defined empowerment in 1991 as “a process whereby patients have the knowledge and self-awareness necessary to influence their own behavior and that of others in order to improve the quality of their lives” . This isThe three main pillars of empowerment used in the treatment of diabetes are the belief that (1) diabetes is a patient-managed disease; (2) care for a patient with diabetes should be conducted as education, that is, to provide the necessary knowledge for the patients to make their own decisions; and (3) patients should identify and implement their own treatment goals, which have a real impact on their lives.The overall aim of empowerment is to provide the patient with critical thinking skills and the ability to make autonomous, informed decisions. Furthermore, empowerment facilitates and supports the patients' reflection on their experience of living with diabetes. Reflection occurring in the doctor-patient relationship  is essential for independent, positive changes in behavior, emotions, and attitude. In summary, the patients are encouraged to become active participants of self-care, and health care professionals should facilitate this process.In recent years, the number of publications highlighting the importance of empowerment as a way to encourage people to take control and responsibility for managing their health has increased. Despite the many articles in the field of empowerment, including in the field of diabetes, there is no agreement from the scientific community concerning the definition, objectives, and methods of conducting this type of therapeutic support . HoweverCurrently, the readiness of patients with diabetes to change is assessed using the Diabetes Empowerment Scale (DES) and two forms are in use: the full version (28 questions) and the short version  [The Diabetes Empowerment Scale (DES) has shown sufficient internal consistency, construct validity, reproducibility, factorial construct validity, and concurrent validity among patients with type 2 diabetes . The resThe Swedish version of the DES questionnaire showed a correlation between higher diabetes empowerment and longer diabetes duration in adult patients with type 2 diabetes . Women rIn summary, before training and possible reeducation during the years of care occurs, the health care professionals/educators should assess patients' readiness to change with the DES survey.If a patient is willing to change, an empowerment-type therapy should be performed. The stages of therapy are shown as follows.Stages of the Empowerment Therapy by Funnell and Anderson Stage I: Identify the ProblemWhat is the hardest thing about taking care of your diabetes?Tell me about it.Give examples.Stage II: Explain Feelings and MeaningsWhat do you think about this?Why do you think so?How do you think, why is it so?Stage III: Build a PlanWhat do you want?How could the current situation be changed to make you feel better?Where do you want to be on this after some time ?What are the options for your conduct?What are the barriers to your goal?Who can help you?What are the costs and benefits of each of your choices?What happens if you do nothing?How important is it to do something with this on a scale from 1 to 10?Build an action plan.Stage IV: ActionDo you want to do what is necessary to solve the problem?What are the stages of actions that could be carried out?What do you intend to do?How will you know that you have achieved a success?What will you do right after leaving here?Stage V: Experience and Assess the Execution of Your PlanHow did it go?What have you learned?What are the obstacles encountered?What, if anything, would you do differently next time?What will you do after leaving here?Empowerment allows the patient to gain/regain control over their life; the process helps recognize, promote, and strengthen the capacity of the patients to be responsible for their own lives. This approach recognizes that although health care professionals/educators have expert knowledge of the disease, this does not mean they have expert knowledge of the patient's life. In the course of therapy, the patient becomes a well-informed, active partner in their own care, and the health care professional is given the task of helping the patient in decision-making to achieve the patient's goals and overcome learning barriers.During empowerment therapy, health care professionals should listen to the patients and ask questions about what the patient needs from them to better manage their diabetes. Health care professionals should stop being responsible for patients and become responsible to them. In addition, health care professionals should show that they care first about the patient as an individual and secondly about their diabetes. The patient, in turn, must understand their role as the person making decisions and take responsibility for them. Furthermore, health care professionals must abandon the illusion that they have control over their patients, including their decisions on glycemic control and effects of therapy. Many health care professionals will be pleased with this type of action, that is, those who define success as creating a relationship with the patient. While developing a relationship with the patient takes more time, this approach increases the efficiency of the visit and may reduce the overall number of visits in the long term. For example, compared to routine consultations, in the Empowerment, Motivation and Medical Adherence (EMMA) program, doctors spoke less and patients more, and modern communication tools were used . This apQuestions about the type of therapy , topics, frequency and number of educational visits, the contact time between the educator and the patient, the use of new communication techniques, or ways to tackle barriers to self-control remain unanswered. Furthermore, the review of the literature indicates the effectiveness of empowerment in terms of illness beliefs, compliance to medication, and monitoring blood glucose. There is, however, no long-term observation and evidence of changes in body weight, physical activity, and depression symptoms for large groups of patients with diabetes/obesity undergoing empowerment. Therefore, the process and rules of empowerment should be defined in accordance with the Evidence Based Medicine. This will allow us to carry out reliable, prospective studies to prove the efficacy of this approach and to establish the standards of care for patients with diabetes and/or obesity.Patients provide 98% of their own diabetes care.The health and well-being of the patient is the result of their own decisions and actions in daily life.Diabetes is so integrated into the life of the patient that most activities of daily life influence it and, in turn, daily life is influenced by diabetes and its treatment.As patients control their daily decisions, they are responsible for these decisions and the resulting consequences.Patients cannot delegate control or responsibility for the treatment of diabetes, regardless of how much they want to. Even if the doctor is in control, the patient can change his/her mind about any doctor's decision. Thus, the patient controls and is responsible for the treatment.Health care professionals cannot control patients and, therefore, cannot be responsible for the independent decisions of their patients.Health care professionals should do everything in their power to make sure that their patients make informed, independent decisions, that is, that they have the knowledge and understanding of diabetes treatment and an awareness of aspects of their personal lives that affect their decisions.In summary, the fundamental assumptions of empowerment are the following:Most studies on the use of empowerment therapy were conducted in adult patients with type 2 diabetes and/or overweight/obesity. The objectives of these studies included better quality of life, normalization of body weight and lipid profile, improved metabolic control, and prevention of diabetic complications. The main limitations of these studies were the small study sizes, short observation times, methodological difficulties in conducting the research and assessment of its effects, and the small differences in treatment effects between the study and reference groups. Therefore, conflicting results of the use of empowerment therapy have been reported.Empowerment perceptions strongly influence self-efficacy and self-care and thus affect metabolic control in patients with type 2 diabetes . TherefoThe so-called readiness to change, measured by a dedicated DES survey, is associated with the quality of life in patients with type 2 diabetes and their treatment. After using the Diabetes Conversation Map™ tool, the proportion of patients with type 2 diabetes showing willingness to start lifestyle changes increased from 20.3% to 65.7% . One of Most studies show a positive effect of empowerment therapy on HbA1c levels and lipid profile. For example, after the 6-month empowerment-type intervention among African-Americans with type 2 diabetes, a statistically significant improvement in metabolic control was observed compared to the control period  . InteresCurrently, we do not know what specific characteristics determine the success of empowerment therapy. Age, sex, duration of diabetes, and acculturation did not affect the results of empowerment interventions  among first-generation immigrants from Armenia aged ≥65 years with type 2 diabetes . HoweverWhile most studies conducted to date show positive results, several studies have not confirmed the effectiveness of empowerment in all aspects of diabetes care. For example, in a group of 344 patients with type 2 diabetes, intervention was introduced to assist the patients in their decision-making ability, as well as to provide individually tailored training and more treatment options . HoweverWhile we usually focus on a limited number of short-term goals in psychological interventions , the most important goal is to reduce the long-term complications of diabetes, including cardiovascular disease. When the Patient Empowerment Program (PEP) was used at least once in a large group of patients with type 2 diabetes, a reduction in the occurrence of the first distant vascular complications (including nephropathy) and reduction in overall mortality were observed compared to matched patients without the intervention , 39.Overweight and obesity are one of the main problems associated with both type 1 and type 2 diabetes, as they increase the risk of cardiovascular disease in these patients. However, most therapeutic programs used in diabetes are verified based on achieving metabolic control (mainly HbA1c) rather than normalizing body weight. Indeed, only a small number of studies have used the normalization of body weight as a goal. In one of these studies, a positive effect on the normalization of BMI, systolic blood pressure, and stress levels was demonstrated following empowerment therapy among adult patients with type 2 diabetes . In addiVery few reports concern the use of empowerment in childhood obesity. The Pediatric Obesity Empowerment Model-Group Medical Visits (POEM-GMV) program examined the use of empowerment in children (average age of 10 years) who were overweight or obese . This stIn summary, while there have been some conflicting reports, overall empowerment therapy seems to improve the quality of life, metabolic control, lipid profile, and BMI and reduce the associated long-term complications (including obesity and cardiovascular disease risk) in patients with type 2 diabetes.Five basic elements are applied in the treatment of type 1 diabetes: insulin, diet, self-control, exercise, and education. Compliance with medical recommendations in this disease entity is very burdensome for the patient. Effective methods of influencing the emotional burden of type 1 diabetes are unknown. For example, among 2,419 Danish adult patients with type 1 diabetes, high emotional burden occurred more frequently in younger women with comorbidities and chronic abnormal metabolic control . HoweverThe current standard of care in type 1 diabetes is flexible intensive insulin therapy, which should lead to the achievement of correct metabolic balance and good quality of life. However, this system is more complex and technically difficult than other insulin regimens. For example, despite the fact that patients were subjected to empowerment therapy during the Dose Adjustment for Normal Eating (DAFNE) courses, they still expected and required additional support from health care professionals . This suThe German PRIMAS educational program included elements of empowerment for people with type 1 diabetes and resulted in the improvement in both diabetic parameters and the degree of patient satisfaction with their treatment . SimilarTheoretically all aspects of empowerment including education, self-management, and shared decision-making can be covered by mobile health technologies, so-called mHealth . For exaFinally, it is worth considering whether empowerment therapy is better used in patients with long lasting type 1 diabetes rather than at the time of diagnosis. Indeed, empowerment seems to be the ideal tool for obtaining a better quality of life and proper metabolic control in patients who have become tiresome of the disease or who have decreased motivation due to the ongoing routine.Although many years have passed since the development and popularization of the idea of empowerment, much controversy and misunderstanding in this area remains. The misunderstanding of what empowerment actually entails occurs in both health care professionals and patients. Indeed, our current review highlights that the term empowerment is often used interchangeably, with different intended meanings. For example, some use the term to indicate a simple reeducation process aimed at improving metabolic control and better compliance with medical recommendations; others use the term empowerment to describe a process whereby the patients become motivated and comply with medical recommendations, rather than simply leaving the diabetes care in the patients' hands .The introduction of truly embracing empowerment by health care professionals is extremely difficult because we are profoundly embedded in a traditional approach to care. This is because most educators believe that diabetes education is aimed at increasing patients' adherence with diabetes recommendations. On one hand, these difficulties arise from the type of training of health care professionals. This approach is effective in acute diseases and is focused on convincing the patient to follow the medical recommendations; however, it does not work in chronic diseases, such as diabetes or obesity. The essence of the work of empowerment educators is to provide the information to the patients about the effects and consequences of their health behavior. Health care professionals cannot control the patients and are not responsible for patients' self-control. On the other hand, due to methodological confusion, many educators/health care professionals implement the educational systems, which are based on an incorrect view on empowerment, and therefore the effects of these programs may be confusing . The expAll these limitations can be clearly seen in pregnant women with diabetes: for example, despite talk of empowerment, in practice, professionals often resort to traditional medical models and although women's glycemic control can improve during pregnancy, prolonged improvements in HbA1c patterns are not sustained .Anderson and Funnell indicate a number of misconceptions in the perception of both what empowerment is and what is included in the methods of treatment . It shouMisconceptions in Empowerment according to Anderson and Funnell: The Beliefs of Health Care Professionals My patients do not want to be “authorized, empowered” and/or they want me to tell them what to do.I want to use empowerment in my patients to maximize compliance. Empowerment means that the patient is doing everything he should.I'm trying to “authorize, empower” my patients. I am concerned when I fail to get results.There are patients who become “empowered”, patients who do not become “empowered”, and those who cannot be “empowered” because of age, education, and so forth.I'm not sure when to use empowerment. I use empowerment in some patients; this is my spare wheel. I never use empowerment in newly diagnosed patients.Education based on empowerment means focusing only on the problems of the patient.I am using the empowerment approach, because it allows patients to use any diet and adjust their own insulin doses.Responsibility for the health of patients depends entirely on the patients themselves.Empowerment assumes that the patient is able and wants to take responsibility for his diabetes and to be an equal partner in the decision-making process.Empowerment assumes that the doctor simply helps patients to acquire knowledge and skills necessary for informed choices about diabetes.Empowerment assumes that knowledge regarding taking control will be understood and remembered by patients upon communication.In turn, the barriers in empowerment that are observed in patients are frustration, fatigue, financial problems, transport/access to the therapy center, and scheduling difficulties [iculties .Finally, there are a number of general difficulties in implementing empowerment therapy . First, Treatment of diabetes, similarly to most chronic diseases, depends on the ability of the patient to cope with everyday problems and to consistently comply with medical recommendations. Therefore, E (for empowerment) has now been added to the classical ABCD  algorithm in diabetes care . Health


Lung cancer aetiology and clinical aspects have been mainly studied in men, although specific risk factors probably exist in women. Here we present the rationale, design and organization of the WELCA study (Women Epidemiology Lung CAncer) that has been launched to investigate lung cancer in women, focusing particularly on hormonal and occupational factors.WELCA is a population based case-control study and planned to recruit 1000 cases and 1000 controls in three years, based on study power calculation. Eligible cases are female patients newly diagnosed with lung cancer, living in Paris and the Ile de France area and aged up to 75 years. Almost all Parisian pneumology and oncology clinical departments are involved. The control group is a random sample of the population living in the same area, frequency-matched on age and additionally stratified on the distribution of socio-professional categories of women residing there. After acquisition of written consent, research nurses administer standardized computer assisted questionnaires to all the subjects in face-to-face interviews and acquire anthropometric measures. Besides usual socio-demographic characteristics, information is gathered about menstrual and reproductive factors, hormonal treatments, lifestyle and leisure characteristics, occupational history, personal and familial medical history. Biological samples are also collected, in order to establish a biobank for molecular epidemiology studies. Molecular characteristics of the tumours will be obtained and patients will be followed up for five years.The WELCA study aims to answer key questions in lung cancer aetiology and clinical characteristics specifically in women. The role of hormonal impregnation is investigated, and the interactions with cigarette smoking or body mass index (BMI) will be analyzed in detail. The occupational history of the subjects is carefully reconstructed, focusing in particular on the service sector. The creation of a biobank for collection of serum, plasma, DNA and tumour tissue will allow the genetic and biochemical characterization of both the subjets and the tumours. The follow-up of the patients will help in disentangling the role of hormonal factors and tumour molecular characteristics in survival. EGFR gene and ALK translocation in adenocarcinomas, have been found to be differently distributed among female and male patients  or trachea [ICD 10th revision: C33] are eligible to participate in the study. All histological types are considered, except carcinoid tumours. The case identification is performed at each ward by personnel participating in the multidisciplinary coordination meetings (MCM), during which all patients reports are routinely discussed.Physicians inform the eligible patients and, if the written consent is obtained, arrange the blood sampling. They inform the patient that the interview will be carried out by a clinical research nurse who will contact her soon. The research nurse proposes the time and place of interview to the patient and sends her a written document to prepare the interview.The control group is a random sample of the population residing in the study area. A polling institute with extensive experience contacts the women through random digit dialing, a procedure that gives each number (including unlisted numbers) an equal probability of being sampled. The list of numbers generated is then sorted to exclude business numbers or unassigned numbers. Each number is called 15 times before being abandoned as not answered. Calls are made in the morning or in the evening on weekdays and during the day on Saturdays, so that each woman has the same probability of being contacted. The selection of controls is conducted every two months and about 60 women are recruited each time.Controls are frequency matched for age and county of residence with the cases. Furthermore, to minimize selection bias, controls are additionally stratified on the distribution of socio-professional categories of women residing in Paris/Ile de France, according to INSEE: workers, businesswomen/craftswomen/shopkeepers, managerial and professional occupations, intermediate professions, employees, farmers. Women who are without professional activity when contacted  are classified according to their last job. A specific category is intended for women who never worked.When an eligible subject is contacted by the polling institute investigators, the main objectives of the study and terms of participation are explained and agreement to participate is sought. Women who agree are informed that a research nurse will contact them in the next days. After making an appointment, the nurse sends the women the same preparatory written document as for the cases. At interview, the nurse collects the written consent to participate and then proceeds with the questionnaire administration and the biosample collection .A steering committee including the principal investigator, the study monitor and two pneumo-oncologists  has been set up to facilitate the implementation and the proper conduction of the study. A clinical coordinator (JT) meets the research nurses every 2–3 months, in order to maintain their training and to follow the report of clinical characteristics of the cases . The research nurses have been specifically hired for the study and have been trained particularly regarding lung cancer characteristics, eligibility criteria and the use of the computerized questionnaire. The study monitor meets them every two weeks to follow the case and control recruitment. A newsletter is sent by the study monitor to each partner monthly to follow the number of inclusions by centre and to maintain their implication in the study.Interviews are conducted face to face at home of the subjects by the research nurses, using a CAPI procedure , and last one to two hours. Interviewers daily transfer the completed questionnaires to the polling institute, which returns SAS files.The standardised questionnaire (available on request) allows the collection of usual socio-demographic characteristics , reproductive and hormonal history, personal and family medical history, full professional history, lifestyle and recreational physical activity.hormonal history include age at puberty, regularity and duration of menstrual cycles during adult life, contraceptive methods used, age at menopause and adverse effects, history of oophorectomy. Data on exogenous hormones use are gathered by detailed questions on OC, possible treatments for infertility and HTM, including the brand of drugs used (with paper images list support), and the beginning and end date of each period.Data concerning Reproductive factors are collected via questions on pregnancies (number and outcomes), children (number and sex), age at first birth and infertility (if appropriate). In addition, women are requested to give the name of their doctor gynaecologist and/or GP, to be contacted in order to enable validation studies on the reported consumption and brands of OCs and/or MHTs.medical history are focused on history of cancer and lung diseases, including infections (like pneumonia or tuberculosis), and fibroses linked to carcinogenic exposures . The history of cancer in first-degree relatives of the subjects is also collected.Questions about For each subject, height is collected and weight is measured. Changes in weight during adulthood by decade are also recorded, both in kilograms and size clothing.smoking habits are carefully gathered and include cigarette smoking, with beginning and end dates, together with quantity per day and type of cigarettes  for each smoking episode. Specific questions are dedicated to smoking of cannabis, with quantity per day, beginning and end dates, and to passive smoking at work or at home.Data on occupational questionnaire includes general questions on work history and, for each job, information on the activity and products of the company, a description of the tasks performed  and a description of the work environment. In addition, specific questionnaires have been developed concerning tasks, jobs and sectors that are frequently found or are considered of particular interest for the study: house cleaning, dry cleaning and laundry, hairdressing, catering and cooking, health, beauty therapist, nail salons.The Finally, for each job interviewers collect an accurate description of the working hours, the duty cycle over a weekly period, and the number of working days per week, in order to be able to consider troubles in circadian rhythm.Research nurses collect clinical characteristics and vital status of the cases in medical records every 6 months for 3 years and then every year for 2 years. Information about diagnosis and medical care are gathered such as tumour localization, presence of metastasis, histological type, molecular profiling of tumours if available, stage and TNM classification, therapeutic decisions and responses.A centralized biobank for molecular epidemiology studies is established to collect and store blood or saliva from all the subjects and tumour tissue from the patients.A 20 ml peripheral blood sample is taken by venipuncture from each subject  and treated in local laboratories. All procedures follow a written standardized protocol that has been expressely developed. Briefly, blood is transported at 4 °C to the laboratory. The sample collected into two serum separator tubes with gel is allowed to clot for at least 60 min and, after spinning for 15 min at 4 °C and 3000 rpm in a standard centrifuge, serum is aliquoted in 0.5 ml cryotubes and stored at −80 °C. Similarly, blood collected into one tube containing EDTA additive is spun in the same conditions, then plasma and buffy coat (for DNA extraction) are carefully removed separately and aliquoted. Aliquots are periodically transported in dry ice to the biobank for final storage at −80 °C and subsequent analyses.In case subject refuses blood sampling, a collection of saliva with an Oragene kit is proposed. Kits are stored at room temperature in the biobank until DNA extraction. The refusal to provide a blood or saliva sample will not constitute grounds for exclusion from the study. Specimens are labeled with date of sampling and a numeric code that is unique for each subject.Serum and plasma are used for analysis of hormonal levels  and other circulating biomarkers.DNA of the subjects will be extracted from leukocytes in the buffy coat or from saliva for the identification of genetic susceptibility factors in future projects.The study monitor is in charge of the collection of biopsies or tumour specimens, contacts the pathology departments and organizes the transport of paraffin blocks and slides to the biobank. Tumour tissue is used for immunohistochemical studies on hormonal receptors. In the framework of a molecular study, all tumours will be analysed using targeted next generation sequencing . In addition, the availability of tumour tissue could allow to detect the presence of viruses that are suspected to play a role in lung cancer development, like HPV .Minimum ORs that may be detected with 1000 cases and 1000 controls, a power of 80% and a 5% level of significance (two-tailed test) are 2.67, 1.67, 1.47, 1.39, 1.31 for exposures whose prevalence in controls are 1%, 5%, 10%, 15% and 30% respectively.In France, a global ethics approval based on the list of participating centres is sufficient for epidemiological studies that are not clinical trials, and it was obtained from the Institutional Review Board of the French National Institute of Health and Medical Research and by the French data Protection Authority . The Protection to Persons Committee gave a favourable opinion about the biological collection, which has been authorized by the Ministry of higher education and research (CODECOH N° DC 2014–2078).Each subject (case or control) has a code number which is used for the identification of the blood sample and the questionnaire instead of any nominative information. This procedure guarantees the confidentiality of personal data, the respect of regulatory requirements and the study blindness. The research team keeps the link between identification number and the subject’s name.WELCA is a large population based case-control study designed to assess the role of hormonal and reproductive factors as well as occupational exposures in lung cancer among women.Several aspects make the WELCA study innovative and competitive. We were able to include the clinical wards that treat the vast majority of lung cancer patients in Paris/Ile de France area. Having limited the study to a single large region densely populated like this is an asset to the study, first, because the number of eligible female lung cancer patients is high, and secondly because the collection of biological samples, including tumour material, is made easier.The study is presented to the patients by their physician to maximize their participation and interviews of consenting women are conducted shortly after, in order to minimize survival bias in the participation in the study.Control selection is always a matter of concern with this design. In order to minimize selection bias, we built up a control group taken from the general population, following an incidence density sampling, frequency matched on age of the cases and additionally stratified on socio-economic status of the women residing in the recruitment area.Recall bias may not be ruled out completely in case-control studies, but it can be considered minimal in WELCA because data are collected by the same research nurses for cases and controls, using a standardized questionnaire and in the same conditions for both cases and controls.Lung cancer prognosis remains discouraging among women. To reduce lung cancer incidence and mortality, it is important to identify the risk factors for lung cancer in order to implement proper prevention strategies. The high prevalence of women on hormone therapy (for birth control or menopause) requires the urgent development of studies to elucidate its relationship with lung cancer. Occupational exposures to carcinogens play a major role in the aetiology of lung cancer. Very few studies have examined the exposures in jobs that are typically performed by women to date. Professional activity is an area where prevention is possible. Thus, it is urgent to identify those situations that could cause an increased risk of lung cancer and to establish adequate prevention strategies.The biological samples collected for the project  together with the questionnaire will allow to set up innovative molecular epidemiology projects, specifically on lung carcinogenesis and susceptibility. One of the aims will be to relate tumour mutations to hormonal and reproductive factors as well as occupational and smoking history, an issue that has never been investigated, to our knowledge.


This article deals with the trade in medicines into Russia in the seventeenth century. Both the early modern medical drug trade, and Russian medicine, have previously received substantial attention, but no work has thus far been undertaken on the Russian angle of the drug trade. Drawing on previously unused documents, this article traces the kinds of drugs acquired by the Moscow court. In contrast to the dominant view of official Russian medicine as divorced from native healing practices and fundamentally reliant upon Western European trends, these documents reveal that drugs were sourced as locally as Moscow markets, and from as far afield as East Asia and the Americas, but that not all drugs were accepted. As many of these imports came through Western European markets, this article also sheds further light on what drugs were available there, demonstrating the great diversity of drugs traded in early modern Europe. Russia in the seventeenth century had a particularly unusual form of official medicine: until 1654, all medical practitioners employed at court or in the army were foreigners from Western Europe.There are problems in tackling the Russian question. Very few customs records, so important to trade studies, are extant for Russia; not a single seventeenth-century custom book for the vital early modern Russian port of Arkhangelsk survives.The records also show a greater degree of similarity between official and unofficial medicine than has otherwise been thought. Recent studies on unofficial medicine have focused on the practitioners, who were Russians, or non-Russian subjects of the Russian empire, and so unlike the foreign, courtly practitioners. These unofficial practitioners often got caught up in witchcraft trials over their practice, something that, despite persistent rumours of their magical practices, the court practitioners never endured.There is now a significant literature on the history of globalisation, global trade and global links in the early modern period.Imperiia (1721), and emerged as a world power. This startling trajectory—from near-collapse in the 1600s to a major role on the world stage in the 1700s—is one reason the seventeenth century has been named as a key, ‘transitional’ time for Russia.The Russian empire is an early modern phenomenon. As late as the fifteenth century, ‘Russia’ was a group of towns held together by a common language and culture, and by the filial relations of the princes of those towns. It was Ivan III (r. 1462–1505), in the very late fifteenth century, who brought the various towns under the suzerainty of Moscow, giving Russia its other early modern name of Muscovy. Muscovy then continued to expand as a power in the sixteenth century, with Ivan IV (r. 1547–84) conquering the khanates of Kazan’ (1552), Astrakhan’ (1556) and Sibir’ (1580). Following the death of Ivan IV’s son and successor, Fedor, in 1598, the country slid into a period of chaos known as the Time of Troubles, in which the realm was not entirely under the control of the centre. Having been elected to the throne in 1613, the new Romanov dynasty then went about consolidating the conquests of the sixteenth century, but added few of their own. Perhaps the most famous Romanov was Peter the Great (r. 1682–1725), under whose rule Russia adopted the term During the same period, Russia was developing its foreign links. Muscovy conquered many of its immediate neighbours to its East and South, and maintained some contact with the other Eurasian powers, in particular the Ottomans, Safavids and Qing. However, these links did not translate to a substantial presence of people from those empires at the Russian court. A substantial amount of time and effort was put into developing links with Western European powers. Three regions in particular developed relations with the Russian State: England, the German lands and the Netherlands.This was reflected in the kinds of foreign expert found in Moscow. The court recruited increasing numbers of such experts, in particular people skilled in medicine, warfare, firearms production, mining and construction. These were often recruited through diplomatic and trade links with Europe, and so many of these experts were English, Dutch and German Protestants, although other nationalities, and for that matter, some Catholics, were also present.materia medica.The importance of these diplomatic, mercantile and personal links are immediately obvious in the practitioners of official Russian medicine. From the 1480s on, the Russian court preferred to employ Western European medical practitioners over native healers. By the seventeenth century, the activities of foreign medical practitioners at the Russian court had been formalised as a part of the department known as the Apothecary Chancery, which existed until 1714, when it was replaced by the Medical Chancellery.Whilst the kinds of medical practitioner being used remained broadly stable across the seventeenth century, the Apothecary Chancery’s list of patients fluctuated. The tsar’s family and high-level courtiers always had access to such services, apart from cases when nobles who had fallen out of favour were temporarily banned from using the department.This official medicine has left us a wealth of documents. Much work has already been done on the materials pertaining to the medical staff of the department, and to its institutional history.Despite the importance of official medicine, and the great interest of documents coming from official sources, we should remember that official medicine was also limited. For people in the provinces in particular it was almost completely out of reach. Given the size of the department, it is also unlikely that it could have even completely provided for the needs of Moscow. We also know that even those Russians who had access to official Russian medicine did not completely abandon local practices: Boris Ivanovich Morozov, a former head of the Apothecary Chancery, simultaneously consulted both an unofficial practitioner in his own employ and the Apothecary Chancery physician Samuel Collins during his final illness in 1662.One problem for historians has been how to access this unofficial medicine. Practitioners were commonly not literate, and even if they were, they did not keep records. Almost the only way Russian unofficial healers enter the historical record is in trials, a situation in which we necessarily only get a partial, skewed and fundamentally negative picture of their activities. Nevertheless, Eve Levin has made great use of such documents to open up what we can know about unofficial Russian healing of the seventeenth century.Inventing the Indigenous emphasises how the introduction of New World products into Central Europe in fact led to many intellectuals refocusing their interests on the value of local products.Many studies have been written on Russia’s early modern empire, focusing in particular on the organisational, administrative and political questions of ruling such a large, culturally diverse polity.Local markets certainly stocked local drugs. Apothecary Chancery records show the department purchasing a number of items which could have been sourced locally. In 1651, dill and juniper berries were amongst the supplies acquired from various Moscow markets.hare’s hoof [zaiach’e kopyto].One root is taken by people for stomach complaints [lit. womb] and for difficulty breathing, and the second root is for horses, it is given to broken-winded horses, and the third root is for teeth, it grows in fields and kitchen gardens.Market traders provided their wares to the Apothecary Chancery, and also to unofficial healers. The unofficial healer who treated Boris Ivanovich Morozov in 1662 was certainly using local supplies, specifically a herb known as the karniana, another herb kanisa, and they [the Apothecary Chancery staff] said that those herbs are wild herbs [lit. field herbs].[there are] the herb  The use of the term ‘wild herbs’ or ‘field herbs’ partly denotes an uncultivated plant, but may also indicate that the herbs were to be found locally, in the fields. Like the market traders in medicines, unofficial healers also commonly relied upon local substances in their medicines.The Apothecary Chancery staff, to whom such evidence was commonly sent to gain their opinion, also sometimes made a statement on the origin of the herbs in question, as in 1664: Of all groups in Russia, the court had the greatest possibility of exploiting foreign sources for medicines. However, records show that the court invested substantial time and money in gathering at least a proportion of their medical drugs from around the empire. Such efforts were coordinated by the Apothecary Chancery, but necessitated the involvement of governmental couriers, governors, regional administrators and peasant populations both in regions close to Moscow and much further afield. Moreover, this process continued from the 1630s well into the eighteenth century.povinnost’], and then passed on to the Apothecary Chancery. Juniper berry collection, then, was an activity of the central Russian provinces, and one that was organised as a form of traditional service obligation.Perhaps the most commonly collected objects from around the Russian empire were juniper berries, which were required in large quantities to be made into the alcohols in which early modern medicines were commonly suspended for convenient consumption. Rachel Koroloff has argued that collections of juniper berries were particularly centred on the vicinity of Iarolslavl’, an historically important town located 250 kilometers to the north-east of Moscow.povinnost’. Despite the differences in organisation, the collection of St John’s Root from the Tobolsk area was markedly similar to the collection of Juniper berries in the Iaroslavl’ region, including the central role of the ordinary apparatus of the state to undertake the process.From at least the middle of the seventeenth century, the Russian state also exploited the botanical possibilities of its wider empire, most notably Siberia. The use of Siberian natural riches was not new: for centuries, Siberian furs had been prized across Europe and the Near East.gosudareva dela [lit. the Tsar’s business]—a state secret.In only one instance did the seventeenth-century Russian state undertake a botanical expedition proper: the search for a Siberian source for rhubarb. Rhubarb had been traded using land routes across Eurasia—originating in the Chinese territories, and moved by Bukharan merchants to Russia, whence it was then sent on to Western Europe—since at least the middle of the sixteenth century.Consideration of local drugs thus breaks down some of the barriers thought to have existed between official and unofficial medical practice in seventeenth-century Russia. Market traders, unofficial healers and the court medical department, all had an interest in using local drugs. The court did so on a huge scale, constructing, or attempting to construct, entire supply systems to funnel local and imperial medicines to Moscow. Private trade seems to have been much more small-scale, with individual market traders dealing one-on-one with certain peasant collectors. In the case of unofficial healers, they also seem to have been involved in rather small-scale dealings. It is also interesting that, despite the often negative attitude of Russian authorities towards unofficial medicine, they themselves used private market traders to source certain items. Although in many ways official and unofficial Russian medicine were very different, and sometimes in conflict, they both shared a common interest in local drugs, albeit sourced on radically different scales.Russia’s closest contacts—in terms of medicine, but also trade and diplomacy—in the seventeenth century were with a small group of Western European nations, most notably England, the Netherlands and the German lands. Earlier work on the Apothecary Chancery has established the fundamental influence of these groups of foreigners on the personnel, library and medical practices of the Apothecary Chancery. Less is known about the importance of the Western European connection for medical drugs. Apothecary Chancery records allow us to examine both the ports through which Russia sourced its medical drugs, and the geographic origin of those drugs, to assess the relative importance of Western Europe in that process. Conversely, the great detail of Russian records concerning this trade with major European markets also allows us to explore further the history of medical drugs in Western Europe.Aleksandreiskii list—suggests a link with Alexandrine senna, which grows in Egypt but was commonly traded in Europe. This is not surprising: Mogilev was a border town, meaning local merchants had particularly good access to foreign goods. The presence of senna demonstrates that some imported medicaments were being traded on Russian markets. Despite the problems of identifying the specific geographic origin of Eurasian plants, it does seem that unofficial Russian medicine had some access to medical drugs from Western Europe.Although Russian market traders sourced a proportion of their goods locally, some of those drugs may have been imported from Western Europe. In 1654, the Apothecary Chancery purchased mint oil and wormwood oil from Mogilev.The Russian court provides much clearer evidence for the role of Western Europe in medical drug imports, as import lists from the Apothecary Chancery tell us not only what was imported, but from where. Many of the items included in these shipments could be Western European in origin: rosemary, lavender and mint, all repeatedly appear in such lists of imported drugs. However, again we face the issue of not knowing exactly where such plants originated, as they grew in so many locations. Given the central importance of Western Europe for Russian medicine overall, it is also worth considering the proportion of imports that can be more or less conclusively traced as being from Western Europe. In the earliest available list, from 1602, drugs which were European or Mediterranean in origin represent two-thirds of the 164 drugs.Import lists also provide valuable information regarding the ports of origin for these shipments. Drug imports were often arranged by medical staff, who arrived at court with such supplies, such as in 1602, when the English apothecary James Frencham arrived with medical drugs (in unknown quantities) for the court.From the 1640s on, drugs were not only procured via medical practitioners working at the court, but also via merchants. Even in these cases, medical practitioners continued to play a significant role: they drew up ‘shopping lists’ of items the merchants were to source for the court.The role of European substances in official and unofficial medicine was broadly similar to that of local and imperial drugs. Both courtly and non-courtly practitioners made use of Western European contacts to source medicines, with significant overlap as to what specific items were sourced. The main difference seems to have been one of scale. The court had the resources and connections to bring in shipments of several hundred items, and did so periodically from the 1640s on. From what we know of unofficial medicine, private traders were not able to bring in such huge quantities. The difference between court and non-court usage of European drugs was one of scale, not a fundamental rift.A central question of the early modern drug trade has become how the shifts in trade networks, including the more frequent travel to East Asia, affected the medical drugs available in Europe. This can partly be addressed by considering the long-term history of the spice trade, as spices were often also medical drugs. Indeed, Timothy Walker and Harold Cook have argued that, in some senses, ‘medicines were a subcategory of the spice trade’.priannye zel’i] from the annual fair at Arkhangelsk.Spices were commonly found on Russian markets in the seventeenth century. In 1654, the Apothecary Chancery was able to buy seven different spices from markets in the border trade town of Mogilev, including nutmeg, saffron and cinnamon.Seventeenth-century Russian documents also provide ample evidence of the continuous use of various spices as medicines at the court across the century. All extant seventeenth-century import lists, dating from 1645 through to 1696, list multiple spices, notably cinnamon, saffron, cardamom and sandalwood. Mace, china root and pepper also frequently appear. Two mid-century stock-takes of Apothecary Chancery supplies also list all these items.funty (1.2 kg).funty (8.2 kg), although only in some shipments; in others, the quantities remained similar to what they had been in the 1660s.The shift in usage of these goods across the century is better explored through a limited number of items. Nutmeg and cinnamon are two of the most commonly encountered spices in Russian drug documents. Tracing their frequency, and the quantities in which they were imported, tells us more about how spices as medicines evolved across this period. There are limitations to what can be known from the absolute quantity of a transported good, as the amount needed for a dose varied from ingredient to ingredient, and from recipe to recipe, and may also have varied across time and between different medical practitioners; moreover, the Russian documents only provide information on the quantities of drugs from the 1640s, and in some cases the 1660s, onwards. However, looking at the traded quantities does allow us some idea of how important a drug was likely to have been, and also how its importance may have changed over time. This is demonstrated by the changes in the quantities of nutmeg available between the 1660s and the 1690s. In the 1660s, nutmeg was traded in quantities of 3 zolotniki, a contemporary Russian measure of 4.226 grams, commonly used to measure small amounts of high-value items, such as precious metals.funty.funt was equivalent to 96 zolotniki, and so this alone signifies a substantial upward trend in the quantities traded.funty, a huge increase from the earliest recorded trade of 16 zolotniki. In today’s measurements, in 1646 cinnamon was being traded in quantities of around 65 grams, but in the 1690s, it was traded in quantities as large as 40 kilograms.Cinnamon provides a rather different picture. From the 1640s to the 1670s, cinnamon was traded in Spices as medical drugs thus continued to be important in early modern Russia. Indeed, there is even some evidence that the quantities of certain spices being imported increased rather substantially across the century. Spices were available in large quantities, and indeed some variety, even in unofficial medicine; the availability at court was greater, both in quantity and type, as seems to be the case with all drugs. The Russian evidence thus broadly mirrors that of Wallis’s data for London, showing the continued significance of spices as medicines across the seventeenth century.The other substantial shift in early modern trade networks with potential repercussions for medical drugs was the discovery and exploitation of the New World by European powers. Certainly Spain and Portugal, two of the early major European presences in the Americas, invested much time and effort into trying to commoditise the medicinal plants of their new colonies. However, the extent to which they were successful is debated. Following the scepticism of a number of scholars as to the uptake of American drugs in Europe, Valeria Finucci has written that, ‘[i]n the end, historically speaking, and no matter the particular interests of merchants and the experimentations of doctors and apothecaries, the New World therapeutics did not have much of an impact on the official pharmacopoeia, which kept its fairly traditional approach well into the eighteenth century’.torgovii chelovek] Ivan Efimov, who worked on the Vegetable market in Kitai-gorod.The shape of the trade in American drugs is rather different to that of spices. American drugs were available in Russia outside the court, but not until rather late. In 1694, the Apothecary Chancery procured sassafras and cinchona, two of the most important American drugs, from one market seller , ungul. Al. [moose hoof] or pil. lepor. [hares’ hair] in it, they will not take it, though to save their lives, so precise are they in observing their Fasts’.The prohibitions on prescribing animal-based medicines seem to have been enforced. As well as his comments about theriac, Collins also complained that he was not permitted to prescribe medicines containing animal parts during fast periods, as it conflicted with the prohibitions of Russian Orthodoxy, writing ‘If a Medicine has funty, sometimes over 100 funty (40 kg) at a time. It is also significant that animal medicines appear only sporadically in the trade documents from the first half of the seventeenth century, and in every shipment in the second half of the century. No animal medicines were imported in 1602, and only spermaceti was imported in 1645.funty of scorpion oil, 8 funty of spermaceti, 20 funty of crabs’ eyes and 120 funty of deer horn were imported.Import records also support the idea of the partial use of animal-based medicines at the Russian court. Certain animal-based medicines were imported, but the variety is limited, with only four items regularly appearing: crabs’ eyes, deer horn, scorpion oil and spermaceti. However, the quantities in which they were imported were substantial. Particularly in the second half of the seventeenth century, all items were imported regularly, in multiple This change in the status of animal-based medicines in the late seventeenth century may be linked to two reports written for the Apothecary Chancery in the 1660s. A number of animal-based medical drugs are discussed in a 1664 report written by Dr Andreas Engelhardt. Interestingly, this document does not mention any of the most commonly recorded animal parts from the trade documents, nor, for that matter, theriac or mummia. Instead, the report focuses on parts of other animals: bears, wolves, foxes and hares.As animal-based medicines could be created locally, it might perhaps be expected that animal parts would feature more heavily in the lists of medical ingredients purchased from local Russian markets than imported from overseas. At least some animal-based medicaments were considered valuable outside the court: in 1691, the Apothecary Chancery pupil Leontii Tikhanov was sentenced to be beaten for stealing a bezoar from the department, speaking to a value for that object beyond the court.Theriaca ex venenis confecta , which uses theriac as a metaphor for finding success in defeat.The trajectory of the two medicines directly referred to in the Apothecary Chancery’s oath—theriac and mummia—is rather different from that of animal-based medicines as a group. Indeed, only one import document, from 1679, lists theriaca andromachi; none list mummia.Following Schiebinger’s arguments about the importance of non-transfers in the history of cross-cultural medical exchange, we can see evidence from the oaths as an important corrective for the evidence from the import lists. Although Russia drew substantially on Western European sources and practices for their medical drugs, that was always a selective process, and in the case of medical drugs, corpse medicine and animal-based medicine were substantially limited in the first half of the seventeenth century, although that restriction waned later in the century. This evidence echoes the conclusions drawn by Levin and Renner regarding other areas of early modern Russian medicine: the Russian court spent substantial time, effort and money importing Western European medical practitioners, books and practices. However, this was not a slavish imitation of Western European norms. Rather, that importation went hand-in-hand with the selection and adjustment of that medicine to suit Russian purposes.Devoting attention to documents relating to medical drugs reveals aspects of early modern Russian medicine, and indeed aspects of early modern European medicine more generally, that other sources cannot. Medical drugs in Russia tell us about the relationship between official and unofficial medicine, and revise our ideas of the relationship of Russian medicine with medicine elsewhere in Europe, and indeed the world. Histories of early modern Russian medicine have almost exclusively focused on the Apothecary Chancery, and understandably so, as the records of that institution represent a substantial collection of medical documents for that period. The patient circle of the Apothecary Chancery expanded during the course of the century, but even by the 1690s it only encompassed a minority of Russians, with the vast majority looking elsewhere for their health care. In fact, the Apothecary Chancery records provide the opportunity to examine unofficial healing practices, in particular the medical drugs stocked by local markets and purchased from them by the court. The very fact of these documents demonstrates that there was a consensus between unofficial and official medicine regarding a proportion of medical drugs. Indeed, even new medical drugs like the American imports had made it onto the markets by the 1690s. Despite the notable disjunctions, and even conflicts, between official and unofficial medicine in other areas, in the sphere of medical drugs there was at least some agreement.This agreement covered the value not only of local drugs, but also of products from much further afield: spices from East Asia, and American products. This alters our understandings of the geographical limits of Russian medicine. Medical practitioners, and medical texts, came into Russia from a small number of Western European nations. In stark contrast, medical drugs were regularly sourced from within the empire, from East Asia, and even from the Americas. Western Europe remains an important part of the picture—both the East Asian and the American products were commonly imported via Western Europe—but it takes the role of a middleman, not a dominant actor. The continued significance of Western Europe means that Russian sources can also tell us about trends there: the fact that the Russian court could purchase such substantial amounts of both spices and American plants from Hamburg, among other places, in the middle of the seventeenth century tells us that the spice trade was of lasting importance across the century. It also shows us that American drugs were heavily traded across Europe by the middle of the century, substantially undermining claims that they were never a significant part of European medicine. The Russian court’s interest in recording its purchases reveals the state of medical drugs both within Russia, and across Europe, as being consistently geographically diverse.Conversely, despite the continued importance of Western Europe to Russian medicine, Russian drug records do not show a slavish imitation of Western European trends. Indeed, two of the most popular and well-regarded medicines of early modern Europe—mummia and theriac—were banned from the Russian court at the start of the seventeenth century, although that ban did not last more than a few decades. Here evidence from medical drugs once again echoes other work on Russian medicine, notably the conclusions of both Eve Levin and Andreas Renner, that early modern Russian medicine was highly and fundamentally selective of Western European trends and models. This is an important point for placing Russian medicine within current discussions of global histories. Broad trends are always modified by local considerations, in this case making plants grown on a continent whose very existence was recent knowledge preferable to medicines known in Europe for centuries.The research upon which this paper is based was supported by grants from the Wellcome Trust, and the Max Planck Institute for the History of Medicine. I am grateful, as ever, to the staff of the Russian State Archive of Ancient Documents [RGADA], Moscow, for the use of their materials, and their patience and support. Earlier versions of this paper were presented at the workshops ‘Trading Medicines: The Global Drug Trade in Perspective’ at the London School of Economics, and ‘Continuity and Change in Russian Therapy’, at the University of Oxford. My thanks go to the participants of those workshops, as well as Rachel Koroloff, Erika Monahan, Matthew Romaniello, Patrick Wallis, two anonymous peer reviewers and my collaborators in creating this pair of articles, Jan Willem Veluwenkamp and Werner Scheltjens, for their invaluable comments on previous drafts of this article. Any remaining errors are entirely my own.This work was supported by the Wellcome Trust and the Max Planck Institute for the History of Science.


Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin.Falls are a leading cause of injury death. Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used.The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits.Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct  Unintentional falls have been the leading cause of injury death in adults aged 65 years and older from 1999 to 2014 –5. ReseaStepping On is a multifaceted fall prevention program that uses a series of small group sessions followed by a home visit and a 3-month booster session to teach fall prevention strategies to community-dwelling older adults, improve fall self-efficacy, encourage behavioral change, and reduce falls  — Two workshops were held at an ILRC located in an urban area in Southeastern Wisconsin. The leader of one workshop was from a health background (ILRC RN), while the leader of the other had a non-health professional background (ILRC senior service manager). Both leaders had implemented one workshop as a pilot and had received feedback based on a content expert’s fidelity observations. Both workshops utilized home visits. The total number of participants enrolled at this site was 19.Parks and Recreation Center — Two workshops were held at a Parks and Recreation Center located in an urban area in Southeastern Wisconsin. The leader of these workshops was a speech therapist by training, and a fitness expert by current occupation. The first workshop at this site utilized home visits while the second utilized phone calls from the leader in lieu of home visits. The total number of participants enrolled at this site was 23.Parish Nurse Program — Parish Nurse Program Two workshops were held through the parish nurse program in a small town in a rural area of Southeastern Wisconsin. The leader of these workshops was a parish nurse (RN). The first workshop at this site received a home visit while the second received a phone call from the leader in lieu of a home visit. The total number of participants enrolled in this site was 21.Four research questions guided this evaluation. The implementation metrics of interest and methodology to examine each differed and are described below by question, and summarized in Table Stepping On Leaders: “occupational therapist, physiotherapist, and other health professional and health promotion worker in the area of falls-promotion with older people”  elements—occurrence, and, PT elements—quality  held at the ILRC by expert observation using a checklist during four of the seven workshop sessions. The observer was a retired nurse (RN) who had served as a peer leader for several previous rt panel . Fidelit—quality . PT elem—quality .Stepping On and reach large numbers of older adults at risk for falls. Within each of these settings, however, a number of organizational barriers may exist which could prevent successful uptake and implementation. The investigative team studied the implementation in an ILRC, a park and recreation center, and a parish nurse program to examine the implementation metrics of participant reach, program feasibility, and program uptake.The original program called for implementation in a suitable community-based venue that is easily accessible to the public. The investigative team identified types of community-based settings, which had potential to implement In-depth qualitative interviews of leaders and site managers after workshop completion at all sites asked about barriers and uptake, acceptability, adaptability, and feasibility of implementing the program at the site. Qualitative protocols were developed by the study team. Interviews included semi-structured and open-ended questions. Additionally, sites provided basic demographic information  regarding clientele served at their site. This information was used to examine the extent to which workshop participants represented the demographics of the clientele at each site. Interview transcripts were hand coded and examined for themes by two independent coders .One concern for the investigators was that rural areas may not have access to some of the experts required to provide guest information sessions within the program. This included a PT to contribute to three of the sessions. Additional, lack of transportation alternatives may impede reach to older adults in rural areas. We conducted rural versus urban analyses to examine implementation metrics of participant reach, and program feasibility.t-tests with STATA v.12.Rural and urban were defined based on location of the workshop, using the State of Wisconsin Bureau of Aging and Long Term Care classification of rurality . LocatioStepping On workshop was added to the list of offerings and participants signed up for it. The ILRC did not hold workshops of any type and consequently, the site manager made phone calls to offer the program to residents. The parish nurse who led the workshop recruited participants at the third site through advertising in the church bulletin and through personal invitation to clients who she felt might benefit.Methods of recruitment of participants depended on the site. The parks and recreation center had waiting lists for the class and had no problems recruiting participants. The The home visit is one component called for by the original program to assist with, reinforce, and support follow-through of fall prevention strategies and activities, including exercise, and supplement participant assessments of fall hazards and assist with remediation of those home hazards . In resoStepping On study. The first tool was completed by the leader immediately after each home visit or phone call with a participant. This tool contained structured and open-ended questions regarding the discussion that occurred between participant and leader as part of the home visit or phone call. Questions asked about content of discussions and numbers of recommendations about three target areas that the manual suggests are discussed on the home visit: strategies the participant uses for fall prevention, performance of workshop exercises at home, and home hazards identified. Qualitative analysis of key themes was done by two independent reviewers.Three tools were developed by the study team to examine the question of home visit versus phone call within the parks and recreation and parish nurse sites. These tools were based on the home visit questionnaires designed for the original The second tool was a qualitative and semi-quantitative survey completed 1 year after the home visit or phone call. Research staff contacted the participants by phone and asked them to assess the extent to which they had followed through on items and strategies discussed in the home visit/phone call. Frequency tabulations and Fisher’s exact tests were conducted for differences in performance on both tools by leader by site for the parish nurse and parks and recreation sites. Qualitative comments were reviewed for key themes.A third tool was a questionnaire mailed to participants within 2 weeks of the home visit/phone call. It asked participants to rate the perceived benefit of the encounter overall, and of elements of the encounter considered as key elements based on the Delphi consensus using a scale of 1 to 10, with 10 being the most benefit. Participants were asked to say if an element occurred as well as rate their perception of usefulness of that element. Frequency tabulations and Fisher’s exact tests were conducted and qualitative comments were reviewed for key themes.This study was reviewed and approved by the Institutional Review Board at the University of Wisconsin-Madison School of Medicine and Public Health. All informants  gave informed consent to answer questionnaires and/or be interviewed.Stepping On program.The nine fidelity subscale scores for each leader are presented in Table I think if we could not pay the PT, it would be very difficult, if not impossible to get one with the shortage of PTs at this time.” The other sites did not pay the PT. The parks and recreation site also had difficulty finding a PT, largely due to timing. The site manager at the senior center noted that “PTs book schedules months in advance so in order to get a PT to commit to all classes, you would have to do this months in advance.”The three sites had different experiences in implementing the program. Scheduling the PT was noted as an area that could be burdensome for the leader and/or site manager in two of the three sites, in particular for the first time the site held a workshop. The parish nurse site paid the PT to participate. “Leaders and site managers noted that program tasks that were burdensome when leading their first class were not as burdensome with the second. Leaders noted that pacing the session, their preparation of the guest experts, facilitating exercises and the progression of exercises all improved with the second class. Of note, experts, all of whom were volunteers except for the one paid PT, who were difficult to schedule for the first class were not difficult to schedule for the second class, likely due to the fact that the same experts who were used in class one were used in class two.Stepping On imposed the largest burden on the ILRC. Staff members were not given additional time or a reduction in workload to offset the time spent on the workshops. Leaders commented “it was hard to balance job with class responsibilities.” The research placed additional demands on the program staff, particularly around when workshops were offered. Workshops were held according to the research schedule and not when the facility would normally have offered them. The site manager noted that recruitment was “harder” at the ILRC and involved a lot of time making phone calls. Conversely, the Stepping On mission and workshops were aligned with the mission of both the parks and recreation and parish nurse programs. The parish nurse noted that it was difficult to get the recommended number of participants  and of the population attending the center as a whole  was predominately female. The population of the city where the parks and recreation center was located is 79.0% Caucasian/White and 21% Hispanic. However, all workshop participants were White.The gender composition of the parish nurse workshops  was not representative of the gender composition of the older adult congregation population . The population of the city where the church was located is 91.0% Caucasian/White and 9% Hispanic, with much of the Hispanic community attending the church sponsoring the workshop. However, all workshop participants were White. Per the site manager, Hispanics attending that church do not participate in group activities with non-Hispanics. In addition, many Hispanics aged 65 and over in the congregation do not speak English, and many are not literate.Workshop attendees at the ILRC were older, all from senior centers, and had less formal education than did attendees from other sites. A higher percentage used assistive devices and there was a higher average number of falls in the 6 months prior in this group. The characteristics of participants at the parks and recreation and parish nurse programs were similar.Stepping On workshops did as well. The reach in the rural setting was no different than the reach in suburban . Participants at the ILRC lived at the apartment complex and thus did not travel to attend workshops.There was no significant variation in one-way distance traveled by participants attending workshops in the rural site (parish nurse) compared to the suburban (parks and recreation center), despite the fact that the parish draws from a 20 miles radius for the congregation. Participants in the parish nurse workshop came from within a 5 miles radius from the church. The recreation center draws from a 5 miles radius for 95% of its participant population, and the participants in the p = 0.0111). However, the experts in rural areas did not report that their travel was burdensome. There were no rural/urban differences in self-reported burden for travel. There were no rural/urban differences in terms of PT miles traveled and burden.Guest experts had to travel significantly more miles to attend workshops in the rural site compared to the other sites. Non-PT experts in rural areas traveled significantly more miles  to get to the class location than non-PT experts in urban areas . With the non-health professional at the ILRC, there were several significant differences between the groups with strategies, exercises, and number of home hazards identified  as compared to the phone call group , thus leaders had done home visits before and were comfortable with the idea. Participants, having received home visits before, were also comfortable receiving home visits as part of the program. In contrast, the parks and recreation center staff did not do home visits as part of any programming and leaders and the site manager noted that some participants were uncomfortable with the idea of the leader coming to the home.You cannot see their body language [with a phone call],” the ILRC leader commented. Leaders also commented that it was impossible to observe and correct exercises over the phone and felt that participants may be more honest at a home visit as compared to the phone.The home visit placed a burden on two of the three organizations (ILRC and parks and recreation center). The parks and recreation center felt the home visit was time consuming and imposed a travel burden. The ILRC staff found the preparation for home visits more burdensome than expected. All leaders from all three sites preferred the home visit to the phone call, even with the additional burden. “n = 17) had an overall perception of that encounter as less helpful compared to participants receiving the home visit . Of the six elements considered key to the home visit or phone call, participants reported a significantly greater number of these elements occurring with the home visit versus the phone call . In particular, referrals were made less often in the phone call versus home visit, ), and participants viewed the referrals as less helpful when made by phone compared to in-person. At 1 year follow-up with participants, comparing those receiving a home visit with those receiving a phone call, there were no differences in the number of actions taken in response to the home visit/phone call discussion of strategies, exercises, and home hazard remediation.Two weeks after the home visit or phone call, participants receiving the phone call , and guiding the PT to ensure that exercise is practiced during the therapist’s session and participants get the opportunity to practice mobility activities outdoors. These fidelity lapses may be due to individual rather than educational background differences. Teacher/leader training has been demonstrated to be a key component of successfully implementing interventions in a community setting .This study has a number of limitations. First, small sample sizes precluded examination of differences in participant outcomes of falls as well as a rigorous quantitative analysis at the site level. Second, participation at the participant level in the research study was often affected by the season. In the winter months, many older adults leave Wisconsin for warmer climates. This affected attendance at the parish nurse and parks and recreation sites, but not at the ILRC given that the residents lived at the class location. Third, data on reach were limited to specific demographic data that the sites collected for their target population . Thus, for example, we do not know if the age distributions of workshop participants represented the age distribution of the catchment population.Stepping On was implemented at the frontline community level in order to inform future program guidance and the best formats for delivering programs. This research was essential to successful implementation and widespread replication of Stepping On. These findings have already informed the third North American edition of Stepping On, the training program for Stepping On leaders, and the Stepping On Implementation guideStepping On leader. Rather than limiting training to those with physical therapy, occupational therapy, nursing, or similar health professional background, the program disseminators now offer training to social workers, fitness experts, and health educators who have some prior training and work experience with older adults and experience with group facilitation. Further, the program has been modified so that while a home visit is strongly recommended, it is no longer required. For those interested in implementing Stepping On, the disseminators stress the fact that although guest experts can be recruited on a volunteer basis, sufficient lead time is needed, particularly for PTs. Disseminators also stress that to maximize reach, the workshop needs to be implemented at a location within 5 miles of where participants live.The goal for this research study was to understand how, when, by whom, and under what circumstances Stepping On. Only by testing implementation in a community versus laboratory setting are we able to determine the “how, when, by whom and under what circumstances” (Stepping On,In conclusion, the types of findings in this implementation research study are invaluable to the successful spread of stances” –11. ProgThis study was carried out in accordance with the recommendations of Institutional Review board at the University of Wisconsin-Madison School of Medicine and Public Health with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Institutional Review board at the University of Wisconsin-Madison School of Medicine and Public Health.AS assisted with study design, development of data collection tools, conduct of the research, data analysis, and was responsible for manuscript preparation. JM was responsible for conceptualizing the theoretical and empirical formulations of the research project, literature review, study protocol and design, and analyzing and interpreting data, and provided feedback on draft versions of the paper. AC, PL, KM, and TS assisted with design of the research study, development of data collection tools, and analysis of results and provided feedback on draft versions of the paper. LC assisted with conceptualizing the theoretical and empirical formulations of the research project, study protocol and design, analysis and interpretation of data, and provided feedback on results. VG assisted with development of data collection tools, collection of data, and analysis of results, and provided feedback on draft versions of the manuscript. VL assisted with development of data collection tools and provided feedback on draft versions of the manuscript.JM and LC are co-authors on the Stepping On Leader Manual, Third North American Edition, Freiburg Press, Cedar Falls, IA; 2011. The other authors declare no conflict of interest.