The methodologicalframework to validate the questionnaire was a combined process that included sevensteps: translation to Portuguese; first translated consensus version; evaluationby Expert Committee; consensus on the Expert Committee version; back-translation;consensus of back-translated versions; semantic validation. The study wasconducted in two phases: phase one was the translation and back-translationsprocess, with five expert committee members. Phase two was the semanticvalidation, with 24 participants, who answered an instrument about theirimpressions of the questionnaire and suggested modifications.  in phase one, items were included, excluded, and replaced to make the contentequivalent and valid for use with Brazilian context. In phase two, the majority ofthe participants were mothers, who made suggestions about the relevance andclarity of the items in the questionnaire.  the authors discussed these recommendations and made adaptations, turning thequestionnaire into a valid and reliable tool for application. The parents' role as caregivers of sick children changes with the newresponsibilities that affect the time they have available, often implying in the loss oftheir employment. Psychological adjustments are needed and, when they have other children, parental responsibilities need to bereorganized.Childhood cancer exerts great financial impact on children and their families. Costs forfamilies may be direct, indirect and psychosocial. Direct costs are related to actualfinances associated with treatment, rehabilitation and general care expenses. Indirectcosts may include a loss of professional productivity, remunerated and non-remuneratedwork, such as cleaning and domestic responsibilities. Psychosocial costs are decreasingpsychological and social conditions in children and other family members. These direct,indirect, and psychosocial repercussions may contribute to the loss of daily routines ofthese families. Treatment related hospitalizations or health related care at home makeit challenging to maintain their earlier responsibilities, while at the same time copingwith the health care demands imposed by the cancer diagnoses and treatments. The paployment. Psychoe needed and, whrganized.. These women had lower education levels, often become unemployed, and haveinsufficient financial resources. The focus of their lives is the care of their sick children, most oftentotally directing their attention at the sick child, even if they have other children athome. This new situation may cause conflicts in the family with other children and thehusband/partner. In some families, one or both parents must quit a job to dedicate time totheir child's treatment. Consequently, family income from these women or from the couple wascompromised.Most of the caregivers who stay during hospitalization with their child with cancer arefemale, specifically mothers. These esources. The fo/partner. In somreatment. Conseq(-) to cover the high costs of medications and medical care. Other financialexpenses were incurred with transportation and meal expenses during hospitalizations andmedical office visits.Most families of children with cancer often have limited time available due to thehealth care demands of children. Parents may lose their job, at a critical time whenthey need financial resources-7 to .Changes in family dynamics, marital relationships, and social support entail additionaldifficulties that contribute to the increase in family costs. Families often restrictedleisure activities or incurred additional debts to maintain normal activities. Familiesmay increase loans through credit cards, or they may sell family goods or properties.Some parents held a second job or organized funding events to meet the financial burdensassociated with health care of their children with cancer. developed in Sweden have associated the diagnosis of childhood cancer withboth short- and long-term impact on parent's work status. Comparing the time of thediagnosis with one year after the end of the treatment, fewer fathers were at work and agreater proportion of mothers were on sick leave. Although the economic and workingsituation could be normalized with time, the income of the family was affectednegatively after the diagnosis until three months after the end of thetreatment.Other negative consequences include changes in the parents' professional life. Astudy developreatment.Costs of caring for children withcancer. This questionnaire has not been translated in Portuguese, and has not beentested for use in Brazilian families. Therefore, the purpose of this study was topresent the cultural adaptation of this questionnaire, offering a valid and reliabletool to evaluate the economic repercussions of childhood-juvenile cancer in Brazilianfamilies.Given all the direct, indirect, and psychosocial costs associated with having childrenwith cancer, there is very little in the literature that measured or quantified thesecosts, particularly in the context of Brazilian families. However, there is aquestionnaire available in English called the cancer. This qIn this methodological research with a cross-sectional design, a questionnaire toevaluate the family costs of care delivery to children and adolescents with cancerwas subject to cultural validation.. Another step indicated by Guillemin, assessment by an Expert Committee, was added to the Group's steps. Thecombined process included seven steps: 1. Translation to Portuguese ; 2. First translated consensus version (translation I); 3. Evaluation byExpert Committee; 4. Consensus on the Expert Committee version (translation II); 5.Back-translation; 6. Consensus of back-translated versions (translation III); 7.Semantic validation of items.The methodological framework to validate the questionnaire was an adaptation of theDISABKIDS Group's steps. Anotheuillemin, assessCostsof caring for children with cancer, which included these six steps explained before; and 2) semanticvalidation of the questionnaire adapted to the Brazilian Portuguese language and tothe Brazilian culture.The study was implemented between March 2010 to December 2012, and it was conductedin two phases: 1) translation and back-translation of the questionnaire  cancer, which  of the original questionnaire were contacted to obtain permission toadapt and translate the instrument for use in Brazilian families. Approvals werereceived from the Institutional Review Board at the University of São Paulo atRibeirão Preto College of Nursing (Process 1256/2010) and the National ResearchEthics Committee . Approvals were also received from thedirectors of the pediatric clinic and the Pediatrics and Child Care Department of theUniversity of São Paulo at Ribeirão Preto Medical School Hospital dasClínicas (HCFMRP/USP).The authors of the Consent to participate in the research was obtained, in compliance with theguidelines of National Health Council Resolution 196/96, using Informed Consent Forms(ICF). Details about the research were provided to participants, including researchobjectives, data collection procedures, and the importance of using the ICF copy,contact information of the researchers in case of any questions or concerns, possiblerisks and benefits, and freedom to drop out of the research at any time. Participantswere informed that all responses were anonymous and confidential. Two copies of theICF were signed.Costs of caring for children with cancer wasoriginally developed in English by authors from the United Kingdom. This questionnaire has 58 questions that included items: 1) demographiccharacteristics of parents ; 2) clinical information ; 3) current expenses related toillness ; 4) employment,and 5) public or charitable financial support received .The questionnaire  Kingdom. This qCosts of caring for children with cancer. Two authors fluent in English and familiar with the research themeindependently translated the questionnaire from the original English language toBrazilian Portuguese (translation I). Secondly, an assessment process was added toenhance the scientific rigor of the process. The assessment was made by an ExpertCommittee that included five nurses who were knowledgeable and experienced in thetheme. The authors discussed and developed a consensus version.The translation was the first phase in the adaptation process of the questionnaire cancer. Two au(-). This instrument was designed to facilitate the analysis of thetranslation process developed by experts.The Expert Committee used an instrument for assessing equivalence between theoriginal and translated versions of the questionnaire. This instrument was composedby multiple choice questions, which assessed whether the item was translated inaccordance with the following assumptions: a) conceptual equivalence; b) equivalenceof items; c) semantic equivalence; d) operational equivalence; and e) contentvalidity-14. TThe Expert Committee separately assessed all questionnaire items, according to theproperties included in the evaluation instrument. The Expert Committee was instructedto mark the items with an X in the corresponding space, according to the followingcriteria: -1= not equivalent (does not agree with the translation); 0= inconclusive;+1= equivalent (agrees with the translation). In case of -1 or 0, the ExpertCommittee was instructed to include comments and suggestions on the lines below eachinstrument item.The research team analyzed both versions, conciliated the translations and drafted afinal translated version (translation II). Two bilingual persons who were unfamiliarwith the main theme back-translated the questionnaire back to English. Theback-translated questionnaire was then forwarded to the original authors in order toanalyze and deliberate on the changes that were needed during the cultural adaptationprocess. The meanings and objectives of the final translated version were the same asthe English version, resulting in an adapted Portuguese version for use in Brazilianfamilies. was used for semantic validation. The interview instrument consisted ofthree multiple-choice and two open questions. The multiple-choice questions assessed:1) whether the items and questions in the translated questionnaire were relevant tothe situation they experience; 2) if they faced any difficulties with understandingthe items in the questionnaire, and 3) if the items were clear and consistent. Theopen questions assessed: 1) how the participants understood the meaning of thequestion, and 2) if they found it necessary, how they would reformulate the item orquestion in their own words.Three authors developed in the semantic validation phase. Parents or caregivers ofchildren with cancer were interviewed about their impressions on the questionnaire.An interview instrument from the Group was use divided the questionnaire into subgroups, with a view to guaranteeingmore reliable answers. The questionnaire had ten sections (sections A-J). Theresearch team decided to make groups of two or three sections, ranging from 12 to 17questions. These numbers of questions were thought to be reasonable so that eachparticipant could evaluate the items appropriately, and minimize fatigue, time andeffort for each participant. Each subset of items was then evaluated by three parentsor caregivers for the children with cancer.To facilitate participants' evaluation, the Group dividedFive experts in pediatric and oncology nursing who were fluent in English wereinvited to be part of the Expert Committee. The authors developed this phase throughface to face meetings at the University of São Paulo at Ribeirão Preto College ofNursing, and electric mail communications.Parents or caregivers of 24 children and adolescents with cancer who were beingfollowed at the HCFMRP/USP were invited to participate. They had to be the familymember actively involved in the care of the sick child, such as mothers, fathers,siblings over 18 years of age, maternal or paternal grandparents, who could provideessential information to understanding the economic repercussions of cancer in thefamily. Their children had to be: 1) under the age of 16 at the time of the cancerdiagnosis; 2) younger than 20 years at the time of parent participation in the study;3) followed at the pediatric clinic or infant outpatient clinic of the researchinstitution; and 4) living with their parents. In the event that both parents werepresent, only one was asked to participate. Children and adolescents suffering fromother chronic conditions associated with cancer, like Down syndrome for example, wereexcluded, as well as parents and/or responsible caregivers without minimal literacyskills to understand the questionnaire items, as verified by health professionals atthe clinic who were more familiar with them. The interviews were done at thePediatric Inpatient Unit and Pediatric and Child Care Outpatient Clinic ofHCFMRP/USP, where children and adolescents received treatment and follow-up care..Descriptive statistics were used to analyze the agreement of Expert Committee memberson items on the questionnaire. The database was structured in an EXCEL worksheet to code the variables. The double-entry technique was usedto minimize possible data processing errors. Then, the data were exported toStatistical Package for the Social Sciences (SPSS) software, version 16.0, tocalculate frequencies and percentages. Items with agreement levels of 80% or moreamong the participants were considered.. The same analysis process was applied as in the Expert Committeephase.Descriptive statistics were used to determine frequencies and percentages ofagreement on the items on the multiple choice questions. Items with agreement levelsof 80% or more among the parent participants were considered. The saFor open ended responses, related to reformulation and wording of items on thequestionnaire, the suggestions were analyzed through discussions among the authorsabout the relevance of the suggested reformulations. Items that most closelyapproximated the Brazilian context were considered for adaptation of thequestionnaire.The translation process to Brazilian Portuguese took three months. To achieve acultural adaptation that reflected the Brazilian context, extensive literaturesearches and discussion meetings with experts were made. Discussions were related tothe rights of cancer patients, and therefore, included discussions with one facultymember with expertise in patient law, one lawyer and one social worker. Thediscussions with the social worker included issues related to available benefits andfamily leaves allowed by Brazilian legislation for patients and parents of childrenwith chronic illnesses (not specific to cancer). These issues also emerged from herprofessional experience in support groups for parents of children with cancer.. Consensus could not be reached on some items, such as those related toeducation levels, and ethnicity categories, which was adapted by using skin colorclassification appropriate to the Brazilian context. The Expert Committee raisedquestions about these items, requiring that adaptations be made and resubmitted tothis Committee. To adequate the questions without consensus, the Expert Committeeprovided citations from the literature. The questionnaire was then back-translated toEnglish. The back-translated English version was forwarded to the original authorsfor evaluation, who approved the Brazilian Portuguese version of thequestionnaire.The translated questionnaire was forwarded to the Expert Committee for evaluation.After all Committee members had evaluated the questionnaire, a first version wasobtained. Most items had 80% or more agreement among the Expert Committee. Consenútil in the Brazilian culture. This word wasreplaced with ajuda, in the belief that útil wouldsound pejorative. Fifth, questions about the participants' ethnic origin were changedin accordance with the Brazilian Institute for Geography and Statistics'classification (IBGE). The distinctions among yellow, white, indigenous, mulatto and blackpeople were made due to the Brazilian historical miscegenation and, finally, thequestion about education was changed completely. The original questionnaire,education involved the age when the individual stopped studying. In Brazil, therewere wide variations in the age when education stopped, depending on the financialand social conditions and values. Therefore, we adopted the division according toeducation level defined in Brazilian law that regulates education, Law 9.394, issuedin 1996.For cultural adaptation to Brazilian population, six changes were made. First, wasthe discrepancy between the geographic dimensions in Brazil and the United Kingdom,conversion was made from miles to kilometers. Second, questions about benefits andaids for patients and their parents needed to be changed completely, because thesewere different from the United Kingdom. Brazil did not have legal support to protectparents of children and adolescents with cancer, and few benefits were available topatients. Third, content about the parents or caregivers' type of work and leave ofabsence were changed according to Brazilian legislation. For example, self-employedwork and leave of absence need to be clarified. Fourth, the word "helpful" wascommonly translated as n (IBGE). The diin 1996., to increase representativeness of the sample.The semantic validation phase was spread over five months; two months for datacollection and three months for data analysis. Participants were 20 mothers, threegrandmothers and one sister. The level of education for half of the participants wasprimary education and the other half was secondary education, which is consistentwith the recommendation by the Group, to incBenefício dePrestação Continuada (BPC) and about the result of the BPC application;4) how long the parents or caregivers were absent from work; and 5) colorclassifications. These changes were made to increase the interviewee's understandingof the questions/items and appropriateness of the questionnaire in Brazilianfamilies.The instrument used for the interviews allowed the participants to make changes, sothat the items are clearer on the questionnaire. There were 24 reformulations thatwere suggested. The research team analyzed the significance, keeping in mind theBrazilian population and the objectives of the translated and culturally adaptedquestionnaire. Five reformulations were incorporated in the Brazilian Portugueseversion. These included items related to: 1) how frequently the child and theresponsible caregiver attend the treatment center; 2) what they know about the socialrights of cancer patients; 3) receiving a social benefit Costs of caring for children with cancer, originallydeveloped for the British population. The instrument was used for evaluating theeconomic repercussions of children's cancer in British families. We followed a combinedprocess of the two approaches(-) to translate and culturally adapt this questionnaire for use in BrazilianPortuguese speaking families. We made modifications that included and excludeditems.The study demonstrated the cultural adaptation of the Brazilian version of thequestionnaire, proaches-11 toeditems., and found that their questionnaire Costs of caring for childrenwith cancer has the potential to make important contributions to pediatricnursing in Brazilian families of children and adolescents with cancer.To our knowledge, this is the first Brazilian Portuguese questionnaire that specificallyevaluated the family costs of care in children with cancer. Because of the lack ofresearch devoted to this topic, we reviewed the literature and adapted the tooldeveloped by the original authors, and fo. It is, therefore, important to note that this was not a multicenterresearch, and would not be feasible to implement in other Brazilian regions, withoutfurther semantic validation in other areas. We found that the combined methods wereuseful and increased our understanding of the applicability of the questionnaire inBrazilian families in our area.Brazil is a country of continental dimensions and different cultural and socialcontexts, which can affect the adaptation and validation process about instruments foruse in Brazilian parents or caregivers. It is,Costs of caring for children with cancer in future research, whichis in progress at the time of this writing. Our preliminary findings have the potentialto increase our understanding of the financial costs in families of children andadolescents with cancer, in a specific population followed at the HCFMRP/USP.We recommend the application of our adapted Brazilian Portuguese version of theIt is important to note that the cultural adaptation of the questionnaire was intendedfor research purposes, and not for routine clinical use of this questionnaire. However,the questionnaire may be useful for characterizing the costs of families attendingdifferent oncology treatment centers with the future intent of developing public lawsand policies that meet the socioeconomic and health needs of families of children andadolescents with cancer.Costs of caring for children withcancer questionnaire for use in Brazilian Portuguese families, using thecombined rigorous methods.We culturally adapted and validated the We found that parents, grandparents, and sibling participants in our study understoodthe items on the questionnaire and it was satisfactorily and acceptable. They had nodifficulty with the items during the entire cultural adaptation process, and theBrazilian Portuguese version reflected the Brazilian popular vocabulary and culture. Therecommendations by the parents, grandparents and sibling participants were incorporatedduring the semantic validation phase, which permitted to further improve the adaptationof the questionnaire to the Brazilian language and culture.The Brazilian Portuguese version of the questionnaire is now available, which representsan important contribution to family nursing research. The questionnaire could facilitatestudies related to the economic repercussions and advance the research related topsychosocial care delivered to families of children with cancer. The availablequestionnaire could also allow professionals to assess the financial repercussions ofcancer within the family, and enabling them to assist the family members to mobilizeinternal and external resources to help them cope with the disease, and consequentlylead to comprehensive health promotion for patients and their families.


Group reminiscence therapy is a brief and structured intervention in which participants share personal past events with peers. This approach has been shown to be promising for improving wellbeing and reducing depressive symptoms among institutionalized older adults. However, despite the considerable interest in reminiscence group therapy, controlled studies to determine its specific benefits as compared to generic social interactions with peers (group conversations about everyday subjects) are still lacking.We have designed a randomized controlled trial aimed at comparing the effects of group reminiscence therapy with those of group recreational activity on the psychological wellbeing of an institutionalized sample of older adults. The study includes two groups of 20 hospitalized elderly participants: the experimental group and the control group. Participants included in the experimental group will receive six sessions of group reminiscence therapy, while the control group will participate in a recreational group discussion. A repeated-measures design will be used post-intervention and three months post-intervention to evaluate changes in self-reported outcome measures of depressive symptoms, self-esteem, life satisfaction, and quality of life from baseline.The protocol of a study aimed at examining the specific effects of group reminiscence therapy on psychological wellbeing, depression, and quality of life among institutionalized elderly people is described. It is expected that the outcomes of this trial will contribute to our knowledge about the process of group reminiscence, evaluate its effectiveness in improving psychological wellbeing of institutionalized individuals, and identify the best conditions for optimizing this approach.NCT02077153) on 31 January 2014.This trial was registered with ClinicalTrials.gov (registration number:  It has been estimated that in Europe the elderly population (aged over 65) will increase significantly over the next few decades, with the number of seniors reaching over 150 million by 2060. An even more dramatic growth will be experienced in the over-eighties population, which will triple to more than 60 million individuals by the same year [As a consequence of this demographic shift, the percentage of dependent seniors in need of institutional care in nursing homes will increase proportionally. A major clinical and policy challenge posed by residential care is the high prevalence of mental health problems among institutionalized elderly individuals. Therefore, the development and provision of effective mental health care interventions for nursing home residents has become an important goal for researchers and practitioners .Reminiscence therapy has been proposed as a potentially effective strategy to improve quality of life and psychological wellbeing for elderly nursing home residents . This apet al. [The effectiveness of reminiscence therapy has been investigated by several meta-analyses , 9–13. Pet al.  aggregatIn summary, the findings of previous meta-analytic studies indicate that reminiscence therapy is a promising non-pharmacological approach to improve mental health in elderly individuals. However, more randomized controlled trials are needed to assess the effectiveness of this strategy and its specific benefits for institutionalized seniors .et al. [Based on the need for further randomized controlled trials in this area, the present study aims at assessing the effects of group reminiscence on psychosocial wellbeing in institutionalized, non-demented elderly individuals. First, we will examine the specific effects of simple reminiscence as compared to a placebo intervention in which participants are engaged in everyday conversations (discussion of current events). The findings of previous meta-analyses are inconclusive on this issue. The review carried out by Bohlmeijer et al.  found noet al.  observedSecond, we intend to assess the impact of reminiscence on a broad range of psychosocial outcome indicators, including depression symptoms, positive wellbeing , and quality of life. Since we aim to evaluate the specific effectiveness of simple reminiscence by comparing it to conversation on current events, clinically depressed residents will not be included in the trial. More specifically, we will examine four hypothesis. Hypothesis one is that we expect an improvement of self-esteem, evaluated through the Rosenberg Self-Esteem Scale , in the The present study is a randomized controlled trial, which involves two groups of participants living in the ageing research and treatment center of Istituto Auxologico Italiano: the experimental group (EG) and the control group (CG). The total sample size is 40 participants, or 20 per group (sample size estimation details are reported in the following section).In order to be included in the study, individuals have to meet the following criteria: be 65 years of age or older; have an absence of major depressive symptoms, as indicated by a score lower than 17 on the GDS ; have anThe number of participants was calculated in order to have a sufficient size to prove the effect of training, reducing type two  statistical errors. The limit of 0.05 will be used for type one errors .Sample size calculation used an assumption that participants in the experimental group would report improvements, based on outcome over time, and that these effects would differ from those achieved in the control group. As noted in the introductory section, previous evaluations of this kind of reminiscence intervention have produced moderate effect sizes , 21. AccThe intake session will use the following questionnaires: the Mini Mental State Examination  to assesFor the assessment of group reminiscence outcome, we will administer several questionnaires at baseline, post-intervention, and three months post-intervention. The Life Satisfaction Index  will record psychological data from each individual for the entire study. Security and privacy issues will be addressed according to the respective situation and the consent of the participant. Questionnaires will be collected at the end of all the scheduled sessions and at the three-month follow-up.In order to study the efficacy of the group reminiscence intervention, a between-subjects design will be used, with two experimental conditions and repeated measures across baseline, post-intervention, and three months post-intervention. Specifically, we will compare the following conditions. Experimental group: individuals will participate in group reminiscence meetings dealing with specific phases of their lives; they will share their memories and listen to the ones related by the other participants. Control group: individuals will participate in group conversations about current events.Informed consent will be obtained from each participant. Psychometric outcomes will serve as quantitative dependent variables.The present study is a randomized controlled trial. Participants will be randomly assigned to one of the two groups of the trial, balanced on gender and pre-test scores.The intervention will last six weeks. Each week participants in both the experimental group and the control group will attend a group setting; in the experimental condition, participants will share their memories with peers, and in the control condition, participants will talk about current news.The guidelines reported in group reminiscence literature  will be Participants will be assured that all the memories shared during the sessions will be confidential and will not be disclosed outside of the group. Every session will incorporate a theme, recalling specific autobiographic experiences in a chronological order. From the first to the sixth meeting, the topics will be best memory, childhood, school years, war, job, and holiday. Participants will be encouraged to bring photos or objects related to past themes. At the end of each meeting, the theme of the following session will be disclosed. The researchers can also bring materials as cues for reminiscence.Every meeting will offer topics for discussion taken from newspaper and newscasts. Personal opinions will be promoted, and links with the daily life of participants will be welcome . A group discussion about these various themes will take place in every meeting from the first to the sixth. The main goal is to stimulate social interaction and communication, without discussing either personal events from the past or private memories. Final individual meetings will be scheduled for participants in both groups in order to administer the questionnaire and collect feedback from the users.Data analyses will use IBM SPSS Statistics software . Descriptive methods will be used to demonstrate the consistency of the two groups, to describe participants’ characteristics, and to report levels of participation and dropout. Analysis of variance will compare baseline characteristics of the two groups involved in the study, and determine overall significance of improvement across the outcome measures.This trial (project ID: 03A901) was approved by the Ethics Committee in the Istituto Auxologico Italiano, Milano  on 11 September 2012.As the age of the population continues to rise, an increasing number of older individuals will enter a nursing home for professional care assistance. Defining effective strategies to help the elderly in adapting to the long-term care environment and maintaining their mental health will be a major challenge for researchers and practitioners. It is important for the nursing home staff to understand the many losses that residents face as they enter the facility, and the possible reactions they may have because of this life-changing event. Living in a nursing home may lead to depression, loss of self-efficacy, and loss of trust in personal skills and resources. A group reminiscence program, with a specific path guiding older people to re-evaluate their past life events, has the potential to strengthen the personal value of the institutionalized individual and foster their sense of identity. Listening to others, responding to them, and feeling close to life events of other people could provide a benefit in the quality of life; the elderly would find a safe place where they can experience positive interactions. Effectiveness of reminiscence therapy has received experimental support in several studies , yet thePatient recruitment was ongoing at the time of manuscript submission. Recruitment began October 2012. Data collection will continue at least until June 2014.


Analyzing the historical and social path of an occupation using the sociology ofprofessions and the perspective of scientific knowledge promotes an understandingof the origin of physical therapy in Brazil and of discussions of the professionin its contemporary context.expertise and as part of the group of occupations that evolved into the profession ofphysiotherapy in the first half of the twentieth century. The aim of this paper was to discuss the professionalization process of physicaltherapy in São Paulo. The authors tried to analyze bath therapy, massage therapy,and physical therapy as occupations involving distinct  The analysis undertaken was a qualitative study based on an analysis ofhistorical documents. Eighty-six professional records from the Service ofInspection of Professional Practice in the state of São Paulo and healthcarelegislation from the 1930s and 1940s were analyzed.The distinction between physical therapy practitioner and profession ofphysiotherapy can be seen by examining registration requirements for rank-and-filenurses with expertise in interactions; this distinction suggests the emergence ofspecialized expertise that was clearly a part of neither medicine nor nursing andcontributed to expertise in physical therapy since the 1950s. The regulation of physiotherapy practices, the recognition of expertise, theaccreditation of practical nurses by the State, and the institutionalization of acourse for physical therapy practitioners in 1951 are key elements of theprofessionalization process for the physical therapy profession in Brazil. In this context, unregulated physical therapy practices in the 1930s and1940s in São Paulo, Brazil led to the physiotherapy regulated profession, which is oneof the 14 health-related professions regulated in Brazil.Understanding occupations and professions as processes imbued with historical value canhelp one understand the adoption of certain therapeutic practices, including those usedin specific historical contextsThe predominance of studies that form a part of physiotherapy knowledge based on thebiomedical model is a cause for concernExpert knowledge, technical and intellectual recognition, accreditation, andprofessionalization of therapeutic practices are considered important for the socialorganization of work in the healthcare sectorfisioterapia ) is understanding as a field of practiceand formal knowledge. On the other hand, we defined physical therapy (terapiafísica ) as a physical resource used by different occupational categories.In the paper we trace the shift from physical therapy as an occupational practice - oncecolonized by nurse practitioners and physicians - to physiotherapy through a range ofmechanisms, including the development of labor organizations, economic rationalization,changes to the structure and socialization of professional expertise, and thedevelopment of accrediting institutions involved in the social configurations ofBrazilian physiotherapy's professionalization history.This paper examines the ways in which physiotherapy became established as a professionin Brazil. Unlike Anglo-Saxon language, physiotherapy and physical therapy in Portugueselanguage are not often used interchangeably. For the purpose of this manuscript,physiotherapy  whoguided by the precepts of the labor movement, allegedly regulated occupationalactivities as part of his political strategy for modernizing the State using scientificadvances in relevant areas30-1945 wexpertise  or the result of asocialization process that enables the development of a range of skills and specializedknowledge, that an occupational group pursues professionalization to create a set ofpractices, control labor activities, formalize teaching, receive recognition from peersand the public, become regulated and accredited by the State11, and promotesocial closureIt is through the acquisition of interactional expertise 14 Professions use the dissemination strategies of formal educationalinstitutions and are characterized by the acquisition of the ability to perform aspecialized practice through their own bodies of knowledge called contributoryexpertise expertise ,when officially recognized, guide the principles of the labor market into theorganization and accreditation schemes provided by universities, associations, and/orthe StateOccupations are characterized by the dissemination of knowledge acquired informallyoutside the official education systemPhysiotherapy was established as a profession in the state of São Paulo through theincorporation of occupational practices relating to physical rehabilitation, a processthat is similar to the professionalization of occupational therapy (OT). However, theauthors could not find records that allowed them to affirm the earlier existence of OTas an occupation. The authors did observe that the distinction between the twoprofessions in the period analyzed was based on therapeutic interventions with a focuson technical training so that an occupational therapist was responsible for therehabilitation of the upper bodyTherefore, the aim of this study was to identify physical therapy practices as evidenceof the existence of an occupation that led to the professionalization of physiotherapyin the state of São Paulo. The authors believe that this study will help provide ahistorical context for physical therapy as a profession and promote a discussion aboutits scope, professional identity, and social role in the Brazilian healthcare system asa starting point for future investigations.16 in thecollection of records at the Professional Practice Supervision Service of São Paulo18-23 The primary data analyzed were fromthe study called "History of Health Workers [História dos Trabalhadores da Saúde]"conducted in 2007 by the Public Health Memory Center of the Health Institute of theState Secretariat of Health of São Paulo.The method used for data collection was documentary researchThe collection was preserved in the Documentation Center of the Butantan Institute atthe Emilio Ribas Public Health Museum and included 119 professional licensing recordscovering the period between 1892 and 1978. According to Mott et al.In 1951, with the institutionalization of the "Raphael de Barros" physiotherapy degreeprogram for technicians and operators at the Faculdade de Medicina da Universidade deSão Paulo (FM/USP ), São Paulo, Brazil, physiotherapy started to have its ownregistration records. These records extend to 1978, when the Federal and RegionalCouncils of Physical Therapy and Occupational Therapy (COFFITO/CREFITO) were permanentlyestablished.The records were organized in Microsoft Excel 2007 spreadsheets and contained data onnine factors: name; gender; occupational category; date, city, state and country ofbirth; legislation in force at the time of registration; and year of registration .The profile description of a practical nurse and the differentiation between the terms"physical therapy practices" and "physiotherapy" will be addressed to provide ahistorical context for the institutional disputes over therapeutic resources, which,since 1969, have become part of the physical therapy profession.expertise, and the types of accreditation institutions involved in their socialconfigurations.Physical therapy practice and Physiotherapy are a healthcare practice that use physicaland natural resources such as fresh or salt water, heat, cold, electricity, massage, andexercise as therapeutic resources. In Brazil the former is regarded as an occupation andthe latter as a professional category, and they are differentiated by labororganization, rationalization, the structure and socialization of Therefore, the authors consider physical therapy practice to include the activities ofmassage therapists, bath therapists, and physiotherapists practitioners in the 1930s and1940s, and physiotherapy the set of practices accepted by the biomedical communitybetween 1951 and 1969, when the physiotherapy degree program for technicians andoperators was created at FM/USP, and the profession began to be regulated, respectively.expertise  to perform a set of social tasks that are used by membersof the same professional or occupational category25, the forces that drove the accreditation ofphysiotherapy expertise  should be discussed.This distinction is justified by the notion of a profession as a historical constructassociated with specific social contexts that involves using a specificIn the 1930s and 1940s in Brazil, the Getúlio Vargas government played an importantrole in the organization of the social division of labor by creating a general systemof laws aimed at regulating occupations and professions in the healthcare sectorThe strategies used by the Stateexpertise.Rationalization is considered the subjection of social spheres to the criteria ofrational decision-making, a characteristic of the institutionalization process and ofthe conversion of technique into scienceinteractional expertise  regulated by the State, the authorspropose an analytic framework within a broader historical context to explain thetransformation of physiotherapy practices into expertise  specificto physical therapy as a profession. It is notable that, although physiotherapynurses were not considered in the legislation analyzed, two nurses, a Brazilian and aGerman, were registered under this title, suggesting the existence of a categoryrecognized for its members' use of a combination of resources in their practices.The LRFEP allowed the recognition of therapeutic techniques specific to members of agiven occupational category, unlicensed practical nurses. By describing 86 massagetherapists, bath therapists, and physiotherapists practitoners as havingexpertise  historically manifests itself within a networkof social and political relationships that are elements of the labor structurefounded on the rationalization of therapeutic practices based on qualifications,merit, and competence that allow expertise to be recognized as a prerequisite forprofessionalization. However, expertise  is a result not only ofspecial cognitive processes but also of social practices, of the context in which itoperates, and of disputes over power. It has two types: interactionalexpertise  and contributory expertise Therefore, Interactional expertise is the ability to perform tasks based on anaccumulation of knowledge that was informally acquired and incorporated, by means ofexperience or wisdom, through enculturation in a scientifically established field. Inaddition, this type of expertise should enable its practitioners to add knowledge totheir areas of practice, - i.e., allowing contributory expertise. Therefore, physiotherapy practices are considered, in this context, as the outline ofa field within other fields- e.g. medicine and nursing-and inserted into a specifichistorical context.expertise  that was disputed by medicine and nursing. Despite thehigh degree of interactional expertise , the knowledge of theseexperts -non degree nurses-was not necessarily formallyrecognized.Important events, including the two World Wars, the polio epidemic, occupationalaccidents, and the process of urbanization and industrialization in São Paulo,created a social demand for the unique technical resources of physical therapypractices. In this context, the technological advances in the field of rehabilitationand the discovery of the therapeutic potential of physical and natural resourcesOne example is that of Moreiraexpertise  between Europeancountries and Brazil as one of the political strategies employed by Vargas in thisperiod to stimulate the modernization of the country and, consequently, of nationalscienceThe migrations in Brazil during the 1930s and 1940s influenced the creation of anoccupational category for physiotherapy nurses. This fact is evident when comparingthe number of foreigners (52) and Brazilians (32) registered with the LRFEP and canbe explained by viewing the exchange of The city of São Paulo was home to many foreign workers, and the average age of theregistered workers, 42 years, suggests that practitioners used physical therapypractices before the accreditation requirement, demonstrating that these practicesexisted before the teaching of physiotherapy was institutionalized.expertise  could be define as an occupationdefining by FreidsonPhysical therapy This organization of labor, which was regarded as the result of interactions andsocial construct processes, promoted the dissemination of physical therapy practicesin the daily practice of professionals during the 1930s and 1940s as an importanttechnique for rehabilitation and healthcare in the context of several professionalcategories. By gaining strength and technical and intellectual recognition,physiotherapists became accredited by the State as licensed practical nurses.expertise  as a prerequisite for the implementation of socialpolicies in a stratified system of occupations. This decision led the State toprofessionalize certain practices, including physical therapy practices.As previously mentioned, the Vargas government acted as the accrediting institutionfor the regulation of health practicesexpertise  stimulated the development of a plan for theprofessionalization of this group of occupations starting in 1951. Massage therapist,bath therapist and physiotherapist nurses, finding fertile ground for their work,even without autonomy, were able to monopolize occupational practices linked to theidea of expert knowledge through accreditation by the State. This exclusivetherapeutic practice, which became a part of the field of knowledge, led to socialclosure in the social division of labor after the regulation of the profession beganin 1969By observing the political processes by which those practices were incorporated intomedicine and nursing, the authors can confirm that the existence of physical therapyinteractional expertise that was politically recognized and socially necessary, was considered bythe state legislature in São Paulo and officially became an occupational categorywith Decree No. 20.931 on January 11, 1932The occupation of physical therapy nurses, who had an 18Therefore, physiotherapy practices were not technically autonomous at this time.Accreditation did not guarantee that these professional activities could be practicedindiscriminately because "[...] physical therapy, orthopedics, and beauty institutesand commercial establishments with medicinal showers or baths as well as those thatuse electrotherapy, radiotherapy, and post-surgery exercises should operate under theresponsibility and technical supervision of doctors or pharmacists."interactional expertise , showed recognition of the value ofknowledge and of scientific knowledge in the healthcare sector in Brazilexpertise  became anobligatory condition of the work of unlicensed nurses in the healthcare sector.However, the legalization of these practices, which was obtained throughexpertise.  Theformer had the dominant expertise  needed to teach and oversee thepractice of nurses, and the latter was responsible for delivering therapeuticpractices.This requirement of the state of São Paulo underlined the power relationship betweenmedicine and nursing when, in 1938, State Decree No. 9.707The following year, unlicensed nurses were recognized by state law with the approvalof Decree No. 10.068 in 1939The State became the accrediting institution that was responsible for the regulation,supervision, and definition of the occupational activities of each group, therebycontrolling these professions and occupations. Massage therapy was accepted as theprimary physical therapy practice; the evidence for this fact is that massagetherapists accounted for 86% of the 74 registrations in this period.expertise , when considered as a resource for human care, becamea discipline in the area of knowledge known as "the art of nursing," which usedresources such as "[...] hot and cold packs, compresses, poultices and suction cups,hot and cold therapies [...]"Gender differences in the division of labor in the Brazilian healthcare sector weredriven by the distinction between care and cure; the former was predominantlyconducted by women and the latter by men. This fact may explain the greater emphasison scientific power to the detriment of the practice of care, which was considered aphysical therapy practice and currently an integral part of physiotherapy's"therapeutic arsenal". An example of this distinction is found in the formalizationof the teaching of physical therapy practices in nursing by Decree-Law No. 8.778 inJanuary 22, 1946The contradiction between the institutionalization of this discipline in nursing,which was a profession primarily taken up by women, and the predominance of malephysical therapy nurses registered in the LRFEP (n=56) demonstrates the clash betweenthe "art" and "science" of in the healthcare sector. The former was directed towardcare and the latter was directed toward the therapeutic efficacy advocated by Westernscientific medicine.expertise , which was institutionalized in the teaching of "[...]clinical orthopedic clinic, physical therapy, and massage therapy [...]"The scenario changed in 1949 when the content of nursing and nursing assistant degreeprograms was regulated through Decree No. 27.426At that time, the competition for physical and natural resources between theinstitutions of medicine and nursing intensified. The predominance of medicine inthis historical period is clear because physiotherapy degree program for techniciansand operators were established in 1951, and physical therapy practices began to betaught by physicians at FM/USP instead of being part of the nursing degree program.The training of technicians lasted until 1967 when the physiotherapy and occupationaltherapy degree programs, still held at FM/USP, began to be regulated throughOrdinance GR 347interactional expertise  of physiotherapy practices transforminginto contributory expertise,  was initiated.From that moment, physiotherapy began to define its own scope of practice whileremaining under the tutelage of medicine. Although it was incipient, theprofessionalization process and, consequently, the possibility of theSocial changes and the elements associated with them, including the establishment ofan occupational group such as physiotherapy, were slow processes that requiredreflective critical attention. Physiotherapy is a professional category with a legacyrelated to its practical and theoretical knowledge. Reflections of its historicalcontext should be reconsidered to allow an understanding of the professional identityof the contemporary physical therapist to be an essential condition for facing thecurrent challenges of the profession.expertise  accepted as an occupation in São Paulo in the 1930sand 1940s.The development of an occupation or profession is a historic variant of the process oforganizing a society and creating a monopoly on opportunities. In this study, theauthors have sought to demonstrate that opportunities, social needs, disputes overmonopolies of certain practices, interactions between professional fields, and Stateaccreditation were all important factors that helped physical therapy practices become atype of interactional expertise  of physical therapy practices was evidencefor the existence of tacit knowledge, which was foundin the records of licensedpractical nurses available from the LRFEP.The activities performed by physical therapy nurses made it possible for thisoccupational category to acquire legal status in 1939 in São Paulo. TheUsing accreditation as a measure of social control and social closure was the politicalstrategy chosen to regulate the healthcare practices adopted by unlicensed occupationalgroups. Therefore, the State was the sovereign accrediting institution in the 1930s and1940s and based the process on the rational-legal organization model by valuing expertand scientific knowledge as a basis for organizing labor and defining the activities ofoccupational groups.interactional expertise , physical therapy nurses encouraged theprofessionalization of physiotherapy through the recognition and accreditation of theirknowledge. Understanding this recognition by medicine and nursing, in addition to theState's accreditation of practical nurses, helped clarify the means by which thisoccupation gained momentum in its fight for professionalization. Therefore, in the 1930sand 1940s, physiotherapists had not only the social authority to perform theiractivities but also permission to establish a new occupational category in the face ofthe existing professional groups, i.e. medicine and nursing, in the healthcare sector inSão Paulo.In Brazil this occupational closure promoted the pre-professionalization ofphysiotherapy, which began a new phase in 1951, when physical therapy practices weredisseminated through the Raphael de Barros Physical Therapy degree program forTechnicians and Operators at FM/USP. Establishing themselves as holders ofinteractional expertise  as evidence for thetransformation of an occupational group into a profession, one may assume that baththerapists, massage therapists, and physical therapy nurse were part of the groupinvolved in the professionalization of physiotherapy. After the 1950s,interactional expertise  was differentiated and organized so that itbecame contributory expertise , which enabled physiotherapy to become aproper profession in the late 1960s.By recognizing


Poverty is pervasive in the Swat Valley, Pakistan. Most of the people survive by farming small landholdings. Many earn additional income by collecting and selling plant material for use in herbal medicine. This material is collected from wild populations but the people involved have little appreciation of the potential value of the plant material they collect and the long term impact their collecting has on local plant populations.In 2012, existing practices in collecting and trading high value minor crops from Swat District, Pakistan, were analyzed. The focus of the study was on the collection pattern of medicinal plants as an economic activity within Swat District and the likely destinations of these products in national or international markets. Local collectors/farmers and dealers were surveyed about their collection efforts, quantities collected, prices received, and resulting incomes. Herbal markets in major cities of Pakistan were surveyed for current market trends, domestic sources of supply, imports and exports of herbal material, price patterns, and market product-quality requirements.It was observed that wild collection is almost the only source of medicinal plant raw material in the country, with virtually no cultivation. Gathering is mostly done by women and children of nomadic Middle Hill tribes who earn supplementary income through this activity, with the plants then brought into the market by collectors who are usually local farmers. The individuals involved in gathering and collecting are largely untrained regarding the pre-harvest and post-harvest treatment of collected material. Most of the collected material is sold to local middlemen. After that, the trade pattern is complex and heterogeneous, involving many players.Pakistan exports of high value plants generate over US$10.5 million annually in 2012, with a substantial percentage of the supply coming from Swat District, but its market share has been declining. Reasons for the decline were identified as unreliable and often poor quality of the material supplied, length of the supply chain, and poor marketing strategies. These problems can be addressed by improving the knowledge of those at the start of the supply chain, improving linkages among all steps in the chain, and developing sustainable harvesting practices. The phrase “High Value Minor Crops” refers to plants that are relatively small contributors to a country’s agricultural output. They fall into two major groups: herbs and spices; and medicinal and aromatic plants (MAPs). Although individually small contributors to output, the importance of these plants in total is evident from the fact that in 2006, their global trade reached US$ 60 billion , 2. EuroThe total contribution to national agriculture output of MAPs is small, but their value per weight is among the highest among traded plants. The pharmaceutical cash crops have a huge potential for remote communities that practice subsistence agriculture and have limited access to regional economy , 9. In mIn Swat District in Khyber Pakhtunkhwa Province of Pakistan, the present supply of MAPs comes almost entirely from wild-harvested material, and not from cultivation. A large number of rural households in Swat District collect MAPs, at the very least as informal gatherers for local use . Many ruEarlier studies have estimated that during the spring and summer MAP collection and trade becomes the main source of household income for 5,000 or more traditional nomadic tribesmen who gatherer these plants from the wild in Swat District , 7, 15. To enhance incomes from MAPs, collectors require a better understanding of the needs of individual markets. This is critically important, especially regarding quality specifications and their implications for pre and post-harvest management and proper product handling. The study for Swat District was, therefore, initiated to identify constraints such as a fragmented information base, training and educational deficiencies, an uncoordinated approach to collection and marketing of MAPs species, and the need to clearly identify traders and markets.The overall objective of this study was to examine how to increase the value and expand the benefit of MAPs collection, cultivation, processing and marketing for people in Swat District. The specific objectives were to attain sustainable harvesting practices, small scale cash crop cultivation and local processing of raw material to add value before marketing. In the study we look at the various steps in the supply chain, from collector/farmer to final domestic market or exporter, examining the ways in which the market value of both raw and processed MAPs could be improved. For Pakistan, economic analysis of the marketing chain of MAPs, from collection to consumption, has been limited.This paper concentrates specifically on describing Swat District and the procedures and results from surveys and focus group meetings undertaken to assess the amount of collections, marketing channels, and prices at each level for the MAPs originating in Swat District. This study was launched in June 2012 to respond to the above challenges and to support the 2011 Framework for Economic Growth .2 and has a population of about 1.3 million with a density of 230/km2, and annual population growth rate of 3.48 percent [Swat District is part of Malakand Division of Khyber Pakhtunkhwa Province and lies in northwestern Pakistan Figure . The dis percent .Figure 1th century AD. The Buddhists admired it for its peace and beauty, it was the envy of the Mughals [Swat District is very mountainous, and its highest peak, Falaksair, measures 6,098 meters in height. The district occupies the floristically rich southern extension of Hindu Kush Raj of the Hindu Kush mountain range. It was originally known as Uddiyana (Garden) during its Buddhist bloom in the 8 Mughals . The maiThe area is not climatically uniform, and altitude and exposure greatly modify the climatic conditions within the area. On the basis of altitude, climate and vegetation, the area can be divided into many climatic and vegetation zones that vary from sub-tropical chirr pine forest to alpine pastures and meadows. Similarly, the diversity of climate and topography of Swat District is reflected by the three main phytogeographic regions: 1) Sino-Japanese region, 2) Irano-Turanian in the north-north west and 3) Saharo-Sindian region in the south .Several species of commercially important medicinal plants are collected from temperate forests, sub-alpine forests and alpine meadows. Many of these species are slow growing perennials that require a number years of vegetative growth before flowering. Due to overgrazing, unsustainable collection and illicit cutting of the forests, most of these species are now classified as endangered. If present rates of unsustainable collection and other inimical factors continue most of the high value potential MAPs will become locally extirpated from many parts of Swat District .Swat District has a generally narrow economic base characterized by agro-pastoralism. The potential for diversifying the economy is rather limited due to remoteness and inaccessibility, the harsh climate, lack of managerial and technical skills, lack of financial resources, lack of physical infrastructure, high cost of doing business in the area, low level of demand for different economic goods and services, and high cost of production in the area , 21.Nevetheless, Swat District can develop through increased forestry and agriculture production in general and through capacity building of medicinal and aromatic plant collectors/farmers in particular. Capacity building training can improve skills of MAP collectors and cultivators, which will enable them to fetch better prices for their quality produce. This sector, can, therefore, be developed mainly through cultivation and intensification to meet domestic requirements.Collection and marketing of MAPs was evaluated in this study for six Swat sub-valleys: Miandam, Madyan, Behrain, Kalam, Lalku, and Sulatand of Swat District. These sub-valleys were selected partly based on earlier studies of HS  and partPeshawar: The MAPs sold in Peshawar herbal markets are generally obtained from Swat District, Lahore, and Afghanistan. Peshawar markets also supply a number of imported MAPs to Swat District and Afghanistan for local uses. The market receives large quantities of herbal materials from Swat District that are subsequently supplied to Lahore. Lahore: Most of the dealers in Lahore herbal market are trading crude herbs imported from India, directly or indirectly. Over 50% of materials traded in Lahore are of Indian origin, and this is mainly due to cross border trade via train. The Lahore herbal market acts as a hub of national trade of MAPs. It is not only catering to the needs of smaller markets in various cities and towns of the province of Punjab but also supplies considerable quantities of materials to the Karachi market. The middlemen of the MAPs trade usually bring the materials from Swat District to Lahore. Karachi: Most of the crude herbal items traded in Karachi markets are obtained from the Lahore herbal markets. However, a few agents also bring the material directly from up-country, including Swat District. Prices of various items in Karachi market are generally 10-20% higher than Lahore, reflecting higher transportation, higher labor costs, and profits of additional middlemen. Both the Lahore and Karachi herbals markets are the major suppliers of materials to the large national herbal pharmaceutical companies. These companies generally purchase materials through middlemen or so-called suppliers.Three cities are the main final markets for traded MAPs once they are moved out of Swat District, Peshawar, Lahore and Karachi. wise man in Arabic, and in Pakistan referring to a person who has expertise in diagnosing diseases and treats them with the use of formulations containing mainly MAPs) were conducted at different potential production sites of the district. Interviews were also conducted at markets in regional and major cities of Pakistan, specifically Mingora, Peshawar, Lahore and Karachi. Information was gathered as to how and from whom the plants were obtained and to whom they were sold [The market study of collection and trade patterns for high value MAP species was conducted during summer 2012 with particular reference to plants from Swat District. Interviews with MAPs collectors/farmers, local dealers and hakims  and Forest Department was consulted. Technical literature relating to collection, trading, processing and national and international marketing of MAPs was also consulted. Additionally, the dealers and suppliers catalogues and brochures of companies involved in the trade of MAPs were reviewed during this study. Accordingly, the areas surveyed can be broadly classified as Interviews with collectors, dealers and other knowledgeable persons about the local use and trade provided information on the sources of MAPs.Interviews with local, regional and national traders, EPB, and interviews with hakims and representatives of herbal pharmaceutical companies provided information on the markets for MAPs.Two different questionnaires, one for collectors/farmers and another for dealers/pharmaceutical companies, were used to conduct this production and marketing value-chain analysis. After preliminary work, the questionnaires were modified to improve the correspondence of the surveys with the objectives of the study.Voucher specimens were collected of all reported species and identified using existing floras and floristic accounts for the region , 23, 24.In studying Swat District as a source, we examined the collection patterns of MAPs as an economic activity and the likely destinations of these products in national or international markets. Information and data on various aspects of collection, such as collection method, time, and marketing of each species were attained from local collectors and farmers through surveys and interview discussions. For this purpose collectors, farmers and traders of ages 20–60 years were surveyed using a questionnaire to document their knowledge of MAPs. Information was gathered as to how, and from where the respondents collect MAPs and to whom they sell. Respondents were also asked about their annual income earned from the sale of targeted plants and returns to the work invested. Surveys were conducted with a total of 120 collectors and farmers participating in the sale of MAPs in various collection and cultivation sites in Swat District. Collectors were targeted by identifying those who had received some training in collection and procession of MAPs by NGOs in the region and using a snowball identification process and focus group information. The surveyed collectors and farmers are the main group bringing MAPs gathered in the forests and fields into the market. However, we do not have a precise estimate of what proportion of the MAPs brought to market in total are handled by the surveyed set of collectors.Focus group discussions (FGDs) were conducted in a local Hujra (meeting place) in three villages. The participants in the FGDs were village elders, MAPs collectors/farmers, local traders, representatives from Non Timber Forest Products Directorate and from the Forest and Agriculture Departments. During FGDs the objectives of the study were described to the participants. The purpose of the FGDs was to focus on specific issues/topics and possible options for activities like data collection on MAPs marketing and production, and cultivation of selected commercially important medicinal plants on the farm land of community members participating in the FGD. Participation was encouraged by all and efforts made to ensure that no one dominated the discussion. Records were kept of the discussions and observations of each FGD, and generally each FGD lasted for 2–3 hours. The FGDs were designed in a manner to be interactive and participatory and were facilitated by the author of this paper. About 350 MAPs collectors and farmers from the three villages participated in the FGDs. These meetings were a very important aspect of the study as they helped in the identification of MAPs collectors, farmers, local traders, wholesalers, primary and secondary middlemen, and MAPs exporters and the important issues they faced.In studying the market chain of MAPs, we also identified and interviewed local, regional and national traders, hakims and representatives of pharmaceutical companies. This served as another important source of information on various aspects of MAPs trade from Swat District in particular and the country in general. Information was collected about major items for sale, source and origin of crude MAPs, approximate quantities of MAPs material transacted annually, annual income of traders, and common problems in this business. The standards and product-quality requirements of traders from collectors/farmers and local dealers for domestic and export-market formulations were also noted. Interviews with 50 participants involved in the trade and business of MAPs were conducted, in addition to the 120 surveys of collectors/farmers mentioned above.Value-added activities currently carried out by the collectors and wholesale and retail dealers in the area include product cleaning, drying, cutting, and, in some cases, washing of the plants or plant parts to be sold. However, these activities are usually conducted only to the extent needed to meet the minimum quality standard required by the local market  and withIn Pakistan in general and in Swat District in particular a number of organizations in the public and private sectors are undertaking research and development work on MAPs. However, the systematic documentation of MAPs regarding production and marketing is not carried out by any public or private organization. Information availability has largely been in an ad hoc and uncoordinated manner in all sectors from production to trade, due to absence of consensus on strategic thrust areas. However, sustainability of MAPs production and trade will depend on the principle that it meets the need of the present without compromising the ability of future generations to meet their needs.Final MAPs markets are split primarily into three segments: domestic commercial; export; and local hakims, other traditional healers and retail shops. The major domestic manufacturers, like Hamdard, Qarshi, Ajmal and others, produce 300–400 medicinal products. However, collectors do not typically have linkages with these markets, and, therefore, must rely on local traders to sell their products within the existing value chain. Collectors are, therefore, often isolated from the final consumers of MAPs products, and do not have a good understanding of market needs beyond the limited information provided by the traders.Sinopodophyllum hexandrum (Royle) T.S. Ying (syn. Podophyllum hexandrum Royle), Saussurea costus  Lipsch. (syn. Saussurea lappa (Decne.) Sch.Bip.) and Viola pilosa Blume , with the aim of augmenting local gathering of these species from the wild. The business of these herbal materials was quickly picked up by some people in Mingora, Madyan and Behrain and is now well established. Mingora and the smaller city of Madyan have become the main supply centers of herbal material from Swat District for the national and international markets. The cultivated plants are mainly used by the pharmaceutical companies.Interviews conducted in this study indicate that the trade of MAPs species began in Swat District about two decades ago. Individuals from India and Karachi visited Mingora and Madyan to obtain plants for both domestic markets and international trade. Further development occurred when Sandoz Pharmaceuticals launched ex-situ cultivation of three species in the area, Morchella esculenta Fr., V. pilosa and Colchicum luteum Baker) were gathered from March to May. Most of the species were sold to wholesalers via middlemen. Of the 80 species, 24 were high value MAPs collected in relatively large amounts for sale. These are eventually sold either in national markets outside Swat District or international markets. Some quantities of these species, and largely the remaining 56 MAP species, are collected and traded by hakims in their medical clinics and in shops at local herbal markets. Hakims mostly collected these plants themselves or had them gathered by adult collectors or children who they rewarded by treating them as patients free of charge. In this way the hakims make a good profit from the sale of MAPs. However, the informal collectors expressed satisfaction with this arrangement. They reported typically gathering 2–3 maunds (1 maund=40 kg) of plant materials per year on the demand of hakims.The study found that during the spring and summer of 2012 collectors and farmers marketed 80 MAPs for commercial use. Most of the harvesting activity took place in the summer but three species  to make it more acceptable to the buyers.Figure In Swat District, the collection and trade of high value MAPs is highly uncoordinated and varying (i.e. from area to area and species to species). One common marketing channel for obtaining plants from Swat District is that dealers from the national market send representatives to local dealers (beopari) in Mingora to put up their demand. The local dealers pass the message to their agents, mainly local shopkeepers in the valleys. These agents inform small shopkeepers and collectors. The collectors bring the species gathered themselves and other tribesmen to the local shopkeepers and agents. Collectors sell the MAPs at a small margin higher than they pay to the gatherers, and most gatherers and collectors are illiterate and do not negotiate higher prices for the plant materials. As a result, they gather large and increasing quantities without receive high returns. The dealers of Mingora get the material from the agents when it is ready, and in this way the plant materials passes through three or four middlemen before wholesale.MAPs are traded in a wide range of materials that are used in medicine and health products in various forms or products that contain elements of these plants. In the regional market of Mingora materials are sold to wholesalers directly or through the middlemen generally known as commission agents. These materials are transported to the wholesalers in the bigger city markets and from there the materials are either stored for export, sold to retailers, or supplied to the manufacturers. In some cases, the specific demand comes from wholesaler dealers who recruit their agents to organize the collection of the required materials, as described above. However, this study found that the interplay of middlemen in trade often acts as a shield, blocking communication between the primary collectors of the MAPs and their consuming centers. The limited access to markets and dependence on intermediaries has a direct effect on the prices. The study concludes that approximately 320 large wholesalers are operating in the markets located in Mingora of Swat District and in main cities of the country. Additionally, markets are located in some smaller towns of Swat District like Madyan, Miandam and Behrain . However, these practices are often lacking at the collectors/farmers level, and these practices are usually done with the purpose of meeting only the minimum quality standard required in the national market. Plants were often dried in humid, dark areas where they are subject to infestation by microorganisms and consumption by insects. Therefore, collectors get minimum monetary return for their MAPs, and products from Swat District face the quality concerns noted above. Secondly, lack of knowledge about the part used and time of collection has led to misuse of the species. Appropriate timing of collection of desired plant parts during the year and lifescycle can have a major impact on the yield percentage and quality of therapeutically active ingredients.In addition, buyers further down the value chain often dictate terms to local traders who buy directly from collectors, including the size of commissions and the provision of credit. Established policies of MAP traders and middlemen at times work to the disadvantage of local collectors. Collectors often have an urgent need for cash. This provides a strong advantage to local shopkeepers and dealers, in that it at times allows them to purchase collectors’ MAPs products at a discount. Given that collectors are often cash poor, they are often willing to agree to lower prices in order to receive cash.Figure Given that the harvesting of MAPs is a part-time activity, and the quantity of MAPs collected by individuals is relatively small, there is also an opportunity to market products via collector “clusters”. The need for an increase in direct marketing by collectors is becoming more and more important. The trade of most MAPs is highly competitive, with strong competition coming from China, India, and other neighboring countries. The ability to bypass certain middlemen would effectively shorten the value chain and would make products from Swat District more competitive in the market place , and again should increase collectors’ margins.Potential also exists for the use of MAP products in new and emerging sector niches, including certain types of food, beverages, pharmaceuticals, and perfumes. Another potential sector is in the pesticide industry, and especially insecticides. Since there is an increasing awareness regarding adverse effects of chemical pesticides, products of natural origin  have received increasing interest of late.Figure Estimated prices along the marketing chain for the 24 reported high value MAPs sold in largest quantities by the surveyed collectors in Swat District are presented in Table The prices of the high value MAPs increase at each step in the supply chain, as Table M. esculenta . This was followed at lower levels by V. pilosa  and Bunium persicum (Boiss.) B. Fedtsch. (400 Rs/kg). The greatest increase shown in Table Aconitum heterophyllum Wall. ex Royle . Other large price differentials are for Asparagus adscendens Roxb.  and Adiantum capillus-veneris L. . As is shown by the two rows for V. pilosa, the value of the plant material is determined by what is in the sample, not just the species involved. Flowers of V. pilosa sell for 500 Rs/kg at the collector level, a mixture of leaves and flowers for 200 Rs/kg. For these products, the international price is 3–4 times the price received by collectors. The price differentials for other species can similarly be traced in Table The MAPs species that on average brought collectors by far the highest price in 2012 was Our surveys of collectors and dealers generated estimates of the quantities of the 24 high value MAPs marketed from Swat District by dealers and traders as well as prices at different marketing levels. The estimated quantities delivered to markets by the 120 surveyed collectors are shown in Table Diospyrus lotus L.  was collected in by far the largest quantity, followed by Persicaria amplexicaulis (D. Don) Ronse Decr. (syn. Bistorta amplexicaulis D.Don)  and V. pilosa . Trillium govanianum Wall. ex D.Don (8000 kg), M. esculenta, Paeonia emodi Royle and Polygonatum multiflorum (L.) All. (each 5000 kg), and A. capillus-veneris and Berberis vulgaris L. (each 4000 kg) were also collected in reasonably great quantities from the surveyed areas and sold in the herbal markets of Mingora and Madyan. Other species were collected in quantities of 3000 kg or less from the studied sites of Swat District.The quantities indicate that The present assessed quantities taken out of Swat District are not based on a managed optimum exploitation of these species in the valleys. Market demands for the most of these species may exceed the existing supply, as the interviews with collectors/farmers suggested larger amounts of these species could have been sold. Similarly, the interviews suggested potential supply can be higher than the present amounts taken out. The differences are due to uncoordinated demand and supply and unawareness about the availability of certain species and their demand in the market. However, sustainability of harvests of endangered MAP species also has to be taken into account as a long run concern.Different stakeholders of the MAP business, e.g. collectors/farmers, agents, shopkeepers, wholesalers, representatives of pharmaceutical companies, were asked about their annual income during the market study. The respondents were reluctant to disclose their income from the MAP business and the responses were invariably discouraging. The majority of them declined to answer this question. The responses from a few people were not in agreement with the quantities and price of materials they claim to sell annually. The only reliable information which came out of this survey from the direct questions regarding the income of different players in the MAP trade was very general. It was observed that the collectors of crude material were invariably on the losing side, earning comparatively little from their hard work. On the other hand, middlemen, wholesalers, and retailers earn larger incomes from this trade.More specifically, collectors/farmers who rent their lands/forest areas were hesitant to give details about their income because they did not wish this information to be passed on to the landowners. The traders were also reluctant to give details due to a fear that the information would be passed to the tax authorities. However, our study revealed that the trade of MAPs is dominated by a few wholesalers and hakims in the surveyed areas. Overall, it was generally observed in the interviews with local collectors, farmers, and dealers, that in the surveyed sub-valleys, the local middlemen receive the most handsome returns. It was also observed that the local wholesalers control price information to the collectors, and that enables them to maintain high profits.M. esculenta and Rs. 16.4 million from the other 23 species. Among these 23 species, the MAPs that were the best income source for the collectors and gatherers, because of their combination of price and quantity, were D. lotus, T. govanianum and V. pilosa. The price for B. persicum (400 Rs/kg) was third highest, but the amount sold was relatively low. The total collector revenue generated from the sale of the 24 MAPs by the 120 surveyed collectors in Swat District is about Rs. 66.4 million.Some estimate of the total income earned at the collector level can be derived from the price and quantity estimates in Table Some additional illustrative income calculations can also be based on the prices and quantities shown in Table If the further assumption is made that about 5,000 nomadic tribesman provide the MAPs brought to market by the 120 surveyed collectors, the average quantity supplied is 35.3 kg per gatherer household. The average revenue of a gatherer household is Rs. 13,279.While our estimate of collector revenue is higher than some earlier estimates , 28, 29,One check on these illustrative calculations comes from estimating an implied daily wage for MAP gatherers. Our study suggests that most income from MAPs is earned during a four-month spring/summer period of collection. The interviews suggest that an average of about 1.7 persons are engaged in gathering and collection per household. Assuming they work six days per week during this four-month period, each household would have spent about 174 person days on MAPs. The total employment under the assumption of 5,000 gatherer households would be 870,000 person days providing the MAPs marketed by the surveyed collectors. Using the revenue estimates from Table Pakistan both exports and imports substantial quantities of herbal material in trade with other countries. The bulk of the MAPs materials are exported from developing countries while major markets are in the developed countries . In 2012Similarly in 2012, the import of herbal material as a whole was worth over US$ 130 million annually [The geographical location of Swat District provides an ideal physical environment for the growth and nourishment of many high value medicinal and aromatic plants. These crops can make a contribution to the economic development of the area in particular and the country in general. This study of the trade patterns of MAPs from Swat District was based on surveys, interviews, and focus group meetings with participants in the market value chain including collectors/farmers, local dealers, shopkeepers and hakims, wholesalers, representatives of the domestic pharmaceutical industry, and exporters. The study reveals that various species from Swat District are sold in large quantities both in national and international markets, indicating their importance as a source of income for the nomadic tribesman and small farmer inhabitants of the mountain communities. At the same time few species harvested in Swat District have been reported from market abroad, but this could be due to the difficulty of species identification in trade or the lack of endemics that can be used as place-holders . The stuThe MAPs trade in Pakistan, including Swat District, operates with minimal state intervention and documentation. This informal market is present in many countries and provides an important source of income to both subsistence farmers, traders, middlemen, vendors, wholesalers and retailers , 34–40. in-situ and ex-situ conservation of Pakistan’s biodiversity including MAPs. However, genetic diversity of traditional MAPs is continuously under the threat of extinction due to unsustainable harvesting techniques. A balance is needed between the value of MAPs for the products derived from them and their environmental preservation. Maintaining the supply of MAPs is a problem mainly because most of them are harvested from the wild. As the trade has become market-oriented and international, the activities of a growing number of gatherers are outstripping natural MAP populations. Hence, there is need to establish this trade on a more scientific and sustainable basis. The vulnerability of MAPs to over-exploitation and threat of extinction needs to be dealt with pragmatically. However, the country has still to go a long way to frame laws and policies to conserve all its genetic materials and to develop bilateral and multilateral exchange of plant germplasm, appropriate breeders, farmers and community rights, and comprehensive action plans to achieve the objectives of trade sustainability and its linkages with conservation.Pakistan is a signatory of the Convention on Biological Diversity (CBD), the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES), and various others . Hence PThere is no systematic management structure involved in collection of MAPs plant material in Swat District, which appears to be on a first-come basis. This is cause for concern because, as Balick  and SagaIn the interviews for this study, very few of the collectors knew about the existence of the major markets for MAPs or were sufficiently trained in such critical skills as the best pre and post-harvest treatments. Olsen and Larsen  also fouHousehold incomes of gatherers and collectors of MAPs can be enhanced if communities acquire a better understanding of the economic importance of high-demand natural plant resources, as well the interests and respective roles of the key stakeholders involved in the market. This must include understanding of the importance of sustainable collection and cultivation practices to the long term livelihood of the community. Educational programs should address the issue of sustainable harvesting and the possibility of cultivating MAPs that are currently collected from the wild. There is also need for a program that focuses on assisting collectors and local dealers in providing consistently high quality, well preserved, material to purchasers, combined with a sharing of information as to why this is important. This paper provides a baseline analysis of the marketing channels and price differences that underscore these needs.The study provides estimates of the price increases as high value MAPs move through the supply chain. These price differences are to be expected, but are also exacerbated by the lack of knowledge among collectors and local dealers concerning the demand for the various plants. Nomadic gatherers and collectors usually have no direct knowledge of the final markets for their products and, therefore, must rely on local traders to sell their products within the existing value chain. To enhance their income from MAPs, collectors and local dealers need a better understanding of the markets they are supplying. This means understanding the extent and seasonality of the demand and market prices as well as quality expectations and their impact on appropriate pre-harvest and post-harvest management and handling of MAPs species.The perceived threats to plant conservation and sustainability of medicinal plant harvesting do require further study to ascertain that these threats are applicable to the situation in Swat District. Larsen and Olsen  argue thThe purpose of this study was to examine the current status of the high value medicinal and aromatic plant trade in Pakistan and investigate the linkages in the market chain from collectors in Swat District to final consumers. During the course of the interviews and focus group meetings of the study, a range of possible interventions were identified that would enable MAPs to become a stronger ‘engine of growth’ for the local economy. Indeed, simply conducting the study helped inform local collectors/farmers about the value-added products derived from MAPs. It is reasonable to expect that improving market linkages between producers and buyers will result in increased economic benefit for local collectors, farmers, and dealers, enabling their communities to become hubs of significant economic activities with a multi-dimensional impact on the economic development of Swat District. Such developments are also essential if Pakistan is to maintain or improve its position as an international supplier of MAPs.