Clinical Control Trial on the Healing Drawing Procedure (HDP) Trauma Treatment Intervention Provided by Non-Specialist Mental Health Providers to Vulnerable Children Living in Taraz, Republic of Kazakhstan - Juniper publishers

 Psychology and Behavioral Science- Juniper Publishers

Abstract

This clinical controlled trial had two objectives: 1) to evaluate the effectiveness, efficacy, and safety of the Healing Drawing Procedure (HDP) group trauma treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms among vulnerable children living in Taraz, Kazakhstan and 2) to explore the effectiveness and safety of non-specialist mental health providers (MHPs) being trained in and delivering the HDP group trauma treatment intervention as part of the task-sharing focused Trauma Healing Training Program (THTP), which is being developed to safely bring effective mental health treatment interventions to high-need, low-resource contexts, specifically in low-and-middle-income countries (LMICs). A total of 22 children between the ages of 7-14 (M = 10.09 years old) met the inclusion criteria and participated in the study. To evaluate the effectiveness, efficacy, and safety of the HDP treatment intervention in reducing PTSD symptoms in vulnerable children, repeated-measures ANOVA was applied, comparing the Treatment Group (TG) and the Control Group (CG). Results showed that the HDP treatment intervention had a significant effect for time, with a medium effect size (F (2,40) = 17.72 p <.000, η² = 470), and a significant effect for group with a lower effect size (F (1, 20 = 76.66, p<.001, η² = .404). Intragroup comparisons of means showed significant differences for the Treatment Group (TG) between Time 1. Pre-test assessment and Time 2. Post-treatment assessment with a large effect, t (14) = 5.42, p=.00, d = .955. These data confirm the effectiveness, efficacy, and safety of the HDP group trauma treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms in children. Results also show the Trauma Healing Training Program’s success in safely bringing an effective mental health treatment intervention provided by specially trained non-specialist mental health providers in a low-resource country.

Keywords: Healing Drawing Procedure, HDP; Posttraumatic Stress Disorder (PTSD); Non-Specialist Mental Health Providers; Low-And-Middle-Income Countries (LMIC); Adaptive Information Processing

Abbreviations: HDP: Healing Drawing Procedure; PTSD: Posttraumatic Stress Disorder; MHPs: Mental Health Providers; THTP: Trauma Healing Training Program; LMICs: Low-and-Middle-Income Countries; TG: Treatment Group; CG: Control Group; WHO: World Health Organization; ISTSS: International Society for Traumatic Stress Studies; PTs: Psychological Treatments; AIP: Adaptive Information Processing; EMDR-IGTP-OTS: Eye Movement Desensitization and Reprocessing Integrative Group Treatment Protocol for Ongoing Traumatic Stress; CCT: Clinical Controlled Trial; EPT: Emotional Protection Team; ANOVA: Analyses of variance

Introduction

It is well established that Adverse Childhood Experiences (ACEs), (e.g., child maltreatment, abuse, neglect, witnessing domestic violence between parents) can lead to the development of posttraumatic stress disorder (PTSD) and can have a profound impact on an individual’s physical health [1-4]. Evidence also shows a dose-response relationship between ACE scores and adult physical health, as well as mental health problems. For example, Merrick et al. found that higher ACE scores increased the odds of experiencing drug and alcohol use, suicide attempts, and depressed affect in adulthood [5]. It is also known that PTSD is common and devastating disorder, that half of global cases of PTSD are considered persistent, and only a very small minority of those with severe PTSD symptoms in low-and-middle income countries (LMICs) receive specialty health care to treat the symptoms of PTSD [6]. While the long-term impacts of the effective treatment of ACEs during childhood are unknown at this time, a parallel issue to be considered is the lack of availability of mental health services in Kazakhstan, as well as globally, to provide such treatment during childhood, and even into adulthood. According to an official 2019 estimate by the United Nations, the population of Kazakhstan is 18,551,428 [7]. The Mental Health Atlas 2020, published by the World Health Organization (WHO), finds that there are an estimated 4,476 specialist mental health providers (MHPs), or mental health professionals, in Kazakhstan. Only 778 of those professionals specialize in the treatment of children and adolescents. That means that there are an estimated 24.13 specialist MHPs per 100,000 citizens resulting in only 12.10 specialist MHPs per 100,000 citizens that specialize in the care of children and adolescents [8]. The need for more available mental health services in Kazakhstan is great, to say the least.

As declared by the WHO, mental health is a basic human right [9]. Yet, like the situation in Kazakhstan, the worldwide shortage of specialist MHPs and the ever-growing gap between the availability of providers and the need for their services is widely understood. Most recently, the International Society for Traumatic Stress Studies (ISTSS) published a briefing paper advocating for increased access to psychological treatments (PTs) in the global context and called for task-sharing and the training of non-specialist MHPs to be seen as a primary source to begin narrowing the gap between the need for mental health services and the availability of such services [10]. While there continues to be much work to be done, there is a small body of evidence that task-sharing PTs can be safely and effectively administered by non-specialist mental health providers [11-15]. This study hopes to contribute to that ever-growing body of evidence.

The Trauma Healing Training Program

This study was conducted as part of the development of the Trauma Healing Training Program (THTP), which is a specialized training being developed in the vein of task-sharing as part of the solution to the global mental health care crisis, particularly in LMICs. This training is being designed to equip non-specialist MHPs with safe and effective AIP-Informed trauma processing interventions to begin narrowing the great divide between mental health services needed and mental health services available in their communities. The THTP is a two-week training that includes learning two different group interventions as well as two individual interventions. Fieldwork is conducted on all four interventions with the in-person supervision and support of the THTP trainer. Specifically, for the HDP portion of the THTP, trainees receive a two-day in-person training on the HDP which includes demonstration of the HDP, lecture including defining trauma and recognizing its impact, learning self-soothing skills, provided understanding of the window of tolerance, as well working memory theory. Besides fieldwork, the training also includes practicum within the training team, so trainees can practice the administration of the HDP on each other before providing it to participants of this research project. In-person supervision and feedback from the trainer was provided throughout the training as well as during all fieldwork. Discussions of how to make the administration of the HDP culturally successful within the Kazakh culture and the specific context of the Caring Heart Public Fund were included. Six months of virtual follow up consultation from the trainer will be provided to the training team along with continued communication with the executive director of Caring Heart as the training team continues to utilize all the intervention tools of the THTP as they work to provide much needed mental health serices to the children of Caring Heart.

AIP Theoretical Model

In her 2018 text, Shapiro describes the Adaptive Information Processing (AIP) model and posits that memory networks of stored experiences are the basis of both mental health as well as pathology across the clinical spectrum [16]. When memories are adequately processed and adaptively stored, they form the foundation for learning and future perceptions, behaviors, and responses. When memories are inadequately processed and maladaptively stored due to high autonomic nervous system arousal states produced by adverse life experiences, pathogenic memory networks are formed, resulting in present-day suffering, difficulty, and symptoms (e.g., PTSD, anxiety, depression) [16]. Shapiro’s AIP theoretical model is the basis for the development of all treatment interventions incorporated in the THTP.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a pervasive mental health disorder with devastating individual and societal effects, such as deterioration of basic functioning, hindrance of personal and professional relationships, and extreme psychological and physiological distress. PTSD leads to maladaptive responses that manifest in different forms, which include, but are not limited to hyperarousal, hypervigilance, flashbacks, nightmares, fear, horror, and impaired affective prosody and inability to adequately interpret emotional cues [17].

Healing Drawing Procedure Group Treatment Intervention

There are three levels to the THTP, and this study was conducted on Level 1, The Healing Drawings Procedure (HDP) Group Treatment Intervention. The HDP is modeled exclusively after the empirically based Eye Movement Desensitization and Reprocessing Integrative Group Treatment Protocol for Ongoing Traumatic Stress (EMDR-IGTP-OTS) developed and extensively field-tested by Jarero et al. [18-22]. Like the EMDR-IGTP-OTS, the HDP is a scripted intervention incorporating elements of art therapy and utilizes the butterfly hug method as a selfadministered bilateral stimulation [19] to process traumatic material.

Previous Treatment Intervention Studies

The EMDR-IGTP-OTS, after which the HDP is modeled, was initially developed by members of the Mexican Association for Mental Health Support in Crisis (AMAMECRISIS) when they were overwhelmed by the extensive need for mental health services after Hurricane Pauline ravaged the coasts of Oaxaca and Guerrero in 1997 [18]. While this study is the initial research project to study the effectiveness of the HDP being provided by non-specialist MHPs, there have been numerous studies showing the efficacy of the EMDR-IGTP-OTS, including with children [23- 27], and provided by frontline workers, or non-specialist MHPs [11].

Objective

This clinical controlled trial had two objectives:

i) To evaluate the effectiveness, efficacy, and safety of the Healing Drawing Procedure (HDP) group trauma treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms among vulnerable children living in Taraz, Kazakhstan.

ii) To explore the effectiveness and safety of non-specialist mental health providers (MHPs), being trained in and delivering the HDP group treatment intervention as part of the task-sharing focused, Trauma Healing Training Program (THTP).

Method

Study design

To measure the effectiveness of the HDP on the dependent variable PTSD symptoms, this study used a two-arm clinical controlled trial (CCT) with a waitlist no-treatment control group design. PTSD symptoms were measured at three-time points for all participants in the study: Time 1. Pre-treatment assessment; Time 2. Post-treatment assessment; and Time 3. Follow-up assessment. For ethical reasons, all participants in the control group received intervention treatment after the follow-up assessment was completed.

Ethics and Research Quality

Due to the lack of an Institutional Review Board in the country of the study, the research protocol was reviewed and approved by the EMDR Mexico International Research Ethics Review Board (also known in the United States of America as an Institutional Review Board) in compliance with the International Committee of Medical Journal Editors recommendations, the Guidelines for Good Clinical Practice of the European Medicines Agency (version 1 December 2016), and the Helsinki Declaration as revised in 2013.

Participants

This study was conducted between September and November 2023 in the city of Taraz, Republic of Kazakhstan, in Central Asia. A total of 22 children (12 female, 10 male) ages 7-14 (M=10.09 years old) living in Taraz, Kazakhstan, met inclusion criteria and were able to complete participation in the study. Children were recruited for this study through their involvement with Caring Heart Public Fund, a legally registered non-profit organization in Taraz, Kazakhstan, focused on meeting the needs of vulnerable children and single mothers. All the children who participated in the study came there each weekday as part of the day program in conjunction with attending local schools. Participation was voluntary, and the participants verbally consented to the treatment while a parent or legal guardian signed a written consent in accordance with the Mental Capacity Act 2005. Inclusion criteria for the participants receiving the intervention were:

a) Being a child less than 18 years old.

b) Being a participant of the programs and services offered by Caring Heart.

c) Voluntarily participating in the study.

d) Not receiving specialized trauma therapy.

e) Not receiving drug therapy for PTSD

symptoms.

Exclusion criteria were:

a) ongoing self-harm/suicidal or homicidal ideation,

b) diagnosis of schizophrenia, psychotic, or bipolar disorder,

c) diagnosis of a dissociative disorder,

d) organic mental disorder,

e) a current, active chemical dependency problem,

f) significant cognitive impairment (e.g., severe intellectual disability, dementia),

g) presence of uncontrolled symptoms due to a medical illness.

Instrument for Psychometric Evaluation

To measure PTSD symptom severity and treatment response, the optimal short-form of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) was used. This screening scale was not used to render clinical diagnoses. Rather, it was used to measure and track the severity of symptoms of PTSD in a context where the administration of the full PCL-5 was not feasible. The optimal short-form PCL-5 has been shown to detect virtually all cases meeting DSM-5 criteria of PTSD that would be detected by the full PCL-5, making it ideal for measuring and tracking symptoms of PTSD [28]. The instrument was translated and backtranslated to Russian, and the time interval for symptoms was the past week. The screening tool contains four items including:

i. Suddenly feeling or acting as if the stressful experience were happening again.

ii. Avoiding external reminders of stressful experiences.

iii. Feeling distant or cut off from other people.

iv. Irritable behavior, angry outbursts, or acting aggressively.

Respondents indicated how much they have been bothered by each PTSD symptom over the past week (rather than the past month), using a 5-point Likert scale ranging from 0=not at all, 1=a little bit, 2=moderately, 3=quite a bit, and 4=extremely. A total-symptoms score of 0 to 16 can be obtained by summing the items. The sum of the scores yields a continuous measure of PTSD symptom severity and can serve as a screen for detecting PTSD. Psychometrics for the optimal short-form PCL-5, validated against the full PCL-5, suggests that a score of 6 is the minimum to determine probable PTSD status based on DSM-5 diagnostic rules [28].

Procedure

Enrollment, Assessments, Data Collection, and Confidentiality of Data

Children were divided into a treatment group (TG) and a control group (CG) dictated by their school schedules. The children who went to school in the afternoon were available to participate in this study in the morning and vice versa. To provide the initial treatment to as many children as possible, the 15 children available in the morning (the morning group) were chosen as the treatment group as there were more children in the morning group. There were seven children available in the afternoon (the afternoon group), and so they were chosen as the control group. Which children went to school in the morning vs. the afternoon was dictated by the schedules of the school they attended. Age or educational level did not determine which school schedule each child had or their placement in the treatment or control groups. After the conclusion of all data collection for this study, for ethical reasons, the children in the control group were also provided with the same HDP intervention. For data collection Time 1, Trainees of the THTP were all trained in completing the optimal short-form PCL-5 with the children. The optimal short-form PCL- 5 was translated and back-translated into Russian as the entire training was conducted in English, with Russian translation. All trainees spoke Russian, and some trainees were also fluent in Kazakh. As each child was paired with a trainee to complete the assessments, care was taken to match Kazakh-speaking children with a Kazakh-speaking trainee and Russian-speaking children with Russian-speaking trainees. Trainees instructed the child to play a mental movie of all their difficult life experiences to identify the memory that bothered them the most. That memory was noted on the short form PCL-5 assessment paper and was used for all subsequent assessments as well as the HDP treatment intervention. Demographic information and consent forms, which also incorporated the exclusion criteria, were completed by a parent or legal guardian for each child as well.

]

For data collection, Time 2. Post-treatment, the short-form PCL-5 was completed in person with each child one week after the completion of the HDP treatment intervention. The THTP trainees reminded each child of the memory that bothered them the most before answering the instrument to ensure participants were focusing on the same adverse experience each time, they completed the assessment tool. For data collection Time 3, three-week follow-up, the optimal short-form PCL-5 assessment was conducted three weeks after treatment was completed. The assessments were completed with each child in person by the same THTP trainee that had previously conducted the assessments with each child for data collection Times 1 and 2. All data was collected, stored, and handled in full compliance with the EMDR Mexico International Research Ethics Review Board requirements to ensure confidentiality. Each study participant gave their consent to collect their data, which was strictly required for study quality control. All procedures for handling, storing, destroying, and processing data were following the Data Protection Act 2018. All people involved in this research project were subject to professional confidentiality.

Withdrawal from the Study and Missing Data

All research participants had the right to withdraw from the study without justification at any time and with assurances of no prejudicial result. If participants decided to withdraw from the study, they were no longer followed up in the research protocol. There were no withdrawals during this study.

Treatment

Participants received six administrations of the Healing Drawings Procedure (HDP) treatment intervention as a group to reprocess pathogenic memories that were an average of 51.4 months old (4.28 years old). Two administrations of the intervention were provided each day for three consecutive days, totaling six hours of treatment. All administrations of the intervention were done in Russian with Kazakh translation. A different team member from the THTP training team volunteered to administer each set of the HDP while three other team members served as the Emotional Protection Team (EPT) per the 1:5 adultto- child ratio required for the HDP intervention. The remaining team members who were not either the leader or part of the EPT observed from the back of the room. Throughout the three days, all team members served either as the leader or as an EPT member; many served in both roles.

Clinicians and Treatment Fidelity

Nine of the non-specialist MHPs participated in the THTP and were members of the training teamwork for Caring Heart. Two trainees work for a similar organization in Shymkent, Kazakhstan. Consequently, the trainees all had different roles within their organizations, including teacher, program coordinator, administrative assistant, speech therapist, house mom, and social worker. While there are professional mental health services available in Taraz, they are quite limited in general and are not specialized in treating trauma to the best of the author’s knowledge. These non-specialist MHPs successfully administered the HDP intervention to the participants as part of the fieldwork portion of the THTP. The THTP trainer, a licensed mental health professional in the United States, also an EMDRIA Approved Consultant and EMDR Basic trainer, provided the two-day HDP portion of the training in person and supervised the fieldwork as part of the overall THTP. This team of non-specialist MHPs were chosen to participate in this training and research project primarily because of their demonstrated competence as leaders and teachers and because they already have working relationships and rapport developed with the children.

Treatment Safety

Treatment safety was defined as the absence of worsening adverse effects, events, or symptoms. No adverse reactions were reported or identified during subsequent post-treatment data collections or the remainder of the THTP.

Examples of the Pathogenic Memories Treated with the HDP

Examples of pathogenic memories treated during the HDP sessions were: Being physically abused and / or neglected, witnessing domestic violence between parents or other adults, being taken to a state-run orphanage, and subsequent fear of being returned there.

Clinicians’ Experience with the HDP Treatment Intervention

While trainees initially were concerned about asking the children to focus on their disturbing memories, they were quite pleased to see the results as the children processed through the traumatic experiences as witnessed through the reduction in the identified SUD (Subjective Unit of Disturbance) as is utilized in the HDP. Trainees were particularly impressed that they could provide relief to 15 children over the course of 6 hours rather than working with them individually on simple behavior modification.

Statistical Analyses

Analyses of variance (ANOVA) for repeated measurements comparing two groups, Treatment Group (TG) vs Control Group (TG) was applied to analyze the effects of the Healing Drawings Procedure (HDP) treatment intervention across the time at threetime measurements: Time 1. Pre-treatment assessment; Time 2. Post-treatment assessment; and Time 3. Follow-up assessment. Eta squared (η²) is reported to show the effect size. Comparison of means analyses was carried out using the t-test for both independent samples and within groups. Cohen´s d is included to report the effect size for t-test results.

PTSD

Results showed that the intervention had a significant effect for time on PTSD with a medium effect size (F (2,40) = 17.72 p <.000, η² = 470), a significant effect for group with a lower effect size was observed (F (1, 20 = 76.66, p<.001, η² = .404), no significant interaction was found.). Comparison of means between groups did not show significant differences for Time 1. Pre-test assessment (M = 6.53, SD = 3.22 vs M = 9.42, SD = 3.86). For Time 2. Post-treatment assessment, significant differences between the Treatment Group (TG) and Control Group (CG) were found, with a large effect size, t (20) = - 3.78, p=.001, d = -1.72, (M = 1.73, SD = 1.62 vs M = 7.57, SD = 5.62). For Time 3 Follow-up assessment, significant differences between the Treatment Group (TG) and Control Group (CG) group were also found, with a large effect, t (20) = - 3.85, p=.001, d = - 1.37, (M = 1.53 SD = 1.68 vs M = 7.00, SD = 5.03). Intragroup comparisons of means showed significant differences for the Treatment group (TG) between Time 1. Pretest assessment and Time 2. Post-treatment assessment with a large effect, t (14) = 5.42, p=.00, d = .955. See Table 1 and Figure 1.

*Statistically significant differences between groups

Discussion

This clinical controlled trial has two objectives: 1) to evaluate the effectiveness, efficacy, and safety of the Healing Drawings Procedure (HDP) group trauma treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms in a population of vulnerable children and 2) to explore the efficacy and safety of non-specialist MHPs being trained in and conducting the HDP intervention as part of the task-sharing focused Trauma Healing Training Program (THTP) being developed. A total of 22 child participants met the inclusion criteria and participated in the study. Participants’ ages ranged from 7 to 14 years old (M = 10.09 years). The data supports the effectiveness, efficacy, and safety of the HDP group trauma treatment intervention in reducing posttraumatic stress disorder (PTSD) symptoms in children. The results of the statistical analyses showed that the HDP group treatment intervention had a significant effect for time, with a medium effect size, and a significant effect for group with a lower effect size. A comparison of means between the treatment and control groups did not find significant differences for Time 1.

Pre-test assessment and for Time 2. Post-treatment assessment showing a similar baseline. Significant differences between groups were found for Time 2. Post-treatment and for Time 3. Follow-up with a large effect size in both assessments. Intragroup analyses of means showed significant differences for the Treatment Group (TG) compared Time 1. Pre-test assessment and Time 2. Post-treatment assessment with a large effect. Scores were maintained for Time 3. Follow-up assessment in this group confirming the effect of the treatment. In reference to objective number 2, exploring the effectiveness and safety of non-specialist mental health providers (MHPs), being trained in and delivering the HDP group treatment intervention as part of the task-sharing focused Trauma Healing Training Program (THTP), the study results also show the THTP success in safely bringing an effective mental health treatment intervention provided by specially trained non-specialist mental health providers in a low-resource country.

Conclusion, Limitations, and Future Directions

PTSD is a pervasive mental health disorder that has devastating effects on individuals and society. Therefore, there is a need for evidence-based, time-limited, cost-effective, and safe interventions to enhance the treatment of posttraumatic psychopathology. This study’s results showed that the HDP group treatment intervention can effectively, efficiently, and safely be provided in person to a child population with pathogenic memories to reduce PTSD symptoms. The participants reported no adverse effects or events during the treatment intervention administration or at the three-week follow-up. None of the participants showed clinically significant worsening/exacerbation of intrusion symptoms on the short-form PCL-5. Clinicians’ reports based on their experiences also suggest that the HDP is a provider friendly treatment intervention that can be successfully applied by novice and seasoned providers alike, yielding similar treatment results, facilitating clinician confidence. Limitations of this study are the lack of randomization, the different sizes of the groups with a small sample, and the three-week follow-up. Therefore, we recommend a randomized controlled trial with a child population with pathogenic memories (e.g., adverse childhood experiences) or on PTSD Criteria-A experiences, with larger samples, and with follow-up at three or six months to evaluate the long-term treatment effects.

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Predictive Biomarkers in Idiopathic Pulmonary Fibrosis: A Comprehensive Analysis for Early Diagnosis and Patient Stratification - Juniper publishers

Pulmonary & Respiratory Sciences - Juniper Publishers

Abstract

Idiopathic Pulmonary Fibrosis (IPF) presents a complex challenge in respiratory medicine, characterized by insidious onset and relentless progression. This comprehensive analysis delves into predictive biomarkers across diverse domains to enhance early detection, precise patient stratification, and personalized therapeutic interventions. Blood biomarkers, including Krebs von den Lungen-6 (KL-6) and Surfactant Proteins A and D (SP-A and SP-D), offer diagnostic precision and prognostic insights, unraveling the dynamic interplay between immune responses and fibrotic activity. Genetic biomarkers highlight the role of genetic polymorphisms, shedding light on susceptibility and disease progression and paving the way for personalized therapeutic interventions. Imaging biomarkers, exemplified by High-Resolution Computed Tomography (HRCT), enable definitive diagnosis by unraveling distinct radiographic changes in IPF. Molecular biomarkers, such as microRNAs and cytokines, usher in a new era of molecular classification and prognostic assessments, promising tailored interventions based on molecular profiles. Cellular biomarkers, represented by circulating cells, provide non-invasive tools for disease monitoring and prognosis, showcasing the intricate interplay between immune responses and fibrosis. Collaboration across diverse research avenues has been employed in this synthesis to comprehend the complexities of IPF. Predictive biomarkers are beacons guiding the way toward earlier detection, precise stratification, and personalized therapeutic strategies, significantly improving respiratory health.

Keywords: Idiopathic pulmonary fibrosis; Predictive biomarkers; Blood biomarkers; Genetic biomarkers; Personalized therapeutics

Abbreviations: IPF: Idiopathic Pulmonary Fibrosis; KL-6: Krebs von den Lungen-6; SP-A: Surfactant Protein A; SP-D: Surfactant Protein D; ILD: Interstitial Lung Diseases; SNPs: Single Nucleotide Polymorphisms; DPP9: Dipeptidyl Peptidase 9; TGF-β1: Transforming Growth Factor-beta 1; CTGF: Connective Tissue Growth Factor; PDGF: Platelet-Derived Growth Factor; FGF: Fibroblast Growth Factor; VEGF: Vascular Endothelial Growth Factor; EGF: Epidermal Growth Factor; IGF: Insulin-Like Growth Factor; HRCT: High-Resolution Computed Tomography; UIP: Usual Interstitial Pneumonia; DLCO: Diffusing Capacity of Carbon Monoxide; PAH: Pulmonary Arterial Hypertension; miRNAs: MicroRNAs; AE: Acute Exacerbations; BAL: Bronchoalveolar Lavage; Th1/Th2: T Helper Cell Subsets 1 and 2; M1-M2: Macrophage Polarization States; CCL18: Chemokine Ligand 18; CHI3L1: Chitinase 3-Like 1; MMPs: Matrix Metalloproteinases; Tregs: Regulatory T Cells

Introduction

Idiopathic Pulmonary Fibrosis (IPF) presents a formidable challenge in respiratory medicine due to its insidious onset and relentless progression. Recognizing the critical need for early detection and precise patient stratification, this comprehensive analysis delves into the realm of predictive biomarkers in IPF [1]. Current diagnostic methods often capture the disease’s advanced stages, making early detection imperative [2]. This comprehensive analysis explores predictive biomarkers, aiming to unravel their potential to afford a swifter and more precise diagnosis and enable nuanced patient stratification based on distinct prognostic trajectories [3]. From the intricacies of molecular signatures detectable in blood to the nuances revealed by cutting-edge imaging technologies, each facet of predictive biomarkers in IPF will be meticulously examined [4]. The synthesis of these insights promises to revolutionize the diagnostic paradigm and open avenues for tailoring therapeutic approaches to individual patient profiles. To understand the complexities of IPF, this review seeks to pave the way for a future where early intervention and personalized care redefine the trajectory of this challenging pulmonary disorder.

Blood Biomarkers

Krebs von den Lungen-6 (KL-6)

The Krebs von den Lungen-6 (KL-6) antigen and surfactant proteins A and D (SP-A and SP-D) are the primary biomarkers linked to damage (or malfunction) of alveolar epithelial cells.

Serum KL-6 is more accurate than SP-A and SP-D in diagnosing interstitial lung illnesses (ILD and IPF linked to connective tissue diseases) [6]. KL-6 is a mucin-like glycoprotein expressed on the extracellular surface of bronchiolar epithelial cells and alveolar type II cells. It is a chemotactic factor to encourage lung fibroblast migration, proliferation, and survival. When it was initially studied as a serum tumor biomarker, patients with pulmonary fibrosis experienced a relatively high proportion of false positives.

A later study identified it as a biomarker for ILDs. Serum KL-6 has been linked to survival. Those with a serum KL-6 level >1000U/mL had a deteriorated survival compared to those with lower levels in a prospective trial involving 152 patients with idiopathic interstitial pneumonia and 67 individuals with interstitial lung disease associated with connective tissue disease. According to multivariate analysis, elevated blood KL-6 levels were independently linked to survival (HR 2.95, 95% CI 1.71-5.08, p=0.0001) [5]. Data from a study with a large Japanese sample were used to create (Figure 1) to show the different rates at which KL-6 tests positive based on a cut-off value of 500U/mL; data are from 225 patients with various lung diseases and 200 healthy individuals.

Therapeutic effectiveness is also correlated with serum levels of KL-6. In one trial, high-dose corticosteroid pulse therapy was used to treat 14 Japanese patients with quickly progressing IPF. The patients were monitored for a minimum of three weeks during the treatment. Patients exhibited superior response and longer-term survival when their blood levels of KL-6 dramatically dropped. Numerous investigations revealed a correlation between the degree and activity of IPF and serum KL-6 levels. The prognosis of an IPF patient is also correlated with serum KL-6 levels. There is evidence linking higher blood KL-6 levels, particularly those above 1,000 U/mL at first measurement, to a higher death rate. When KL-6 levels are first measured and they are 1,000 U/mL or above, individuals with IPF progress much more quickly than those whose levels are less than 1,000 U/mL [7].

Surfactant Proteins A and D

In the context of Idiopathic Pulmonary Fibrosis (IPF), Surfactant Proteins A (SP-A) and D (SP-D) emerge as pivotal players in the intricate landscape of pulmonary homeostasis. These hydrophilic proteins, synthesized and secreted by alveolar type II epithelial cells, contribute significantly to the innate immune defense mechanisms within the alveoli. SP-A and SP-D, belonging to the collection family, exert antimicrobial properties by facilitating the opsonization and phagocytosis of pathogens, thereby enhancing host defense against lung infections. Beyond their immunomodulatory roles, emerging research suggests a potential involvement of SP-A and SP-D in modulating the fibrotic process characteristic of IPF. These surfactant proteins regulate inflammatory responses and profibrotic pathways, influencing the delicate balance between tissue repair and aberrant fibrogenesis in the pulmonary microenvironment [8,9].

In the quest for understanding the nuanced interplay of SP-A and SP-D in IPF pathogenesis, ongoing research investigates their potential utility as biomarkers for disease progression and severity. Studies propose that alterations in these surfactant proteins’ expression levels or functional activity may correlate with the extent of fibrotic changes in lung tissue. Furthermore, insights into the genetic variations affecting SP-A and SP-D genes have sparked interest in exploring their association with susceptibility to IPF development and progression. The intricate involvement of SP-A and SP-D in both immune regulation and fibrotic processes underscores their multifaceted role in the complex pathophysiology of IPF, offering avenues for targeted therapeutic interventions and diagnostic advancements [10-12].

Genetic Biomarkers

Genetic Polymorphisms

Lately, studies have made significant strides in understanding the genetic underpinnings of susceptibility to Idiopathic Pulmonary Fibrosis (IPF) and its progression. Notably, some literature delved into studies and found the role of genetic variations in the DPP9 gene in influencing both susceptibility and the rate of disease progression in IPF. The authors identified specific single nucleotide polymorphisms (SNPs) in DPP9, which are connected to an increased risk of developing IPF [13]. The study also found a correlation with a faster decline in lung function among affected individuals [13]. This highlights the dual impact of certain genetic polymorphisms on the progress and initiation of IPF. A study by Fingerlin TE, et al. [14] also boosted our perspective of genetic factors associated with IPF susceptibility. The research employed advanced genomic techniques to identify novel risk loci and revealed previously unrecognized genetic contributors to the disease. Besides, it shows that some of these loci were implicated in pathways related to immune response and lung epithelial cell function [14]. Therefore, the findings contribute to our understanding of susceptibility and open avenues for targeted therapeutic interventions based on the specific genetic factors involved.

Concerning disease progression, a study by Ley B, et al. [15] explored the impact of genetic variants on the rate of decline in lung function among individuals with established IPF. The research focused on comprehensive genetic profiling and identified specific polymorphisms associated with a more rapid fibrosis progression. Understanding the genetic factors influencing disease progression is crucial for developing personalized treatment strategies and predicting outcomes in IPF patients [15]. This assertion is echoed by a study by Mai TH, et al. [16] which depicts that the development of accurate IPF treatment is based on considering multiple factors like gender, which is genotypically determined [16]. Thus, these recent studies underscore the evolving landscape of genetic research in IPF, providing valuable information for understanding susceptibility and tailoring interventions to address disease progression. According to Zhang D, et al. [17] the future of idiopathic pulmonary fibrosis depends on the ability to establish marked genetic variations that help shape interventions and predict disease outcomes [17].

Imaging Biomarkers

High-Resolution Computed Tomography (HRCT)

Idiopathic pulmonary fibrosis, as pathologically defined by the presence of the usual interstitial pneumonia (UIP) pattern, is characterized by distinct radiographic changes [18-20]. The high-resolution computed tomography (HRCT) manifestation of the UIP pattern entails bibasal and peripheral, subpleural reticular opacities, frequently accompanied by traction bronchiectasis-a fibrosis indicator. Linear and reticular opacities result from collapsed alveolar membranes due to scarring. Honeycombing is pivotal for definitively diagnosing idiopathic pulmonary fibrosis [21]. On HRCT, honeycombing is typically described as subpleural, clustered, multilayered, stacked, or multi-tiered cystic air spaces with well-defined walls. These cystic spaces generally range from 3 to 10mm in diameter, occasionally reaching up to 2.5cm, and may signify collapsed secondary pulmonary lobules around respiratory bronchioles. In the most recent consensus classification, HRCT findings are categorized into four types; one is a UIP pattern characterized by peripheral, subpleural, basal-predominant reticular opacities, traction bronchiectasis, and honeycombing, with a typical UIP pattern correlating with UIP pathology in 90 percent of cases; second, a probable UIP pattern featuring the characteristics mentioned above except for honeycombing, corresponding with UIP pathology in 80 percent of cases; third indeterminate for UIP, where the basal, peripheral predominance of opacities is absent, and ground-glass or peri-broncho-vascular opacities are present; and fourth an alternative diagnosis [22].

Diffusing Capacity of Carbon Monoxide (DLCO)

A decline in diffusing capacity (DLCO) is a common observation in idiopathic pulmonary fibrosis (IPF). This decrease results from a ventilation-perfusion mismatch at the alveoli due to thickening from fibrosis at the alveolar-capillary interface [23]. Subsequently, hypoxic vasoconstriction occurs, leading to pulmonary hypertension. Venous occlusive disease follows, causing a reduction in pulmonary capillary blood volume, contributing to a low DLCO in IPF patients [24,25]. Additionally, a decrease in DLCO may occur in IPF patients due to thromboembolic disease [26]. Enhancing DLCO in IPF patients poses a challenge. At the very least, it is crucial to maintain the state of interstitial changes and prevent acute exacerbations.

While drugs approved for pulmonary arterial hypertension (PAH) improve pulmonary capillary blood volume, a persistently low DLCO resulting from alveolar-capillary membrane fibrosis in IPF-PH patients suggests limited improvement in oxygenation [23]. Studies indicate a lower DLCO predicts reduced survival in IPF patients [27]. However, despite large declines (15% or greater) indicating significant disease progression, DLCO’s limited reproducibility and specificity restrict its utility in assessing disease progression over time [28]. The recommendation is to monitor pulmonary function tests (PFTs), including spirometry and DLCO, every three to six months in IPF patients to track disease progression. Further investigations should be prompted to rule out pulmonary embolism, such as high-resolution CT (HRCT) or CT angiography [29].

Molecular Biomarkers

MicroRNAs (miRNAs)

IPF is characterized by a significant involvement of molecular biomarkers, particularly microRNAs (miRNAs). These miRNAs have emerged as potential biomarkers with diagnostic, prognostic, and molecular classification implications in respiratory diseases, including IPF [30,31]. Previous studies have indicated that elevated levels of KL-6 in IPF are predictors of Acute Exacerbations (AE) [30]. Notably, miRNAs, as differentially expressed molecules in respiratory diseases, offer diagnostic value and contribute to prognostic assessments, further enhancing the molecular classification of IPF [31]. A study comparing Bronchoalveolar Lavage (BAL) exosomal miRNAs in IPF has proposed unique miRNA signatures that could serve as airway biomarkers [32].

Research by Li H, et al. [31] reported the specific role of miR-26a in IPF. They found that the reduced expression of miR-26a in lung tissues of both mice and IPF patients correlates with TGF-β1 pathway activation and increased expression of the miR-26a target protein CTGF. Inhibition of miR-26a promotes collagen deposition in the lungs of mice, while over-expression inhibits experimental pulmonary fibrosis. Further studies confirm that miR-26a mitigates lung fibrosis by regulating CTGF expression and inhibiting fibroblast differentiation and proliferation [31]. Guiot’s work on miRNA and protein-coding gene expression in IPF identifies 34 overlapping miRNAs, categorized into 7 upregulated (5 profibrotic), 9 downregulated (8 antifibrotic), and 18 with opposite regulation (Table 1). These findings suggest that dysregulation of fibrotic-related miRNAs may contribute to lung fibrotic lesions, particularly in post-COVID-19 patients [33].

Cytokines and growth factors

Growth factors and cytokines are an integral part of the fibrotic microenvironment, which leads to differences in the phenotype of immune cells in the alveoli between patients with pulmonary fibrosis and healthy individuals. Growth factors can participate in the development and progression of IPF in TGF-β-dependent or TGF-β-independent ways. These growth factors comprise platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), connective tissue growth factor (CTGF), and insulin-like growth factor (IGF). Due to the successful marketing of Nintedanib (an antagonist of PDGFR/VEGFR/FGFR), many studies have focused on growth factors and their corresponding receptors.

Th1/Th2 imbalance and M1-M2 polarization are hallmarks of pulmonary fibrosis. Th2 polarization is characterized by increased secretion of IL-4 and IL-13 and decreased secretion of IFN-γ. M2 polarization can be induced by the microenvironment shaped by Th2 polarization and promotes pulmonary fibrosis through the production of TGF-β, CCL18, chitinase 3-like 1 (CHI3L1), MMPs, and activation of the Wnt/β-catenin pathway. Th17 cells can promote fibroblast proliferation and ECM secretion by secreting IL-17. In addition to affecting fibrosis by modulating the Th1/Th2 balance, many studies have shown that interleukins can also directly affect fibroblasts and epithelial cells [34].

Cellular Biomarkers

Circulating Cells

Circulating cells have become a focal point in elucidating the IPF pathogenesis and predicting its progression. These cellular biomarkers, often identified through peripheral blood analyses, offer valuable insights into the systemic manifestations of IPF. Circulating cells, including lymphocytes, monocytes, and neutrophils, undergo phenotypic and functional alterations in response to the fibrotic microenvironment [35]. Recent studies suggest that variations in these immune cells’ proportions and activation states may indicate ongoing inflammation and fibrotic activity within the lungs of IPF patients. For instance, an increased frequency of circulating fibrocytes, a subset of peripheral blood monocytes with fibroblast-like properties, has been implicated in the pathogenesis of IPF, reflecting the intricate interplay between immune responses and fibrosis [35,36]. Furthermore, the identification and characterization of specific subsets of T lymphocytes, such as regulatory T cells (Tregs) and cytotoxic T cells, in the peripheral blood of individuals with IPF contribute to our understanding of the immune dysregulation associated with the disease. The dynamic changes in the circulating immune cell profile underscore the potential utility of these cellular biomarkers as non-invasive tools for disease monitoring and prognosis [37-39].

Conclusion

The comprehensive analysis of predictive biomarkers in Idiopathic Pulmonary Fibrosis (IPF) illuminates a multifaceted landscape where various biomarkers from blood, genetics, imaging, molecular, and cellular domains converge to enhance our understanding of this enigmatic disease. Pursuing accurate predictive biomarkers is imperative given the challenges posed by the insidious nature of IPF, demanding early detection and precise patient stratification for effective intervention. Blood biomarkers like Krebs von den Lungen-6 (KL-6) and Surfactant Proteins A and D (SP-A and SP-D) offer diagnostic precision and prognostic insights, providing a glimpse into the dynamic interplay between immune responses and fibrotic activity. Genetic biomarkers, particularly genetic polymorphisms in genes like DPP9, shed light on the genetic underpinnings of susceptibility and disease progression, paving the way for personalized therapeutic interventions. Imaging biomarkers, exemplified by High-Resolution Computed Tomography (HRCT), unravel the distinct radiographic changes characteristic of IPF, enabling definitive diagnosis.

Molecular biomarkers, such as microRNAs and cytokines, usher in a new era of molecular classification and prognostic assessments, promising tailored interventions based on molecular profiles. Cellular biomarkers, represented by circulating cells, provide non-invasive tools for disease monitoring and prognosis, showcasing the intricate interplay between immune responses and fibrosis. This comprehensive synthesis underscores the collaborative efforts across diverse research avenues to decipher the complexities of IPF. As we navigate this evolving landscape, predictive biomarkers guide the way toward earlier detection, precise stratification, and personalized therapeutic strategies. Integrating these biomarkers into clinical practice promises to transform the management and outcomes of individuals grappling with the challenges of IPF, marking a significant stride in the quest for improved respiratory health.

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Women involvement in Informal Cross border Trade in East African Community: Motivating Factors - Juniper Publishers

Technical & Scientific Research - Juniper Publishers

Abstract

Informal Cross Border Trade (ICBT) is the most fluid sector of trade in Sub-Saharan Africa, and it compares very favorably in efficiency with formal trade in the continent. Reminiscent the rest of the World, women accounts for the highest number of those involved in ICBT in Sub-Saharan region. In East African Community, women accounts for over 60% of informal cross border traders in spite of the efforts to formalize trade. This calls for the study on examination of the drivers of women involvement in informal cross border trade. This paper is based on documented literature to reach a logical conclusion. The scope of the study covers the traditional East African countries; Kenya, Uganda and Tanzania on the borders; Namanga, Isebania and Busia. This paper found out that. Women are driven into informal cross border trade due to two major factors; cultural factors and restrictive measures. The paper concluded that women are involved into cross border trade due to Cultural, social and economic factors. It recommends an empirical study on these areas to understand Women involvement into informal cross border trade in East African Community. Additionally, policy makers should look into possible ways of addressing the barriers to women involvement formal cross border.

Keywords: Women, Drivers, Informal, Border, Trade, Gender, Restrictive, Cultural, Social and Economic

Abbreviations: ICBT: Informal Cross Border Trade, EAC: East African Community; TTC: Trade Transactional Cost

Introduction

African leaders at independence recognized that economic cooperation and integration among African countries was indispensable in the achievement of accelerated transformation and sustained development. In 1980, the Organization of African Union (currently AU) Extraordinary Summit agreed on need to strength intra-African trade through for regional economic blocks. Later in 1991 they would form African Economic Organization under the Lagos Plan of Action which was meant to spearhead formalization of cross border trade within the regional economic blocks [1]. The idea was that a more formal cross border trade among various sub-regional economic communities was to act as a catalyst to improved Gross domestic product and human development Africa [2].

A reality check in Africa since 1980’s however reveals that cross border trade among various sub-regional economic blocks is primarily informal accounting for 60% of intra-trade and 40% GDP (FAO, 2017). Informal cross border trade directly or indirectly escapes from the regulatory framework and often goes unrecorded or incorrectly recorded onto official national statistics of the trading countries [3]. Analysis of several studies reveals that ICBT is quite active even in developed economies and advanced regional economic communities. In Eastern Europe which borders European Union at the Finnish-Russian border in Eastern Karelia, mainly in the towns of Niirala, Tohmaja¨rvi and Sortavala; at the Polish-Belarusian border in Białystok, Kuznica and Brest; at the Polish-Ukrainian border in Przemys´l and Zˇovkva; and at the Ukrainian-Romanian border in Sighetu Marmatiei and Solotvina informal cross border trade has been going on for many years despite the existing regulation and economic data shows that informal trade still accounts for 19% of the GDP [4].

Moreover, in America, there is a strong evidence of informal cross border trade going on between the border of Mexico on the Northern part and United States in South Texas border notably between Ciudad Juarez and El Paso border case. Though no empirical calculation has been made for informality in South Texas, the best estimates suggest that at least 20% of the production end of economic activity (by value) in the region is undertaken via informal means [5]. Scholars have also noted that Informal cross border trade (ICBT) between Entikong (Indonesia) and Tebedu (Malaysia) has existed for hundreds of years before the formation of the concept of state-nations in both countries and corresponding to this, neglecting the inflation rate, the size of informal trading is approximately at 33% from formal trading. It reveals a significant proportion of informal trading in border area, particularly in Entikong in Malaysia with good traded primarily agricultural [6].

Middle East and North Africa States have not been spared either with problems of cross border trade informalities. Although traditionally caricatured as a region with thick economic borders, where the official flow of goods is severely restricted through an array of arbitrary trade barriers, the Middle East and North African border’s regions remain active zones of informal economic exchange. Although there is no region-wide estimate for the size of informal border trade, country-level studies indicate that such trade is both sizeable and significant across the region. A 2013 study on Tunisia found that informal cross-border trade was equivalent to more than half of its official trade with Libya, and more than its entire official trade with Algeria [7].

Similarly in Iran, the size of smuggling in 2007 was estimated to lie in the broad range of 6-25% of total trade [8]. Meanwhile a study for the Algeria-Mali corridor suggests that formal trade pales in comparison to the thriving informal trade across the border [9]. An interesting observation made by United Nations is that for all ICBT activities, women are the dominant players particularly in Africa, Latin America and Asia [10]. Surveys have shown that women constitute between 70 to 80% of people that are engaged in informal cross - border trade [11] dealing in all sorts of merchandize while others offer services. This confirms Hoyman (1987) study which noted that the involvement of women in informal work was nearly doubled compared with men since 9175.

In Sub-Saharan African many women are involved in informal intra-trade cross border trade [10]. Within the Southern Africa Development Cooperation, women comprise about 70 % of those involved in ICBT while in Western and Central Africa nearly 60% of informal traders are women [12]. In Zimbabwe, women constitute 85 percent of the traders [13]. In the Great Lakes region, Titeca and Kimanuka [14] estimate that 85 percent of small-scale traders involved in ICBT in Goma-Gisenyi (DRC-Rwanda) Bukavu-Cyangugu (DRC-Rwanda) Uvira-Gatumba (DRC-Burundi) and Aru/Ariwara-Arua (DRC-Uganda) borders are Women. Among ECOWAS member states ,women have been reported to be the major players in ICBT at 80 % between Sierra-Leone northern border and Guinea at Gbalamuya and with southern border with Liberia at Gendema (Bo-waterside) facilitated by Chata men (Middlemen) who are powerful than the border officials(Vanessa et.al). In Ghana, cross-border trade has a gender dimension in that women are more actively involved in trading across borders than men and are present at all levels of operation with Togo ,Nigeria and Bukina-Faso [15]. Ousmanou [16] study of ICBT among Central African Economic and Monetary Community members concluded that women were the largest participants in this trade various borders such as Ambam, Abang-Minko’o (Camerron-Gabon), at Limbe and Kousseri (Cameroon-Nigeria) and ,Kye’-Ossi (Equitorial Guinea).

In East Africa Community informal cross border trade has a gender dimension and women are slightly more than Men [17]. The EAC (2019), survey noted that a proportion of informal cross border traders among traditional founders of the block (Kenya, Uganda and Tanzania) are women in spite of the efforts to promote formalization of trade in the region [17].

Informal trade is an integral part and unrecognized component of Africa’s economy which has persisted despite the effort to graft it into formal economy globally [18]. The World Bank recommends that all intra-trade should be formalized for states to realize the existing benefits. However, this is not the case in EAC where informal cross border trade accounts for 40% of intra-trade share with women being the majority participants at more than 80% [19]. The dangers of ICBT to states includes the fact that at times the informal imports present unfair competition to domestic industries, products traded informally are often counterfeit goods sold at lower prices, not subject to import taxes, and simply cheaper than locally manufactured equivalents and also represents a significant revenue loss for governments [12]. Many studies focus on impacts of cross border trade in RECs, others on nature and trends [20] limited analysis have focused on drivers of women into informal cross border trade. This paper therefore intends to examine drivers of women into informal cross border trade between Kenya and her neighboring partner states of Uganda and Tanzania).

Conceptualization of Informal Cross Border Trade

The term informal trade first appeared in a report of the International Labour Organization (1972) and then in an article by Hart [21], an anthropologist who had worked in Ghana and Kenya [22]. Attempts at defining ICBT have not been universally conclusive. However, much thinking has gone into this and not only in the context of Africa but a definition that could be universally applied. Lesser and Moisé-Leeman study [23], construe’s ICBT “as trade in legitimately produced goods and services, which circumvents the regulatory framework set by the government and as such avoiding certain tax and regulatory burdens” [23]. Comparably, Afrika and Ajumbo [12] could not agree less with Lesser and Moisé’s understanding of ICBT by referring to it as “trade in processed or non-processed merchandise which may be legal imports or exports on one side of the border and illicit on the other side and vice-versa, on the account of not having been subjected to statutory border formalities such as customs clearance” [12].

Schneider [24] categorized informal cross border trade in three broader areas that can be practiced by formal or informal traders and companies with varied practices as highlighted in Table 1 This Categorization is helpful in measurability of informal cross border trade. Majority of women informal cross border traders operates under category A, which primarily evades payments of charges, duties, other related transactional costs and regulations prescribed by the government and on account of measurability it is the easiest. Informal cross border trades are.

Informal Cross Border Trade Trends Between Kenya and Her Neibouring Countries of Uganda and Tanzania.

The East African Community (EAC) was founded in 1967, dissolved in 1977, and revived with the Treaty for the Establishment of the East African Community signed in 1999 by Kenya, Uganda and United Republic of Tanzania. Burundi and Rwanda became members in 2007 while South Sudan gained accession in April 2016. Known to be the best performing REC in Africa with 22% intra-trade share, EAC is home to more than 177 million citizens, of which over 22% is urban population, with a land area of 2.5 million square kilometers and a combined Gross Domestic Product of US$ 193 billion (EAC Statistics for 2019). Kenya’s GDP (US$70.5) accounts for almost half of the EAC GDP in 2019, followed by Tanzania (US$47.4) and Uganda (US$25.5). Additionally, the share for intra-trade between these Countries accounts for more than half the total trade shares in the sub-region. In 2018, East African Community trade and investment report showed that the total share of export from Kenya to Uganda accounted 39.5%, while Tanzania was at 19.3%.Similary exports from Uganda to Kenya accounted to 46% while from Tanzania stood at 48% of the total share of export (EAC 2018).

Despite impressive data on the share of export between Kenya, Uganda and Tanzania respectively, a significant proportion of cross border trade is conducted informally at about 40% of the total intra-trade share with women being the major players at around 80% (EAC, 2019). Survey from Uganda in 2018 survey showed that Kenya was Uganda’s main source of informal imports representing 41.6% with goods worth US$ 25.0 million. Similarly, this survey showed some gender dimensions with women being the majority. Meanwhile Busia border was the leading entry point for informal imports with an import bill of US$15.7 million (26.2 percent) with Industrial products/goods like building materials, petroleum products, utensils, beer, and soft drinks constituting the largest informal import from Kenya to Uganda [25]. Correspondingly, Uganda’s Informal export to Kenya represented 27.4 percent of the total informal exports amounting to US$ 150 million in 2018 which seen a marginal reduction from 36.3% in the previous year. Main exported commodities on an informal basis included; Shoes, Clothes (New & used),Fish, Beans ,Maize flour, Sandals, Hair synthetic, Eggs, Bread, Bags, Sorghum grains, Cattle, Polythene bags, Bed sheets, Mattresses, Tomatoes, Goats, Fruits and Suitcases (EAC,2018).

According to Kenya National Bureau of Statistics of 2011(The most recent report on informal cross border trade by Kenya Government), compared to other neighboring countries, Kenya’s total unrecorded informal export trade with Tanzania was highest, valued at Ksh 1,447.4 million, during the second quarter of 2011. The informal exports and informal imports were Ksh 909.8 million and 537.5 million, respectively, in the same period. The industrial products worth Ksh 825.9 million dominated Kenya’s informal exports to Tanzania. The agricultural and industrial import products from Tanzania were valued at Ksh 262.6 million and Ksh 250.3 million, respectively, during the second quarter of 2011. The leading agricultural informal exports to Tanzania were Irish potatoes and coconuts. Under industrial products category, the main exported commodities to Tanzania comprised building materials (paints, iron sheets, cement, steel bars, ceiling boards and nails), utensils, beer, soft drinks, margarine, wire wares, plastic buckets and basins and bread. Dry maize, onions, rice, fruits (oranges) and fish were the main imported agricultural products from Tanzania, under unrecorded informal trade during the second quarter of 2011. The leading imported industrial products from Tanzania were artificial flowers, gas, maize flour and articles of apparel and clothing accessories.

Kenya National Bureau of Statistics pointed out that ICBT propelled by women was highest in Isebania, Namanga and Taveta with informal export amounting to 778 million, 17.3million and 88.4 million accounting to 52%, 1.6% and 6% share of export from Kenya to Tanzania. Similarly, value of imports from Tanzania to Kenya was at 283.2 million - Namanga border, 116.3 million-Taveta Border and 44.4 million-Isebania accounting for 22%, 9% and 3.5% total share of imports [26]. Gor [27], also noted that Kenya’s informal imports from Tanzania are mainly agricultural food commodities and Fish. Maize is the leading item followed by beans, fish and rice. Others include yams, carrots, tomatoes, cassava, cabbages, cow peas, sugar, rice, bananas, millet, maize meal and groundnuts. Kenya’s agricultural food exports to Tanzania include wheat flour, bread, root crops, sugar, rice, bananas, maize meal, milk and coffee. Most agricultural commodities traded are largely influenced by the food items grown around the border and in the neighboring areas.

Most participants in informal cross border trade between Kenya/Uganda and Kenya/Tanzania are individual traders, a large proportion of which are women and micro, small and medium sized enterprises [23]. Women involvement in ICBT consequently has a great contribution in deepening regional trade and integration. Perhaps it will be important to find out what drives these women into informal cross border trade despite adoption of customs union and common market by members of EAC which were meant to ease formalization of trade.

Scope of the Study

This study primarily focused on examining women in informal cross border trade of the traditional East African Community. The borders under the study are; Isebania and Namanga on kenya-Tanzania borders and Busia on Kenya-Uganda border.

Methodology

This is purely desk research which used the already documented literature analytically to arrive at the logical conclusion on the subject under the study.

and Tanzania

Drivers of women involvement into ICBT can be classified into two broad categories: Cultural and Socio-Economic factors as explained below

Cultural Factors

There has been a long tradition of movement of people back and forth in the open border area for purchasing daily consumer goods and for business purposes which is a common phenomenon globally [28]. These have been facilitated by common and understandable language, cultural similarities, family relations and trust across the borders. Cultural relations build strong links and cooperation between neighboring nations. Informal trans-border trade often reflects longstanding relationships and indigenous patterns, which often pre-date colonial and postcolonial state boundaries. Cross-border trade is often conducted among people of the same clan or ethnicity group (e.g., Trans-border trade between Kenya, Uganda and Tanzania). The communities spread along the territorial boundaries share a lot in common both culturally and socially. They speak the same or similar languages, they inter-marry and own land on either side of the borders. This alone provides an incentive to these communities to engage in trade to exploit available opportunities on either side of the border [29].

In addition, East African region, trade has thrived due to Kinship ties among the Luos and Kuria in Mara region of Tanzania and the Southern Western Kenya [30,31]. Similalry, Ayot [32] notes that trade along the Kenya -Uganda borders have always thrived due to the surrounding Teso communities. Women have always used these kingship ties to enhance informal cross border trade in EAC [32]. Communities have always resisted any attempt to stifle their cultures. Parallel trade or ICBT can be seen as a form of indigenous resistance to the imposition of colonial borders and metropolitan economic regulations on traditional African economic and social formations [33].

Socio-Economic

Social economic factors are many and divers as discussed below

ICBT and Household Income

Informal cross-border trade supports livelihoods, particularly in remote rural locations. It creates jobs, especially for vulnerable groups such as poor women and unemployed youth, and it contributes to food security in that it largely features raw agricultural products and processed food items (World Bank, 2014). Moreover, the income they earn from these activities is critical to their households, often making the difference, for example, in whether children go to school or not or seek medication. Women’s income from trading activities is of particular importance to households where the spouse in not employed and helps explain the high tolerance for the difficulties that they face in crossing the border [1].

A few studies have shown the ability of ICBT to reduce poverty or empower women. According to Schneider [24], ICBT is a poverty reduction venture because an increase in women’s incomes tends to collate with greater expenditure on children and family welfare, unlike similar increases in the incomes of men. Furthermore, Gerald and Rauch [34] observed that ICBT provides specific opportunities for the empowerment of women through the development of informal and formal sector retail markets, the creation of employment opportunities and provide access to some capital thereby creating an opportunity to alleviate poverty. These traders play a key role in food security, bringing basic food products from areas where they are relatively cheap to areas where they are in short supply.

Regulatory Barriers

African cross border traders, especially women, are constrained by such issues as high duty and tax levels, poor border facilities, cumbersome bureaucracies, lengthy clearance processes, weak governance at the border, lack of understanding of the rules, and corruption. Moreover, cross-border traders face other difficulties before even reaching the borders, such as problems with registering their businesses, securing capital and assets, or increasing the quality and quantity of the products they trade. According to Limao and Venables (2001), Trade Transaction Costs (TTCs) in intra-Sub-Saharan Africa trade are substantially higher and more obstructive than those for other African countries due to the relatively low efficiency of customs procedures and institutions in the region. In fact, perishable agricultural and food products are often subject to additional trade-related procedures which are meant to ensure compliance with sanitary and phyto-sanitary requirements.

Lesser C and Moisé-Leeman E [23] observed that on average, Africa has the longest customs delays in the world. Consignments commonly experience substantial and unpredictable delays of 30 to 40 days before release from customs control. Not only are the delays long, but they are also costly. Recent OECD in 2003 work also emphasizes that the barriers to formal South-South trade, including intra-regional trade in Sub-Saharan Africa, are often more important than barriers to North- South or North-North (formal) trade (Kowalski and Shepherd, 2006). These lengthy and cumbersome processes lead to a considerable increase in border process fees and clearance times per consignment, hence leading to informal cross border trade.

Additionally, another factor that can further facilitate informal cross-border trade is the weak enforcement of laws and regulations, the arbitrary application of trade-related regulations and the pervasiveness of corruption at borders [35]. On the other hand, the arbitrary application of regulations and the quasi-automatic requirement of facilitation payments bribes (Kitu Kidogo) at some border points might incite some traders to engage in illegal practices such as under- invoicing and/or pass through other, sometimes unofficial routes and crossings, to avoid having to disburse such payments. It has been observed that corruption is still one of the most important obstacles to doing (formal) business on the continent and East Africa in particular [36].

Beyond the costs they bear, regulatory requirements are sometimes also unknown or unclear to traders. In recent surveys and workshops conducted in the East African Community (EAC) and for example, traders have consistently cited lack of information on regulatory requirements (e.g., quality standards, customs documents and procedures and certificates of origin and conformity) as a key constraint towards formal cross-border trade in the region. A recent EAC report for example notes that the lack of information on regulation compels many traders to engage in unrecorded trade across the border (EAC, 2019).

Gender Inequalities

The female predominance in informal cross-border trade is often attributed to women’s time and mobility constraints, as well as to their limited access to productive resources and support systems, making such trade one of the few options available to them to earn a living [37]. Women who are informal traders typically have no or limited primary education and rarely have had previous formal jobs. If married, they seldom receive contributions from their husbands to start business operations. Similarly, gender norms restricting women’s mobility, access, and control over resources and decision-making within the household impact how women participate in ICBT.

In spite of the significant role women play in the economy, they grapple with many disadvantages including limited access to land, financial services, information, technology, and training services, all as a result of gender disparities in rights, the gender-differentiated impacts of neo-liberal restructuring, and the erosion of kin-based support networks through migration [38]. Insufficient attention to gender analysis has meant that women’s contributions and concerns remain too often ignored in financial markets and institutions, trade systems, labour markets, economics as an academic discipline, economic and social infrastructure, taxation and social security systems, as well as in families and households. These factors are enables for women involvement into ICBT [39-45].

Summary of Findings

The paper founded that women are the major players involved into informal cross border trade. Women are driven into informal cross border trade due to cultural reasons like historically shared border areas, common language and kinship ties which have deepen trade links. It is noted also that the desire to reduce poverty and improve household income to support livelihood e.g., food, education and medication have pushed women into informal cross border trade. Moreover, restrictive measures such issues as high duty and tax levels, poor border facilities, cumbersome bureaucracies, lengthy clearance processes, weak governance at the border, lack of understanding of the rules, and corruption facilitate women participation into ICBT. Finally, gender inequality notably lacks proper education, denial of property rights which can be used to credit, housekeeping roles, inadequate information and restrictive gender norms have limited women’s involvement into formal cross border trade [46-50].

Conclusion and Recommendations

Women have become so synonymous with informal cross border trade. This paper concluded that the drivers of women into informal cross border trade are but not limited to:

• Common and understandable language, cultural ties, family relations and trust across the borders which have built strong trade links;

• Ability of ICBT to help in improving household income aimed at supporting livelihood and alleviating poverty;

• Gender inequality which has denied women socio-economic opportunities thereby pushing them to ICBT and,

• Restrictive measures increase Trade Transactional Cost (TTC).

In conclusion women are involved in cross border trade due to Cultural, social, and economic factors. The paper recommends that an empirical study involving field visit should be done to widely understand Women involvement into informal cross border trade in East African Community. Additionally, policy makers should look into possible ways of addressing the barriers to women involvement formal cross border [51,52].

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