Prevalence of types of bone disease as determined by bone biopsy in patients with CKD-MBD.
\r\n\tThis book will be a self-contained collection of scholarly papers targeting an audience of practicing researchers, academics, PhD students and other scientists. The contents of the book will be written by multiple authors and edited by experts in the field. The area of interest and scope of the project can be described with (but are not limited to) the following keywords: Alcoholism, Depression, Addiction, Blackouts, Relapse, Binge Drinking, Genetic basis, Neurological Aspects, Treatment, Organ Damage.
\r\n\r\n\tAuthors are not limited in terms of topic, but encouraged to present a chapter proposal that best suits their current research efforts. Later, when all chapter proposals are collected, the editor will provide a more specific direction of the book.
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"61807",title:"The Bone and Mineral Disorder in Patients Undergoing Chronic Peritoneal Dialysis",doi:"10.5772/intechopen.75131",slug:"the-bone-and-mineral-disorder-in-patients-undergoing-chronic-peritoneal-dialysis",body:'\nChronic kidney disease (CKD) is a global public health problem affecting 5–10% of the world population [1]. Disorders of bone and mineral metabolism and vascular calcification have been identified as major risk factors for cardiovascular morbidity and mortality in patients with CKD. In the course of CKD appears a reduction in the ability of the kidney to excrete an adequate load of phosphate which leads to hyperphosphatemia. At the same stages of CKD in which phosphorus retention appears to occur, we are faced with calcium retention too. The main hormones and factors that contribute to the kidney regulation of phosphorus and calcium include parathyroid hormone (PTH), fibroblast growth factor 23 (FGF-23), klotho and 1,25-dihydroxyvitamin D (1,25(OH)2D). It is now accepted that the increase in FGF-23 is an early event in the pathogenesis of mineral disorders in CKD. FGF-23 levels increase early in CKD, and may reflect an increased phosphorus load. This adaptive change favors the reduction of kidney 1-alpha-hydroxylase, which in turn results in lower levels of the active form of vitamin D 1,25(OH)2D3, decreasing intestinal calcium absorption and allowing a decrease in serum calcium. These changes allow increased PTH synthesis and its release. High level of PTH increases bone turnover and bone resorption, stimulates 1-alpha-hydroxylase, and increases phosphorus removal through reducing its kidney tubular resorption. Although FGF-23 and PTH having synergic effects regarding phosphorus removal, they have opposite effects on 1,25(OH)2D3 synthesis by inhibiting or stimulating 1-alpha-hydroxylase, respectively. During late Stage 4 CKD and into end-stage renal disease (ESRD), all these mechanisms become insufficient and most patients show hyperphosphatemia, high PTH, marked elevations of FGF-23, and reductions of klotho and 1,25(OH)2D3 [2, 3, 4]. All these changes together are critically important in the regulation of both initial bone formation during growth (bone modeling) and bone structure and function during adulthood (bone remodeling) [5]. High serum phosphorus was considered the most important uremia-related, non-traditional cardiovascular risk factor so controlling hyperphosphatemia was considered one of the most important goals in managing bone disorders in CKD patients [1].
\nEffective dietary phosphate restriction has resulted difficult in clinical practice so the use of phosphate binders has become the mainstay of efforts to decrease phosphate absorption from the intestine. The generalized usage in the past of aluminum-containing phosphate binders and calcium-containing phosphate binders was reported to be associated with increased incidence of adynamic bone disease (ABD) [6]. The mineral and hormonal changes in CKD patients go beyond bone alterations and are responsible for systemic consequences such as vascular calcification [1]. These changes have a major impact on morbidity and mortality [7] and consequently their control is of great importance in CKD patients. This chapter is a review that briefly discusses etiology, pathophysiology diagnosis of mineral bone disorders in chronic kidney disease patients on treatment with peritoneal dialysis and therapeutic options.
\nDisorders of mineral metabolism and bone disease are common complications in CKD patients. They are very complex and involve a number of feedback loops between the kidney, bone, intestine, and the vasculature. These are associated with numerous adverse clinical outcomes, in particular cardiovascular disease and increased fracture risk [8] which contributes in an increased morbidity and mortality and decreased quality of life of the patients [3].
\nThe work group of the kidney disease: Improving Global Outcomes (KDIGO) recommended in 2006 the use of the term chronic kidney disease-mineral and bone disorder (CKD-MBD) to describe a systemic disorder that incorporates these abnormalities [9]. These systemic disturbances may manifest themselves by the presence of any one or a combination of the following three conditions: (1) laboratory abnormalities of calcium, inorganic phosphorus, PTH or vitamin D; (2) bone abnormalities in turnover, mineralization, volume, linear growth or strength, and (3) calcification of the vasculature or other soft tissues [8].
\nThe work group recommended that the traditional term “renal osteodystrophy” be exclusively used to define alterations in bone morphology associated with CKD and stated that definitive diagnosis of renal osteodystrophy can only be made by bone biopsy [1].
\nIt is well known that the traditional types of renal osteodystrophy have been defined on the basis of turnover and mineralization, with substantial differences in pathophysiology and treatment.
Bone turnover and bone volume may both be classified as high, normal or low.
Bone mineralization may be categorized as normal or abnormal.
In this way, it was suggested that bone biopsies in patients with CKD should be characterized by determining bone turnover (T), mineralization (M), and volume (V) (the TMV system) [9].
\nSix types of bone disorder are distinguished in the CKD-MBD complex [9]: hyperparathyroid bone disease (high turnover, normal mineralization, and any bone volume); mixed bone disease (high turnover with mineralization defect and normal bone volume); osteomalacia (low turnover with abnormal mineralization and low-to-medium bone volume); ABD (low turnover with normal mineralization and low or normal bone volume); and two distinct disorders due to specific causative agents, namely, amyloid bone disease and aluminum bone disease [10].
\nWhile the majority of studies focusing on CKD-MBD in dialysis patients involved hemodialysis (HD) patients, relatively few studies involving peritoneal dialysis (PD) patients have been published [1, 10]. It has been argued that features of CKD-MBD differ between patients undergoing PD and HD, secondary hyperparathyroidism remains the most common pattern in HD patients, and adynamic bone disease was more frequent in patients on PD [1]. This is based on a systematic review which analyzed studies carried out between 1983 and 2006 (Table 1). These findings strengthened the worldwide belief that PD is an important risk factor for ABD development.
\n\n | PD | \nHD | \n
---|---|---|
Adynamic bone disease | \n50% | \n19% | \n
Mild disease | \n20% | \n3% | \n
Osteitis fibrosa | \n18% | \n34% | \n
Mixed bone disease | \n5% | \n32% | \n
Osteomalacia | \n5% | \n10% | \n
Normal bone histology | \n2% | \n2% | \n
Prevalence of types of bone disease as determined by bone biopsy in patients with CKD-MBD.
ABD was first described in association with aluminum overload, being in the past the major cause of this bone lesion [11]. Aluminum deposition along the calcification fronts prevents the mineralization process and also inhibits the deposition of osteoid by directly damaging the osteoblasts [12].
\nAlthough there is a large difference between current and past clinical practice and patient characteristics regarding PD treatment (common use of aluminum- and calcium-based phosphate (P) binders, or PD modality mainly for elderly patients), in recent studies, bone histomorphometry persists to reveal lower turn-over parameters and worst mineralization in peritoneal dialysis patients when compared to hemodialysis ones [13, 14].
\nOver time, it became apparent that adynamic bone or low bone formation exists without aluminum overload and became associated with abnormal calcium balance, the low levels of 1.25 dihydroxyvitamin D, metabolic acidosis, in addition to low levels of estrogen and progesterone, and systemic inflammation. It is referred to be linked with calcific arteriolopathy and cardiovascular disease (CVD) [15, 16].
\nThere are a lot of specific factors which are reported to contribute in the pathogenesis of ABD in peritoneal dialysis:
Accumulation of advanced glycation end products (AGEs) proteins reported in diabetes was also observed in PD patients. This happens during heat sterilization of PD conventional fluids, where glucose is degraded into products that include reactive carbonyl compounds [17]. Serum from uremic patients was also shown to contain high levels of these compounds derived not only from carbohydrates but also from lipids. The generation of high quantities of AGEs and advanced lipid end products modify bone matrix and participate in the processes which lead to the development of ABD [18]. In addition of elevated AGEs, PD patients have impaired glucose tolerance and high glucose levels during explosion to high glucose concentrations. High glucose levels were reported to inhibit bone mineralization in vitro by preventing calcium uptake by bone cells [19], a finding that could further support the altered bone structure in diabetic patients.
High levels of calcium and magnesium found in dialysate. High magnesium concentrations may inhibit parathyroid hormone secretion just as high calcium concentrations do [20], being involved in the pathogenesis of adynamic bone in PD patients [21].
Sclerostin is another factor with impact on ABD in PD patients. Sclerostin is a glycoprotein (22 kDa) product of the SOST gene in osteocytes, which leads to a negative regulation of bone formation by inhibiting differentiation and proliferation of osteoblasts. Recent investigations, demonstrated that increased plasma levels of sclerostin, were found to be associated with reduced bone turnover and osteoblast proportion in dialysis patients [14, 22].
In PD patients, we are faced with high prevalence of hypoalbuminemia which came as a result of loss through the peritoneal membrane or malnutrition. It is reported that low level of albumin contributes to the development of ABD by reducing the plasma level of PTH. Serum intact PTH has been shown to positively correlate with serum albumin in PD patients [23].
The relationship between low PTH level, ABD, increased fracture risk [24], and vascular calcifications may at least partially explain the association of ABD with increased mortality rates. To achieve optimal bone and cardiovascular health, attention should be focused not only on classic control of secondary hyperparathyroidism but also on prevention of ABD, especially in the steadily growing proportions of diabetic, white, and elderly patients in PD [25].
\nIt is generally accepted that the accumulation of phosphorus appears to begin in CKD Stage 3b and contributes to secondary hyperparathyroidism [3]. Persistent stimulation of the parathyroid glands by elevated extracellular phosphorus concentrations, especially when is accompanied by decreased extracellular ionized calcium concentrations, and markedly reduced serum calcitriol levels leads to increased parathyroid hormone (PTH) production [26]. This promotes diffuse polyclonal hyperplasia followed by monoclonal nodular hyperplasia, decreases the levels of calcium-sensing receptor and vitamin D receptor, lowering the activity of 1-alpha-hydroxylase and consequently decreases serum 1,25(OH)2D3 levels [27].
\nIn severe hyperparathyroidism, hyperphosphatemia may be worsening via phosphorus efflux from the skeleton compromising its phosphorus reserve capacity. On the other side, in low bone turnover, the size of the exchangeable calcium and phosphorus pool is reduced and also is drastically reduced the buffer capacity of the skeleton for the excess of phosphorus. In this way, hyperphosphatemia links vascular calcification with low bone turnover.
\nPhosphate excess also has reported to be linked with endothelial dysfunction [28] and elevated FGF23, which contributes to left ventricular hypertrophy [29], being so an independent risk factor for mortality in ESRD [2].
\nPhosphate enters the body by intestinal absorption and is excreted through stools and dialysis fluids (plus urine output in patients with residual renal function). In dialysis patients, elimination of the inorganic phosphate by dialysis is a cornerstone of the management of hyperphosphatemia. The elimination characteristics of phosphate in HD and PD are unlike the urea and other low molecular weight toxins much more similar to those of typical middle molecules although the molecule is only 96D. This is explained with its negative charge, the aqueous cover that increases its effective molecular weight, and the slow intra/extracellular solute transfer rate [30].
\nIn the case of daily dialysis or long nocturnal dialysis, P mass removal is usually large enough to reduce the need of dietary restrictions and the use of P binders. It does not happen in the case of well-nourished patients on standard three-times-a-week dialysis schedule, where to achieve a good P balance is needed an optimal dialysis removal, careful use of phosphate binders, and dietary P control [31].
\nSome studies suggest that continuous PD may be better in controlling hyperphosphatemia than intermittent hemodialysis [32, 33, 34, 35]. This observation supports thesis that PD provides better phosphorus clearance through better preservation of renal failure and its continuous nature.
\nAt the start of PD therapy, residual renal function (RRF) may contribute up to 65% of total phosphate clearance [30, 35]. Urinary phosphate excretion is found to highly correlate with residual renal function and also a strong correlation between RRF and serum phosphate concentration on PD has been reported [32, 35]. It is well known that RRF declines with time on PD and the effect of this decline on phosphate homeostasis has been described in a few observational studies [34, 36, 37]. Phosphate removal is shown to correlate strongly with residual renal function, but it is dissociated from peritoneal Kt/V urea, creatinine clearance, and net ultrafiltration. Peritoneal creatinine transporter status and creatinine clearance cannot be used as surrogate markers of peritoneal phosphate transport and clearance. Prescription of high volume of dialysate is one of the strategies recommended to increase P removal in anuric patients [30]. Hyperphosphatemia is more frequent in patients with low transporter status, so they may achieve higher peritoneal P clearance under continuous ambulatory peritoneal dialysis (CAPD) regimens. In automated peritoneal dialysis (APD), hyperphosphatemia has been significantly associated with a lower number of automated peritoneal dialysis (APD) cycles and a shorter duration of nocturnal treatment, with insufficient dwell time. Here, recommended strategies to improve P management are increasing dwell times or transfer to CAPD [37]. Recently, Van Biesen et al., confirmed that for slow transporters, longer dwells resulted in higher peritoneal phosphate clearances, whereas for high transporters, shorter dwells were more optimal [38].
\nFGF23 is a circulating peptide that plays a key role in the control of serum phosphate concentrations [4, 39]. It is secreted by bone osteocytes and osteoblasts in response to calcitriol, increased dietary phosphate load, PTH, and calcium [40, 41]. In CKD patients, we are faced with high level of FGF23 due to its decreased clearance too [4]. FGF23’s primary function is to maintain normal serum phosphate concentration by reducing renal phosphate reabsorption and indirectly by decreased calcitriol production [42]. FGF23 inhibits the proximal tubular expression of 1-alpha-hydroxylase enzyme, leading to decreased calcitriol synthesis [43]. The net effect of both hormonal actions is to lower serum phosphate concentration. Increased FGF23 is considered as one of the earliest detectable biomarkers of CKD-MBD [44]. Is important to underline that treatments used to control CKD-MBD, such as vitamin D analogs and calcium-based phosphate binders, stimulate FGF23 production.
\nFGF23 also suppresses PTH secretion by the parathyroid gland [45]. Klotho expression declines progressively with decreasing GFR. Moreover, the decrease in klotho expression on hyperplastic parathyroid glands may contribute to the resistance and impaired parathyroid suppression by FGF23 [46].
\nIn the PD patient population, data on FGF-23 are scarce. In a study by Isakova et al., the authors reported that longer dialysis vintage (R = 0.31), lesser RRF (R = −0.37), and lower renal phosphate clearance (R = −0.38) were associated with higher levels of serum FGF-23 [47]. Golembiewska et al. in her study highlights the strong positive association between serum phosphorus and FGF-23 in patients at the start of PD therapy independently from RRF [48]. It is suggested that FGF23 is a more stable marker of phosphate metabolism than PTH or phosphate itself, which could help explain its stronger association with outcomes and support the further development of FGF23 testing for clinical practice [47].
\nFGF23 levels are associated with increased risk of cardiovascular disease and mortality in patients with CKD [47]. Clinical and experimental studies have shown that FGF23 has a direct pathogenic effect causing left ventricular hypertrophy [29]. However, FGF23 does not seem to promote cardiovascular calcification [49].
\nPeritoneal dialysis (PD) patients have a high risk of developing vitamin D deficiency as 25(OH) vitamin D and the precursor of active vitamin D is lost during dialysis, apart from low exposure to sunlight and reduced dermal synthesis.
\nPlasma calcitriol concentrations generally fall below normal when the GFR is <60 mL/min/1.73 m2 [8]. This initially happens due to the increase in FGF23 concentration rather than the loss of functioning renal mass [50]. However, further with the advanced CKD, hyperphosphatemia in addition to increased FGF23 levels contribute to the decline of calcitriol synthesis.
\nFGF23 decreases the synthesis of calcitriol by suppressing the activity of 1-alpha-hydroxylase, which converts 25-hydroxyvitamin D into calcitriol, and by stimulating the 24-hydroxylase enzyme, which converts calcitriol (1,25-dihydroxyvitamin D3) into inactive metabolites in the proximal tubule [43, 51]. Phosphate retention (or perhaps increased phosphate concentrations in the proximal tubule) can directly suppress the renal synthesis of calcitriol by inhibiting 1-alpha-hydroxylase activity [52]. Increased dietary phosphate load and increased calcitriol stimulate the secretion of FGF23 predominantly by bone osteocytes.
\nLow calcitriol concentrations increase PTH secretion by indirect and direct mechanisms:
Indirect effects on PTH are achieved through decreased intestinal absorption of calcium and calcium release from bone, both of which promote the development of hypocalcemia, and hypocalcemia stimulates PTH secretion.
Calcitriol normally acts on the Vitamin D Receptor (VDR) in the parathyroid gland to suppress PTH transcription but not PTH secretion. A decrease in calcitriol concentrations lowers the number of VDRs in the parathyroid cells. This is reported that can be corrected by taking supplementation with calcitriol [53]. The lack of calcitriol and the decreased number of receptors may promote both parathyroid cell hyperplasia and nodule formation. At a later stage of CKD, we have also the contribution of retained uremic toxins, by decreasing both receptor synthesis and the ability of the active hormone-receptor complex to bind to vitamin D response elements in the nucleus [54].
In CKD, the skeletal resistance to the calcemic action of parathyroid hormone (PTH) is reported to contribute to the pathology of secondary hyperparathyroidism [55] due to downregulation of PTH receptors induced by the high circulating PTH concentrations; calcitriol deficiency and hyperphosphatemia [3, 56].
\nStudies have suggested that disorders of calcium balance due to CKD-MBD may play a role in the high cardiovascular mortality in patients with CKD.
\nA positive calcium balance may arise, because the intestinal absorption of calcium overcomes the capacity of the diseased kidney for its excretion. The absorbed calcium enters in the extracellular space and is distributed in three compartments: blood, soft tissue, and bone. Bone contains 99% of total calcium being the major compartment of body calcium. It includes mineralized bone sites suggested to be partly mediated by PTH and a rapidly exchangeable calcium pool. The regulation of this exchangeable calcium pool might be altered in CKD.
\nThe assessment of calcium balance in dialysis patients (including PD patients) becomes extremely complex. It has to take into account not only dietary calcium intake, but also calcium supplement dose, intake of vitamin D analogs (which increase intestinal calcium absorption), calcium uptake by soft tissue, stool calcium output, urinary calcium excretion, continuous calcium flux from the rapidly exchangeable calcium bone pool, and net bone remodeling or turnover, also influx from PD fluid across the peritoneum membrane if a high-calcium dialysate is used as a result of the concentration gradient or efflux of it when is used lower dialysate calcium [57].
\nBoth hypocalcemia and hypercalcemia are associated with increased mortality in patients with CKD [7, 58].
\nHypocalcemia is common among CKD patients and may be associated with increased PTH secretion and abnormal bone remodeling. Ca is a major regulator of PTH secretion. Minute changes in the serum ionized Ca are sensed by a specific Ca membrane receptor (CaSR), which is highly expressed on the surface of the chief cells of the parathyroid glands [59]. Changes in PTH secretion in response to serum Ca are tightly regulated by the CaSR. The fall in serum Ca concentration in CKD, as sensed by the CaSR, is a potent stimulus to the release of PTH. When Ca level goes persistently low, it appears to directly increase PTH mRNA concentrations via posttranscriptional actions and stimulates the proliferation of parathyroid cells over days or weeks [60].
\nA positive calcium balance, hypercalcemia, inhibits the secretion of PTH and stimulates the development of adynamic bone disease in patients undergoing PD. The risk of protein energy wasting (PEW), often referred as malnutrition, is higher especially in the elderly PD patients. This is associated with reduced bone mass [61] and increase fracture risk in this population [1, 62]. In addition, hypercalcemia has been implicated in the pathogenesis of extraskeletal calcification and is evaluated as an important factor in progression of calcification.
\nIn the last decades, although the number of peritoneal dialysis (PD) patients is increased, most of the studies related to vascular calcification development are mainly focused on HD population. The prevalence of cardiac valvular calcification is reported to be high in both modalities, ranges from 32–47% in PD patients [1, 63] to 19–84% in hemodialysis patients [64, 65] and greatly contribute on high cardiovascular mortality in this population [2, 66, 67, 68].
\nRecent studies suggest that vascular calcification is a process that involves more than simple precipitation of calcium and phosphate. A complex series of events causes predisposed vascular smooth muscle cells to differentiate into osteoblasts or bone forming cells. Chronic inflammation is one of the predisposing factors too. Serum fetuin-A, which is a potent inhibitor of extraskeletal calcification, is reduced in CKD patients with severe vascular calcification. A list of contributing factors in vascular/valve calcifications in PD is present in (Table 2).
\nUremic toxins | \n
Older age | \n
ABD | \n
Hyperphosphatemia | \n
Higher dose of Vit D analogs | \n
Higher dose of calcium-based phosphate binder | \n
Hypercalcemia | \n
Hypomagnesemia | \n
Diabetes | \n
Malnutrition, inflammation | \n
High level of sclerostin | \n
Low levels of fetuin-A | \n
Contributing factors to vascular/valve calcification in PD patients.
The increased prevalence of risk factors for atherosclerosis [69], disordered mineral metabolism with a high calcium load and/or uncontrolled phosphate resulting in poor calcium-phosphate balance, as well as the loss of inhibitors of calcifications are considered largely responsible for the higher prevalence of valve and vascular calcification in dialysis patients [70] compared to age- and sex-matched individuals without the evidence of renal disease [71].
\nThe treat-to-goal study revealed that after 3 years in dialysis, 83% of patients had vascular calcifications underlining the importance of the evaluation and control of all the parameters of CKD-MBD [68].
\nAs stated above, regarding bone metabolism and morphology, differences may exist between chronic hemodialysis and peritoneal dialysis treatment. These differences apart from preservation of renal function are mainly linked to deficiency of vitamin D, which is lost in peritoneal fluid and to and poor adherence to oral vitamin D therapy in PD [72]. The latest guideline with new recommendations was provided by KDIGO in 2017, in order to better reflect the complex interaction between CKD-MBD laboratory parameters [73]. It is important to emphasize that there are no separate or different recommendations for diagnostic workup in PD.
\nIn the above mentioned guidelines in CKD Grade 5 in Dialysis (G5D) [73], it is stated with a nongraded level of recommendation, that it is reasonable to base the frequency of monitoring serum calcium, phosphate, and PTH in the presence and magnitude of abnormalities. Guideline evaluated as reasonable measurement of serum calcium and phosphate every 1–3 months, PTH every 3–6 months, and alkaline phosphatase activity every 12 months or more frequently in the presence of elevated PTH. The guideline also had a very weak (2D level) suggestion that instead of calcium-phosphate (CaxP) product, values of serum calcium and phosphate, evaluated together should be used in clinical practice.
\nPTH is a hormone with high biological variation because of feedback control and its short half-life. For instance, 26 blood samples are required in hemodialysis patients to determine the individual homeostatic set-point (within 10%) [74]. In PD patients, it is confirmed the U-shaped curve association between mortality and PTH concentration [75].
\nAlkaline phosphatase. The use of total alkaline phosphatase (ALP) as a biomarker in CKD-MBD is considered limited by its nonspecificity for bone disease, as only approx. 50% of blood activity is attributable to bone ALP. In contrast to the U-shaped curve for mortality and time-averaged PTH confirmed in PD patients [76], higher ALP activity (even within high-normal ranges) was found to be more linearly and independently associated with increased all cause and cardiovascular mortality in this population [77, 78]. In studies reporting a relationship between ALP and mortality in hemodialysis patients, it has been implied that the relationship is driven by vascular calcification mediated by the bone fraction of ALP [79].
\nBone ALP is strongly and independently related to BMD, not accumulated with declining GFR and its concentration reflects directly osteoblastic activity [80], providing a “living biopsy” of bone activity. Most importantly, its biological variation is almost half that of PTH [81]. It is shown that higher b-ALP is an independent predictor of all-cause mortality in male HD patients [82] and high activities of b-ALP are strongly associated with cardiovascular mortality in dialysis patients, including PD population [83].
\n25(OH)D. Peritoneal dialysis (PD) patients have a high risk of developing vitamin D deficiency as 25(OH) vitamin D (the precursor of active vitamin D), is lost during dialysis. Vitamin D (25(OH) vitamin D) is measured to detect deficiency/insufficiency status. Defects of mineralization are presumably because of osteomalacia and hip fractures that associate its low levels [84]. Increase in mortality and hospitalization for patients on dialysis with severe 25-OH vitamin D deficiency was found [85] in a prospective cohort study. 2017 KDIGO guideline suggests (2C) in G5D patients, that 25(OH)D (calcidiol) levels might be measured, and repeated testing might be performed, determined by baseline values and therapeutic interventions.
\nIn order to facilitate the appropriate interpretation of biochemistry data, it is moderately strongly recommended (1B) that clinical laboratories inform clinicians of the assay method or any change in method used, sample source (plasma or serum), or any specific relevant information [73]. It is also recommended (1C) that therapeutic decisions to be based on trends rather than on a single laboratory value and to take into account all available CKD-MBD parameters [73].
\nParathyroid hormone (PTH) and total bone specific alkaline phosphatase (b-ALP) are biomarkers currently used in clinical practice despite some assay limitations. They may reflect bone turnover and bone formation. In an individual patient, no single biomarker or in combination is sufficient to diagnose low, normal, and high bone turnover although whole PTH, iPTH, and b-ALP levels are found associated with bone turnover. This was the conclusion of a recent cross-sectional retrospective diagnostic study of biomarkers and bone biopsies in 492 dialysis patients, with the objective to determine the predictive value of PTH [both intact PTH (iPTH) and total PTH], bone-specific alkaline phosphatase (b-ALP), and amino-terminal propeptide of type 1 procollagen (P1NP) as markers of bone turnover [86]. Rather than simple measurement of PTH, the continued use of trends in PTH is encouraged to guide therapy [73].
\nBMD testing. Identifying biomarkers and imaging test for non-invasive evaluation of patients at fracture risk is very important in dialysis patients, which in their 40s have a relative risk of hip fracture 80-fold that of age and sex-matched controls [87]. Multiple new prospective studies conducted in patients with CKD G3a-G5D demonstrated that lower dual-energy X-ray absorptiometry bone densitometry (DXA BMD) predicts incident fractures and the associations are comparable to the ones seen in the absence of CKD [76, 77, 78, 79, 88]. In the light of these studies, in patients with G5D with the evidence of CKD-MBD and/or risk factors for osteoporosis, KDIGO guideline has a moderately strong suggestion for performing BMD testing to assess fracture risk, if results will impact treatment decisions (2B level) [73]. A DXA BMD result might also impact the decision to perform a bone biopsy [73].
\nBone biopsy. In many centers, experience in performing and evaluating bone biopsies is limited [89]. In one side, DXA BMD does not distinguish among types of renal osteodystrophy. On the other side, (considering the short half-lives of the circulating biomarkers and the long (3–6 months) bone remodeling cycle), it is not surprising that cross-sectional studies have shown conflicting and non-conclusive data on the biomarkers use to predict underlying bone histology [89]. Biomarkers resulted of limited diagnostic use because of poor sensitivity and specificity. Although they correlate with some histomorphometric measurements in bone biopsy, studies have shown only modest positive predictive value of circulating PTH or bone-specific alkaline phosphatase levels for detection of states of high and low bone turnover, especially for adynamic bone disease [90, 91, 92, 93, 94].
\nBone biopsy is the gold standard for the assessment of renal osteodystrophy, which is a component of the bone abnormalities of CKD-MBD. Its goals are to determine high- or low-turnover disease, identify a mineralization defect (both influencing treatment decisions), and rule out atypical or unexpected bone pathology. When trends in PTH are inconsistent, or in patients with progressively decreased BMD despite standard therapy, with unexplained fractures, refractory hypercalcemia, suspicion of osteomalacia or an atypical response to standard therapies for elevated PTH, a bone biopsy should be considered [73]. In the recent KDIGO guideline, it is stated that it is reasonable to perform a bone biopsy, if knowledge of the type of renal osteodystrophy will impact treatment decisions [73]. The bone biopsy is undertaken with a trocar preferably in the iliac crest. Double labeling with tetracycline according to a protocol is required to assess the turnover.
\nBone turnover markers. During skeletal metabolic activity, bone turnover biomarkers are released into circulation and can be measured in the serum.
Serum marker of bone resorption in which levels are not dependent in GFR (not renally cleared) is serum tartrate-resistant acid phosphatase (TRAP5b). Renally cleared markers of bone resorption are serum amino-terminal cross-linking telopeptide of type 1 collagen (s-NTX), serum carboxy-terminal cross-linking telopeptide of type 1 collagen (s-CTX), and carboxy-terminal crosslinking telopeptide of type 1 collagen (s-ICTP or CTX-MMP).
Serum markers of bone formation. Serum alkaline phosphatase, bone specific alkaline phosphatase, and procollagen type IN propeptide (s-PINP) are not dependent in GFR and serum osteocalcin, procollagen type IC propeptide (s-PICP) are renally cleared [95]. 2017 guideline suggests not to routinely measure bone-derived turnover markers of collagen synthesis and breakdown (2C) [73]. Keeping in consideration their renal and dialytic elimination, those biomarkers and circulating fragments need to be studied and re-evaluated prospectively in CKD and ESRD population [95].
FGF23. FGF23 may be a more stable marker of phosphate metabolism in ESRD compared to PTH or serum phosphate. Differently from parathyroid hormone (PTH), which fluctuates diurnally, acutely in response to changes in serum calcium and postprandially, FGF23 levels show minimal circadian and postprandial fluctuations in CKD [96, 97]. Despite no consensus about the ideal FGF23 assay, FGF23 showed significantly less within-subject variability compared to PTH and phosphate (measured contemporaneously). A single measurement of FGF23 could more accurately assess the phosphate metabolism disorder compared to markers actually in use. Prospective studies found elevated FGF23 to independently associate with mortality in incident hemodialysis patients [2, 98]. Accounting together these data further support usage of FGF23 testing.
An increasing number of data have shown the very high prevalence of cardiovascular calcification in dialysis patient population, including patients receiving long-term peritoneal dialysis treatment [63, 64, 65, 66, 67, 68, 69, 99]. Electron beam computerized tomography (EBCT) or multi-slice computerized tomography (MSCT) can measure coronary artery and valvular calcifications, but other more widely available tests as lateral abdominal X-ray and echocardiography also can measure calcifications. Vascular and valvular calcifications are important factors for determining the prognosis of patients on CAPD [100] and patients with confirmed vascular or valvular calcifications are at highest cardiovascular risk [68, 101]. This is the rationale of the use of vascular and valvular calcification information to guide the management of CKD-MBD. Despite the long and ongoing debate [102, 103, 104, 105] about screening of ESRD population, according to 2017 KDIGO guideline, based on low quality of evidence (2C), a lateral abdominal radiograph and an echocardiogram can, respectively, be used (as alternatives to CT-based imaging) to detect the presence of vascular/valvular calcification in patients with G5D [73].
\nAs outlined above, the risk of hyperphosphatemia has been clearly shown for population treated with both hemodialysis and peritoneal dialysis [31, 38, 106]. The role of hyperphosphatemia as a principle actor in the development and progression of vascular calcification has been well documented in this population [70].
\nVascular calcifications are predictive of higher morbidity and mortality in dialysis patients. The main target of pharmacological research in the field has moved from bone toward the cardiovascular apparatus [107]. The control of serum phosphorus at all stages of CKD is considered one of the more important aspects to improve clinical outcomes in CKD-MBD.
\nOn the other side, the complex relationship between abnormal CKD-MBD parameters suggests the need of optimal control of all CKD-MBD parameters in order to modify the mortality risk among PD patients and improve clinical outcomes.
\nPhosphate balance in dialysis patients depends on phosphate intake, absorption (minus phosphate binding), and dialysis removal. KDIGO guidelines in 2017 suggest lowering elevated phosphate levels toward the normal range in dialysis patients [73].
Dietary restriction of phosphorus is an important part of phosphate control treatment in all dialysis modalities. The impact of phosphorus intake on patients is clear: higher levels of dietary phosphorus intake and a higher ratio of dietary phosphorus to protein are associated with an increased risk of death [3, 28, 108]. But because of other important risk factors for patient mortality and morbidity, such as malnutrition and hypoalbuminemia, dietary restriction may not be successful alone and cannot be effective without the help of other treatment measures, mainly the use of phosphate binders.
Type of dialysis may also be an important factor in the adequacy of phosphorus control in dialysis patients [109, 110]. Chronic PD as a continuous dialysis modality has an expected theoretical superiority over intermittent hemodialysis [32, 33, 34, 35].
Compared to hemodialysis (HD), patients undergoing PD appear to have an increased prevalence of low turnover bone disease defined as adynamic bone disease (ABD) [16, 17, 18, 19, 20, 21, 22, 23, 111]. In PD, as discussed above, calcium transfer across the peritoneum is regulated by two different mechanisms known like diffusion and convection. These processes depend on serum calcium levels, calcium concentration in the dialysate, and dialysis dextrose concentration [8].
\nMoraes et al. reported that in patients with PTH < 150 pg/mL conversion to low calcium solutions (2.5 mEq/L) appears to be a simple and effective strategy to bring PTH levels to the range determined by current guidelines when compared with 3.5 mEq/L calcium PD solutions [112]. This supports the finding of Spasovski et al. in HD patients where the lower dialysate calcium (1.25 mmol/l [2.5 mEq/l]) was found to improve bone and mineral parameters compared with the higher concentration of 1.75 mmol/l (3.5 mEq/l) in patients with adinamic bone disease [113].
\nThere is no data on Ca balance in PD patients, so the safety limit for an elemental calcium dose in PD patients is currently uncertain but based on the opinion of Wang the maximal additional elemental calcium given daily in the form of calcium-containing phosphate binder should be kept to not more than 800 mg to avoid calcium overload [114]. Patients with a negative dialysate calcium balance may show an overall positive calcium balance, if they are concomitantly treated with calcium-containing phosphate binders, especially when coupled with vitamin D [114].
\nIt is important to emphasize that the KDIGO 2009 guidelines recommend a 1.25–1.50 calcium dialysate for both HD and PD and this is an additional consideration that should be taken into account when choosing a phosphate binder [1].
\nWithout phosphate-binding therapy, all patients undergoing PD are in a positive phosphorus balance, unless they are severely malnourished. As mentioned before, the reduction of oral phosphate intake, an adequate dialysis schedule and the use of intestinal phosphate binders are three strategies used to manage hyperphosphatemia in dialysis patients [114]. Inevitably, in the long term, patients rarely observe rigid dietary phosphate restriction, especially in the context of PD where a higher number of patients are prescribed a less restrictive diet with a higher content of dietary protein [115].
\nPhosphate binders are essential in control of phosphate overload and in the improvement of outcomes in peritoneal dialysis patients. Phosphate binders are used for their binding actions to reduce the absorption of phosphorus by the gastrointestinal lumen. First, it should be stressed that patient compliance is fundamental not only in limiting dietary intake of phosphorus but also in adhering to the prescribed protocol of phosphate binder administration, frequently linked to the number of pills the patient is required to take and the degree of gastric tolerance of the product prescribed.
\nThere is insufficient evidence that any specific phosphate binder significantly impacts patient-level survival. The decision to use a phosphate binder should be followed by consideration of which currently available phosphate-binding agent is suitable for the patient. Ideally, a phosphate binder should effectively bind dietary phosphate regardless of pH have minimal systemic absorption, few side effects, good palatability, a low pill burden, and be available at a low cost [116]. Traditionally, phosphate binders are classified into calcium-containing phosphate binders and calcium-free phosphate binders.
\nCalcium-containing phosphate binders are available in two formulations: calcium carbonate and calcium acetate. Efficacy of calcium-based phosphate binders is known to be clinically satisfactory, especially when combined with adequate dialysis and dietary measures. Nowadays, calcium salts are considered not free of side effects. Great concern has been expressed about their effect on raising serum calcium levels, especially when used in association with vitamin D or high calcium dialyzing solutions.
\nHigh calcium balance may over suppress PTH, exiting in a state of adynamic bone disease (ABD), which is as dangerous as a high bone turnover state [114]. Furthermore, the excess of calcium may lead to tissue and vascular calcifications, increasing cardiovascular mortality. Regarding the use of calcium-based phosphate binders in PD patients, there are limited data available. The majority of studies comparing calcium salts and sevelamer are performed in hemodialysis patients. These studies confirm the efficacy of calcium salts as phosphate binders and the potential role of them in developing calcifications.
\nCalcium salts should be administered carefully, considering the clinical status of each patient. KDIGO guidelines suggest restricting the dose of calcium salts in the presence of arterial calcification and/or adynamic bone disease and/or if serum PTH levels are persistently low [1].
\nAluminum salts were largely used as calcium-free phosphate binders, but this treatment was abandoned when cases of systemic aluminum toxicity were reported [117].
\nSevelamer is a calcium- and aluminum-free phosphate binder, developed for hyperphosphatemia management in dialysis patients. There are also few data regarding sevelamer administration in PD patients. A study comparing the efficacy of sevelamer and calcium acetate showed the same efficiency of both treatments in control of serum phosphorus and PTH [118]. This study also evaluated the association between sevelamer administration and risk of peritonitis in PD patients, because it has been thought that a higher rate of diarrhea and constipation induced by sevelamer might increase the risk of peritonitis caused by Gram-negative microorganisms due to trans-mural migration of bacteria. Although peritonitis occurred in 11% of the patients in the sevelamer group and in 4% of the patients on calcium-containing phosphate binders, no significant increase in the risk of peritonitis was found [118]. Another study performed in PD patients in Canada showed the efficacy of sevelamer in ameliorating CKD-MBD parameters [119].
\nLanthanum carbonate is another nonaluminum- and noncalcium-containing phosphate binder that has more recently become available for the management of hyperphosphatemia in dialysis patients. Unfortunately, less evidence and studies are available for patients undergoing PD [114]. An open, noncomparative study in patients with hyperphosphatemia undergoing continuous ambulatory PD evaluated safety and efficacy of lanthanum carbonate to reduce serum phosphate levels [120]. This study showed that lanthanum carbonate was generally well tolerated. Furthermore, majority of the patients reached the therapeutic target level in 2 months at doses between 750 and 2250 mg, suggesting that the efficacy dose was lower than that for HD patients.
\nA novel noncalcium iron-based phosphate binder, sucroferric oxyhydroxide is introduced for the management of hyperphosphatemia in dialysis patients. It is formulated as a chewable tablet containing 500 mg iron. Long-term efficacy and tolerability of the iron-based phosphate binder, sucroferric oxyhydroxide, was compared with that of sevelamer carbonate in an open-label Phase III extension study [121]. A representative proportion (9.3%) of patients receiving peritoneal dialysis was included in this long-term analysis of phosphate binders. Extension study data demonstrate that the efficacy of sucroferric oxyhydroxide for controlling serum phosphorus concentration was robust, maintained over the long-term (1 year) and similar to that of sevelamer. Sucroferric oxyhydroxide was generally well tolerated over 1 year. The pill burden over 1 year of treatment was 62% lower with sucroferric oxyhydroxide than with sevelamer [121].
\nThough the prevalence of secondary hyperparathyroidism (SHP) and the related mineral metabolism changes have been reported at almost the same rate in peritoneal dialysis as in hemodialysis patients, PD patients have a higher prevalence of adynamic bone disease suggesting that their bone is less sensitive for a given level of PTH [122].
\nIt has also been widely reported that PD patients have lower vitamin D levels as compared with the HD patients [123]. Among the multiple causes which might explain the higher prevalence of vitamin D deficiency in PD patients, the peritoneal loss of vitamin D binding protein probably plays an overwhelming role.
\nIt is suggested to correct vitamin D deficiency, using low doses of either cholecalciferol or calcifediol (800–100 UI/day), by adding calcitriol or paricalcitol only when, after the first two described steps, the PTH levels are stable at 450–500 pg/mL or show a clear increasing trend in the absence of relatively high calcium (>10.0 mg/dl) and/or phosphorus (>5.5 mg/dl) levels [122]. In these latter cases, it is suggested to start treatment with cinacalcet.
\nMost of studies on administration of calcimimetics in dialysis are performed in hemodialysis patients. Few studies that are PD have a very limited number of patients. So, most of the recommendations for peritoneal dialysis patients are simply transferred from the HD experiences. The calcimimetic cinacalcet was approved by the US Food and Drug Administration in 2004 and by European Committee for Medical Products for Human Use in 2005 to treat secondary hyperparathyroidism in patients on dialysis.
\nCinacalcet acts directly upon the parathyroid cell calcium-sensing receptor (CaR). Upon binding CaR, cinacalcet allosterically increases its sensitivity to extracellular calcium thus suppressing PTH secretion without increasing serum calcium and phosphate levels [124]. A retrospective study was performed at a single PD unit based on 27 patients with moderate to severe SHPT (PTHi > 500 pg/mL with normal or elevated serum calcium levels) who were treated with cinacalcet. Cinacalcet was started due to the lack of response with conventional treatment: diet, phosphate binders, and vitamin D or inability to treat with vitamin D due to hyperphosphatemia >5.5 mg/dL or hypercalcemia >10.5 mg/dL [125]. This study showed that cinacalcet was a safe but not effective therapy in moderate to severe SHPT in PD patients. The gastrointestinal adverse factors made impossible the prescription of higher doses of cinacalcet and an eventual benefit of this therapy at higher doses in SHPT was impossible to evaluate.
\nOn contrary with these conclusions were results of another study performed by Portoles et al. in PD patients. They evaluated efficiency and safety of cinacalcet in eighteen patients undergoing more than 4 months on PD with a severe SHPT (PTH > 500 pg/mL) resistant to conventional treatment with diet, chelants and vitamin D, in a prospective open-label study [126]. The authors concluded that the addition of cinacalcet to conventional treatment in PD patients with resistant SHPT has improved the achievement of targets of K/DOQI guidelines and has been reasonably safe.
\nLindberg et al. [127] evaluated a total of 395 patients on dialysis (349 on HD and 46 on PD). Two hundred and ninetyfour patients (260 HD and 34 PD) were treated with once-daily oral cinacalcet (titrated from 30 to 180 mg/day), while the remaining 101 patients (89 HD, 12 PD) were on placebo in addition to the ongoing standard therapy. This study confirmed that cinacalcet induced a more pronounced reduction of PTH in a larger percentage of patients as compared with standard therapy, with no major difference in the percentage of patients on HD and on PD treatment achieving a PTH level lower than 250 pg/mL (39 and 38%, respectively).
\nCinacalcet treatment was associated with a slight, but significant, decrease in both calcium and phosphorus concentrations as compared with patients treated with the standard therapy only. Gastrointestinal symptoms were reported to be the most frequent adverse effects. However, no difference was observed between HD and PD patients in the incidence or type of the reported side events. A severe form of SHP is an unusual finding in PD patients. Furthermore, the control of phosphate is usually better in PD than in HD patients, at least until the residual diuresis is maintained. Another specific characteristic of patients treated with PD is the higher tendency to status of vitamin D deficiency which might make these patients more prone to hypo rather than hypercalcemia. For all these reasons, it is possible to predict that the need for the use of the most recent and potent drugs which are nowadays available for the control of SHP, including cinacalcet, might be lower in PD than in HD patients [122].
\nThe recommendation on diagnosis and management of CKD-MBD presented in this chapter are based on KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD).
\nThe level of recommendations presented in these guidelines are:
\nLevel 1—we recommend; Level 2—we suggest; the ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level 1 or 2 recommendations.
\nQuality of evidence presented in these guidelines:
Meaning A High: we are confident that the true effect lies close to that of the estimate of the effect.
B Moderate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
C Low: The true effect may be substantially different from the estimate of the effect.
D Very low: The estimate of effect is very uncertain and often will be far from the truth.
None to declare.
Research on journalism and corruption has proliferated in the past two decades, but it is largely unconnected and its conceptual and theoretical framework is far from complete. As such, upcoming research will be of little value in either understanding corruption or curbing its consequences. Corruption is a universal global problem with detrimental effects on economic growth and performance [1], political stability, and societal integration [1, 2, 3]. Despite the dominant satisfaction of the correlation between a large set of variables and corruption, controversial results seem to be quite common due to differences in definitions [4, 5], sources [6], measures, research designs, models, cultures, types of corruption control [7], and period of studies [6, 7, 8, 9]. This general controversy is deeply applicable to the literature of journalism and corruption where several empirical and theoretical studies yield dramatically contradicting results. The existing literature lacks consensus on why it exists, its determinants, consequences, and more importantly, what makes it so differently widespread among cultures and countries [10].
In such a context, it would be important to develop a universal theory that embraces conceptual grounds of journalism and corruption. Yet, without considering the intricate interconnections between journalism and other related intervening variables of the higher socioeconomic levels/layers, such a theory would be misleading. Journalism is thought by many scholars to have an immense effect in controlling corruption. However, they do not know the conditions under which its performance brings about positive results in some countries while serving to protect corrupt policies and corrupt policy makers in some other countries. Journalism combats corruption through its content, freedom, structure, independence, ownership patterns, diversity, ethics, and professionalism, all of which demonstrate significant variations across cultures and nations. As a social institution, journalism does not work in a vacuum; its impact is heavily determined by both the nation system and international system environments in which it operates [11, 12, 13].
A multidisciplinary method, I argue, is the most appropriate approach to synthesize the key variables and underlying relationships across a set of published studies in a variety of disciplines to arrive at a theory of journalism-corruption determinants. A theory that discusses how multiple levels of determinants might be linked, or at least juxtaposed to yield a more comprehensive understanding of causes, and consequences of corruption and that can lead to more effective policy reforms. What I intend to do is to examine and move a body of knowledge forward to understand, interpret, predict, and finally help control the penetration of the most dangerous ill humanity has experienced since its establishment. The worst aspect about corruption is the nature of corruption itself. It takes so many different forms and covers such a variety of public and private activities that often is difficult for the common man or accountability agencies to detect what it really is. The corrupt officials are efficient at disguising their behaviors and covering over any traces. Moreover, it is very contagious. Corruption in one sphere of public or private domain quickly spreads to and penetrates in another like wildfire [14].
Corruption is an undeserved, unfair, unjust, immoral benefit resulting from positions of public trust and responsibility used for unworthy behaviors. It violates any notion of public responsibility on which the construction of democracy is built [14]. Despite the fact that corruption reality is compacted, complicated, diffused, and penetrated among all sectors and layers of the society, studies are often designed and carried out independently [15]. What complicates corruption research is that its causes in one discipline or level of analysis could be examined as a consequence in other discipline or level of analysis [8]. The single act of corruption within a small or big public or private corporation could be traced through several determinants within the corporation itself, the constitutional and legal system, structure of the economy, politics, culture, rule of law, in addition to historical roots of a given country in relation to colonialism, among many other factors and forces.
The suggested theory, then, will be designed in hierarchical levels in which the upper level, the macro level, is supposed to influence the lower level and so on. As Shoemaker and Rees argue, the hierarchy of influences model is useful for research in two important respects. First, any single perspective does not offer a comprehensive view, which is possible only when all levels affecting the variables under study are considered. Massive studies are conducted at a specific level, but findings are explained at higher levels. Second, merging multiple hierarchal levels of analysis provide distinct explanations and direct the attention to the interplay between them [16]. In addition, as most of corruption behaviors occur within the transaction process between actors at different systems within and sometimes outside a given country, the multiple hierarchal levels of study is, perhaps, the only suitable method that detects different causes behind the illegal behaviors. The suggested theory is in line with what many authors believe about corruption. Political corruption, for example, is rooted in the social structure. The state of willingness for political corruption depends less on the psychological or personality characteristics of the individual public servant, and more on the socioeconomic environment and institutional context in which the state and the market are constructed. Furthermore, readiness for corruption is not constant in a public official, and can actually vary over time within the same person depending on the context he/she is found [17].
Literature on corruption is mainly divided between research that emphasizes either the influence of structure (determinism), or the influence of agency (freedom), on human thought processes and behaviors. While agency stands for the capacity of an individual to freely make his/her own independent choice, structure refers to factors such as economy, institution, religion, history, social class, and culture that influence the choices of an individual [18]. The rational choice theory represents the foundation for studies adopting the influence of agency. The unit of analysis is the individual who chooses a specific course of action on a short term as a rational action to satisfy his/her self-interest. Though this school of thought provides good reasons to study the motivation behind the corruption behavior of public officials, it has its own limitations that make it unsuitable to explain the complexities of this behavior (for more details on the limitations of the rational choice theory, see Monroe, 1991) [19]. Therefore, scholars have turned to the structural factors to overcome the shortcoming of the individual-based theory of corruption. My approach is also informed by the argument made by Michael Johnston in his book: Syndromes of Corruption: Wealth, Power, and Democracy. He outstandingly criticizes the current corruption literature that either adopts cross-sectional analytical traditions often applying statistical measures and models to large numbers of countries or the case studies that focus the investigation on specific context. The two approaches have their limits that never allows to appropriate understanding of corruption. Johnston, instead, suggests a middle level of comparison—one that does not deny the benefits of these two traditions but links them together [20]. My conviction is that no one approach holds all advantages, and that every approach has its own limitations and shortcomings that require a combination of multi-systems/layers interactive approach. Corruption is extremely entrenched in the basic historical, political, and cultural structures. This approach is in line with a growing body of historical institutionalism stressing the importance of moving away from examining corruption as individualistic behavior to focus on the informal rules and routines that enforce individuals to act according to these norms [21, 22]. Historical institutionalism, in general, is an analytical approach that pays attention to the ways by which institutions shape and structure behaviors [23]. At this point, it would be useful to identify the phenomenon with which I am concerned.
Corruption as dependent variable here implies that things, behaviors, and policies are not what they ought to be. They have been deviant from the normal and expected paths. In the process of so deviating, the corrupt have unfairly and intentionally gained in some way that should not have happened or would not otherwise have occurred at the expense of everyone else, who, significantly, have thereby been disadvantaged [14]. The existence of corruption requires three elements to simultaneously coexist: first, the powerful person who has a discretionally power; second, an economic rent linked to this authority; and third, low probability of detection by the judicial system [24]. Klitgaard presents an elegant understanding of the determinants of corruption that views it as the ultimate output of the interaction between three pillars: monopoly power, discretion, and accountability. Its existence requires little or no accountability mechanisms, and presence of both imperfect competitive markets and discretion [25]. The corrupt behavior may be either passive or active. That is when the law is not totally or partly imposed or when the public official intentionally applies it selectively and unfairly to favor some persons or some organizations over others in the transaction processes [26]. In a corrupt country, public resources are more likely directed toward protecting the elite of the corrupt regime—the armed forces, the police, the executives, and other cliques of social control—as the regime seeks to perpetuate its control. This is why corruption is usually defined as the criminal misuse of power. A corrupt individual occupies higher social, political, and economic status [27]. Given this fact, it is expected that corruption precludes the socioeconomic development expenditure and widens the gap between the rich and the poor population [28].
In this context, it would also be useful to distinguish between grand corruption on the one hand and petty corruption on the other. The first has been defined as the misuse of public power by heads of state, ministers, and senior officials for private financial gain [29]. The second refers to bribes citizens pay to lower level officials to speed the delivery of services or to fasten the appropriate guidelines [30]. Obviously, the huge and rapidly growing literature around corruption bears a conceptual bias when it confines it to public sector and defines it from a state perspective. Reviewing literature of the conceptual framework of this key term in economy, sociology, political science, and so forth ignores the reality of corruption in private sphere [31].
In most of cross-country comparative studies, corruption indices of Transparency International (TI) are used to measure and compare corruption. This is a composite index including many other sources. Some studies used data from other individual sources, that is, the Political Risk Service (PRS), the Institute for Management Development (IMD), the World Bank and University of Basel (WB/UB), or the World Economic Forum (WEF). For a description of these sources, see Lambsdorff [32, 33]. An older source has been compiled by Business International [1]. In their studies on typology of corruption, Bussell [34] argued for not using one single shared typology across all analyses, as it is highly unlikely that a single typology will be sufficient for all research questions. Given the complex nature of corruption, they argued for a more practical, problem-driven approach. Corruption as Helman [35] argues is a derivative concept, meaning that it depends on a theory of the institution involved. In order to define corruption of an official or institution, one needs an explanation of how the official ought to behave or how the institution ought to function. Corruption can and is being measured through a wide variety of innovative approaches. It is appropriate to rely on a wide variety of different indicators, both subjective and objective, individual as well as aggregate, cross-country as well as country-specific. This is important to monitor results on the ground, assess the concrete reality of corruption, and develop anticorruption programs [2]. The variety of approaches through which corruption has to be defined and insufficiency of any or group of approaches may urge me to suggest a flexible definition for this phenomenon to mean what people perceive in a particular culture as corruption.
The levels of analysis in journalism-corruption determinants can be thought of as forming a continuum ranging from micro to macro, from the smallest units of a system to the largest. A micro level study examines corruption act as an activity practiced by an individual or a specific social institution occupies the lower level of the hierarchical influences. This could be a public official, a newspaper, or other journalism outlet that affects another firm or level. A macro level study examines social and political structures that exist in higher layers of the hierarchy. These levels operate hierarchically: What happens at the lower levels is determined by what occurs at higher levels to cause or deter the corruption behavior of an individual official or a particular system. For more details on how hierarchical levels of analysis work and guide research, see Shoemaker and Reese [16]. The rest of this chapter examines from several perspectives findings and explanations relating to determinants of corruption at different hierarchical levels. The main argument of “the hierarchical universal theory of journalism-corruption determinants” as introduced here perceives corruption act as an outcome of a continuous interaction between five hierarchical levels as shown in the graph below. They are: (1) journalistic level, (2) economic level, (3) political level, (4) cultural level, and (5) the international system level. In general, each level has many sublevels interacting with each other to bring about an effect on corruption that could be negative or positive, minor or major, and finally in one domain or multiple domains. It is understood also that the magnitude of lower level impact is weaker than that of the higher level. It is not expected, for example, that influence of journalism, as institution to be stronger than that of the political system or cultural system.
Given the discussions outlined in the preceding paragraphs, I will move through a sequence of four steps. The purpose of the first step is to identify the number and domains of the interacting hierarchal levels—as shown earlier—that sustain and/or restrain corruption. The second step aims at reviewing the empirical and theoretical studies that examine the main relevant variables and issues. The purpose of the third step is to present the generalizations summarizing the main findings. The fourth step intends to synthesize the main cross-border assumptions; a theory that creates linkages capable to explain corruption, predict it, direct the future studies, and finally contribute to reducing it (Figure 1).
The hierarchal universal theory of journalism/corruption determinants.
At this first level of the hierarchal theory, the revision will confine to conditions and functions of journalism that have distinct implications for corruption determinants, consequences, and policy reforms. In theory, conditions are different from functions, they are the elements and characteristics that enable or disable journalism as a social institution in the fight against corruption. Freedom, independence, and diversity are the main conditions of journalism that empower it to perform the functions of (1) watchdog, (2) accountability, and (3) agenda-setter. These conditions and functions relate to the existence of corruption, its diffusion and control.
A commonly held belief is that a free and independent press serves as deterrent to corruption due to its ability to detect corrupt behaviors and officials. A number of recent papers that consider the relationship between press freedom and corruption lend support to this conviction. Ahrend [36] finds that lower levels of press freedom are correlated with higher levels of corruption, a result that is supported by Chowdhury [37], Stapenhurst [38, 39], and Bojanic [40] who explained the positive effect of press freedom in the presence of democracy [40]. The overwhelming majority of empirical studies support the theoretical view that restrictions to press freedom lead to higher corruption and that political and economic restrictions are strongly and robustly related to corruption [41]. This view is totally supported in OPEC members where journalism was not serving as a check against corruption due to the restrictions imposed on its ownership and performance [42].
The most rigorous work in this respect is that of Brunetti and Weder [43] in which they use alternative measures for both the independent and dependent variables. They carry out several robustness checks utilizing two different press freedom indexes and four different measures of corruption, across countries as well as over time. The results show significant positive effects of press freedom on three of the four corruption control indices. Their results confirm the widely held belief that in countries where the press is mainly free from any sort of restrictions, corruption levels are likely to be low [43]. Though freedom of the press is a prerequisite to combat corruption, without citizens’ access to and participation in press content, its impact would be at its minimum. The results of Dutta and Roy’s study present empirical evidence that these two components of the press—freedom and access—complement each other in controlling corruption [44].
In a different thread of research, Graber [45] demonstrates that the press often deserve less recognition than previously believed for detecting corruption. Similarly, Vaidya [46] indicates that the government-press relationship in different parts of the world appears to suggest a more complex relationship. It might not serve as a watchdog for the public but might prefer to enter in a partnership with corrupt officials. However, not all forms of restrictions to press freedom are strongly correlated with corruption. More specifically, it appears that it is the political pressures that have a slightly stronger effect on corruption [46]. Lindstedt and Naurin [47] contend that in order for transparency to alleviate corruption, the audience should receive the information made available through transparency and they must have the capacity to hold corrupt officials accountable. Transparency on its own has no or little impact to prevent or control corruption.
In this context, two competing views on the relation between perception of corruption and actual corruption deserve more elaboration. The first view sees that higher levels of corruption’s perception led citizens to hold their governments accountable through democratic mechanisms and, specifically, the electoral process. This view hinges on the assumption that higher perception of corruption corresponds to a higher level of actual corruption, and that press is independent and the public uses its power to punish the government. Perception is a function of press coverage for corruption in real world and the role of the press will be to decrease it [48]. The second view implies that heightened perception of corruption can increase its actual level by publicizing the view of corruption as a normal activity and therefore lower the threshold of inhibition for others to engage in the same kind of behavior. Proponents of this view argue that more perception of corruption threatens state legitimacy and creates credibility and trust crises in the state [49].
In fact, existing literature as a whole emphasizes the significant impact of the free press as a highly effective mechanism of external control on corruption because it works not only against extortive but also against collusive corruption [43]. Extortive corruption as explained by Brunetti and Weder [43] happens when the government official has the discretionary power to refuse or delay a service in order to extract a rent from the private agent in the form of a bribe. The collusive corruption occurred when the official and the client have mutual interests and the two partners benefit from the transaction. Generally, press freedom is highly correlated with low levels of corruption, but its effectiveness is only related to collusive corruption [43]. Free press is a prerequisite for investigative journalism, which in turn is a fundamental mechanism contributing to both vertical and horizontal accountability. Journalism as institution would be of little value in curbing corruption unless it is free, independent, and plural. Leaders of international economic bodies such as the World Bank have paid attention to the importance of press freedom as the core of the equitable development [50]. This positive attitude has coincided with publication of several articles that demonstrate a strong correlation between a free press and low corruption levels across countries [50]. Ahrend [50], for example, provides a strong empirical evidence indicating that causation runs mainly from lower levels of press freedom to higher levels of corruption.
The free press investigates wrongdoing, feeds the public sphere with the consequences of corruption behaviors and forms public opinion. This emphatically pressures the governmental bodies especially the judiciary to hold corrupt officials accountable [51]. As a result, in democratic countries, corrupt officials are forced to resign and lose their power. This significant role takes place where a combination of free press, democracy, and rule of law exists. Evidence on such a collaborative role is presented by Hamada, Abdel-Salam, and Elkilany who find that the interaction of press freedom, democracy, and rule of law reduces corruption. Furthermore, they obtain that the effect of rule of law is not contingent on freedom of the press; rule of law affects corruption both in countries where the press is free and where it is unfree [52]. In a similar vein, Besley and Prat [53] test and verify their model, which links a number of characteristics of journalism industry, namely concentration and ownership and obvious political outcomes, namely capture, corruption, and turnover. The model is based on three propositions: (1) media pluralism works against capture, (2) independent ownership minimizes capture, and (3) media capture lessens political outcomes. They conclude that laws of press freedom are not sufficient to protect journalism from government interference. Consistent with this, Djankov finds that countries with greater state ownership of the press have less freedom, fewer political rights for citizens, inferior governance, and less developed capital markets [54]. In general, press freedom and democratization have a symbiotic relationship. Both go hand in hand, and where democracy exists, press assumes its free and critical evaluation of wrongdoing and vice versa. What is not clearly known is the conditions under which these two close variables interact. Historically, a free press requires its independence from the state and the private sector, a kind of independence that enables it to act as an indirect check on corruption that would otherwise flourish in the absence of competitive environment. By creating a diversified atmosphere absorbing different views and enriching a free public debate, journalism sustains political and economic competition, the necessary condition for a clean economic and political environment with a minimum level of corruption [38].
It has long been recognized that journalism plays a key role in curbing corruption. This is because of its fundamental role in enabling citizens to monitor the actions of the government officials. This, in turn, rationalizes the voting behavior of the citizens to the extent that they can punish the corrupt and unresponsive governments. Literature offers two models linking journalism to corruption. The first has been developed by Stromberg [55] focusing on the impact of journalism on policy issues including corruption. The main concept of the model implies that when voters are deprived from free flow of journalism information, they are not likely informed citizens, and the government is more likely to allocate resources that do not serve the interest of people. It also sets policies that are associated with higher rents and corruption [55].
Besley and Prat [53] present the second model in which voters who have been informed by a free press can vote corrupt officials out of office, but where, at the same time, corrupt politicians can capture and silence the press. The latter deprives citizens of any possibility to form an enlightened voting, and hence increases the likelihood for corrupt government officials to continue in office. The model is in line with a long tradition of many political thinkers including Rousseau, Smith, Hobbes, Locke, Madison, Jefferson, and Mill who have argued that press freedom is a prerequisite for citizens to make rational and knowledgeable decisions about public affairs [8]. Regardless of these two models, there are two ways through which journalism fights corruption: tangible and intangible. The first role is apparent when public office-holders are accused, or forced to resign after their crimes are exposed to public space. Investigative journalism that defends social and ethical norms, and intensifies competition, works as an indirect check against corruption [38]. Unlike legislative, executive, and judicial bodies, journalism, as a fourth estate, has no specific means to sanction mismanagement of public officials [56]. Corruption flourishes in the presence of cooperation among horizontal institutions of the state. The independent press can replace cooperation by disputes when it highlights corruption behaviors and thus create unfavorable atmosphere that eradicates corruption [38]. Through the watchdog function of journalism, three patterns of policy effects are generated: The first occurs when the government bodies discuss the problems raised by the press and take the procedures to present solutions. The second takes place if sanctions are applied against persons or institutions as a result of corruption or wrongdoing. The third happens when the parliament made changes in laws and legislations as a response to the investigate reports [57].
The critical role of investigative journalism takes place when it exposes the government’s record to external scrutiny and critical evaluation, and holds authorities accountable for their actions [58]. Several studies offered empirical evidence [43] that watchdog role of journalists enhances the transparency of government actions and decisions, hinders misuse of public office, malfeasance, and thus reduces corruption [43, 58]. As Bovens argues, public accountability is a relationship between an actor and a forum, in which the actor has an obligation to explain and to justify his or her conduct, the forum can pose questions and pass judgment, and the actor may face consequences [59]. Traditionally, theorists of public accountability assume that governmental accountability incorporates a combination of vertical and horizontal institutions [60]. Vertical accountability describes a relationship between unequals where powerful superior actors hold less powerful inferior actors accountable or vice versa [61]. Forms of this type of accountability include electoral accountability, civil society, and journalism. Enlighted voter participation can punish the corrupt officials and replace the incumbent by electing a new government. The free press empowers voters and makes them aware of the corrupt behaviors and incumbents. As a result, they become more knowledgeable and their ability to hold elected officials accountable for their policy decisions enhanced. A variety of models also confirm the fact that policy distortion is a result of ill-informed citizens [62]. Horizontal accountability implies the power of checks and balances exercised by equals [60] where the three authorities of state-executive, legislative, and judiciary monitor each other. As an empirical investigation of this issue, Camaj [63] found that the free press has a greater indirect effect on corruption when coupled with strong institutions of horizontal accountability than when coupled with high electoral accountability. The main contribution of the free press to democratic governance lies in its ability to sustain political accountability [64].
If free press pressures public officials to be answerable for their behavior, forces them to justify their actions publically, and informs the citizenry about such investigations, then it necessarily contributes to holding them accountable [64]. This happens through either its original informational role in which it identifies corruption acts and initiates the investigations or through a subsidy informational role in which it republishes the facts and information provided by other traditional intermediaries [65]. By the original and secondary informational roles, press contributes to horizontal and vertical accountability [64]. The problem arises when the public in many countries lacks interest in politics and motivation to participate in elections. Here, the free press’ role is to hold the governors accountable—not to the public, but to the ideals and rules of the democratic polity itself [66]. This is particularly important given the fact that accountability mechanisms are fragile in many countries [67].
In such countries, social media provide an alternative that triggers accountability mechanisms in a large state-controlled press, limited political competition and censorship of traditional media [68]. Yet, social media role has to be accompanied by users’ interest in acquiring knowledge about corruption, their skills to process it adequately, and their motivation to participate in actions to change the corrupt behaviors [69]. Social media have tremendous power in turning public officials into symbols of wrongdoing, regardless of legal judgment and sanctions [67]. The preceding discussion shows that the mere existence of journalism does not mean anything unless it has access to sources of information and the ability to enlighten the public with what went wrong [70]. By doing so, press coverage influences norms, values, and cultures, which in turn can lead to transformation in politics, economy, and governance [71]. This cultural change happens over time as a cumulative effect of continuous coverage of the press and through the cultivation of new standards of behaviors. Press is a crucial actor in the process of changing norms toward more transparency and accountability. By changing perceptions of what is right and wrong, the press can lead to less or zero tolerance for corruption [71]. On the other hand, if journalism complies with the power of corrupt officials, ignores their intended failure and mismanagement, a culture of corruption tolerance prevails and it will be socially acceptable [72].
A strong association exists between free and independent press and corruption. The causation runs from higher level of free and independent press to lower corruption.
A strong relationship exists between restrictions to press freedom and corruption where more restrictions lead to higher corruption.
Higher public perception of corruption due to freedom of the press and political competitiveness may not lead to controlling of corruption, unless civil mechanisms of accountability work properly. Alternatively, this situation may intensify the actual corruption as it delegitimizes the corruption behavior and views it as normal activity.
The political forms of restrictions are more effective in determining corruption than the economic or any other form of restrictions.
Press freedom and democracy are complements rather than substitutes in the fight against corruption.
The effect of press freedom in reducing corruption is magnified by the existence of democracy.
The watchdog role of the press hinges on the plurality of ownership patterns, diversity of views, and its credibility.
The watchdog journalism can contribute to the early public identification of corruption in which news analysis and information are made available to the public and authorities. It also has a secondary informational role through which it can republish information from other intermediaries.
Press freedom may have a greater indirect effect on corruption when interacted with strong mechanisms of horizontal accountability than when interacted with effective electoral accountability.
Transparency is an important, yet insufficient, factor to curb corruption and it does not prevent corruption if accountability agencies are weak.
More internet and digital media freedom decreases level of corruption only in democratic countries.
Social media improve vertical accountability more in countries where traditional journalism are captured and censored.
The impact of the level of free press in curbing corruption depends on the level of democracy. It is very effective in well-established electoral democracies, but less effective in newly established democracies, and it has little or no efficacy in a weak electoral democracy.
To a great extent, the level of corruption is an outcome of the degree of both monopoly and discretionary power that officials exercise. The two types of monopolies exist in highly regulated economies and definitely in developing countries where administrative rules and regulations are mainly imperfectly defined and overwhelmed by a weak rule of law. Corruption environment is also characterized by ineffective accountability and weak watchdog mechanisms. Empirically, more discretionary power and regulations equal more corruption [73]. Hence, effective strategies to control corruption have to simultaneously work on reducing officials’ monopoly power, their discretionary power, and strengthening their accountability through enabling the watchdog mechanisms [38]. Prior studies provide evidence that competitive economies are less corrupt than economies where domestic firms are protected from foreign competition. The results suggest that the policies aiming at making markets more competitive could play a role in controlling corruption [74]. This approach to corruption control suggests that increasing competition may be a way to reduce returns from corruption activities. Yet this argument is over simple as economists still have not fully identified the conditions under which an increase in competition will effectively reduce corruption [75].
In a similar thread of research, public choice theorists argue that corruption rates are directly corresponding to the degree of monopoly that public office officials have over a specific bureaucratic sphere. In contrast, a negative relationship exists between accountability they bear and the rate of corruption [76]. Since officials in autocracies have monopoly power and discretionary power without any form of accountability, the risk of punishment associated with corruption is often zero [77]. However, consolidated autocracy differs from lenient autocratic governance as it applies rigid regulations that raise the cost of corruption practices to the extent that illegal bureaucratic corruption is often minimal [78].
In a different line of research, democracy and economic freedom prove to be real determinants of corruption. Meanwhile, there is not enough knowledge about how the interaction effect between democracy and economic freedom occurs or under which conditions the interaction represents a cure for corruption. Countries such as Hong Kong and Singapore exhibit a very low level of democracy and a very high level of economic freedom and at the same time have a very low level of corruption. On the other hand, in spite of India’s high level of democracy and low level of economic freedom, it experiences a very high level of corruption. Thus, it is of interest to ask how these two factors, that is, democracy and economic freedom work together in this process [79]. The answer to this question comes from the investigation of Saha and Gounder who found that the interaction effect of democracy and economic freedom has a significant impact on controlling corruption. But the relationship is complex; democracy increases corruption at lower levels of economic freedom, yet in a full mature democracy, corruption is significantly lower [80]. This is consistent with other studies indicating that corruption control is more likely if an economic development is attained first, with democracy following more gradually [81].
Any discussion of economic determinants of corruption has to answer the questions of privatization, public sector wages, government regulations, democracy, and level of economic development. Privatization may have its clear economic advantages, but unfortunately, its impact on corruption is unclear. What happens is the shift of corruption from the public to the private sector. What was formerly taken from state-owned enterprises can then be extorted from private firms. Surely, the public sector corruption is certainly higher, for many reasons, than the private sector. At the top of these reasons is the wages where low public sector wages stimulate corruption among public sector workers [82]. By the same token, it is likely that corruption correlates positively with the degree to which government regulations are vague and lax [83]. In contrast, Treisman found corruption is lower in economically developed well-established liberal democracies, with a free press, and a high quota of women in governmental institutions, and an open and competitive global trade history [84]. The logical question here is under what conditions this result takes place. Does economic development reduce corruption? Alternatively, does corruption impede economic development? To what extent are both determined by some other factors? The general verified finding illustrates that when countries grow rich, they become less corrupt [85]. In other words, corruption is significantly correlated with the level of economic development (1999), a condition that makes policy reforms unmanageable. A country cannot wait forever to attain the economic development in order to control corruption [86].
The preceding debate tells us that differential effect of corruption is a neglected topic. For example, China has been able to grow faster than so many countries while being ranked among the most corrupt countries. Why corruption is less dangerous in China? Or would China have grown even faster if corruption was lower? These kinds of questions have received scant attention and need more investigations [87]. The same debate has to be raised with regard to democracy-corruption relationship and to any other variable that is likely to affect corruption or be affected by it directly or indirectly. A more common and relevant predictor of corruption is the size of the government and state legitimacy. Bigger and illegitimate governments allow more bureaucracies and less legislative oversight and more corruption [26, 88]. Nevertheless, it is not only the size of the government that explains the level of corruption but also whether the big government is democratic. The big size of government reduces corruption if democratic values and institutions prevail. In contrast, it expands corruption if it is undemocratic [89].
Countries that experience higher levels of rents also have higher levels of corruption, with other things equal.
Decentralization of the government, its size and intervention in the market are important, but not sufficient, factors determining corruption.
Competition lowers the rents of economic transactions and therefore decreases corruption as motives to extract rents consequently decrease.
Economic development reduces corruption indirectly through the quality of education and rationalization of decision-making, which maximizes the cost of the corruption behavior.
Equal distributions of wealth mattered more than wealth itself as means of controlling corruption.
Administrative environments that are characterized by vague performance standards tend to have high levels of corruption.
Administrative environments that are dominated by meritocratic recruitment and promotion tend to have low levels of corruption.
A judiciary system where corrupt bureaucrats can be effectively charged reduces the potential rewards of corruption and thus minimizes its level.
The big size of the government does not lead directly to corruption; the relationship is strongly affected by existence of democracy that marginalizes the effect of government size.
The link between autocratic systems and corruption is complex, where tolerant autocratic governments create favorite conditions for bureaucratic corruption, consolidated autocracy tends to deter corruption.
The widely accepted definition of corruption as the abuse of public office for private gains reflects an ideological bias against state activity where national private sectors and global private business experience corruption as well.
I will discuss the prior literature of political level—similar to other levels—along two parallel tracks: the political theoretical frameworks of corruption and the empirical findings of political cross-national comparative studies. Both tracks will be simultaneously presented in a way that contributes to building the hierarchical universal theory of journalism/corruption determinants. Obviously, the most commonly examined political issue is democracy and democratization where the available evidences tentatively indicate the association between higher political competitiveness, democracy, and lower level of corruption; however, this effect is not linear. Some authoritarian countries actually experience slightly less corruption than countries at intermediate levels of democracy. Even authoritarian regimes do not have similar effect with regard to corruption behavior. Dictatorial regimes are significantly more corrupt than single-party and military regimes [90].
Following the transitional phase where countries enjoy more political competitiveness, they tend to be less corrupt [74]. The general idea is that partial, young democracies or countries that experience the transition to consolidated democracy perform worse than authoritarian regimes and much worse than full or older democracies [37, 91]. In support of this ideal view, Montinola and Jackman provide evidence that moderate levels of democracy do not reduce corruption if compared to autocratic regimes. After the transition period to democracy ends, democratic practices do curb corruption [10]. Consistent with this evidence, Ensung suggests that democracy in general decreases corruption with the exception of the early stages of the political liberalization that witnesses higher levels of corruption. His explanation assumes that it is the societal indicators of each society that determine how much democratic reforms can curb corruption [92]. In parallel, with these studies and results, political parties and its strength were also found to be deterring mechanisms. But, corruption prevails in the transition toward modernization where political parties are absent or have no influence on the public involvement in political decision-making [93]. In general, political parties have been found to be behind the prevalence and spreading of corruption as they may reduce the risks of corruption acts [94]. From a political point of view, what influences corruption is not only democracy-related issues, but the overall social, political, and judicial institutions of a given country [20]. Corruption is no more than a contest between those who benefit and those who lose from this illegal and abnormal practices. These two partners reflect the socioeconomic structure in any society. Political changes, therefore, do not curb corruption unless they redesign the balance of power in favor of fighting corruption [140].
The overall result accordingly suggests a failure of the conceptual association posed between democracy and the reduction of corruption [95]. Yet, there exists a complementarity effect of democracy and press freedom. Democratic institutions are much more effective in controlling corruption if the press is free, and free press can only be effective if politicians are accountable to the public [37, 96, 97]. Based on cross-country and panel data, Kalenborn and Lessmann show that conditionality matters, in the sense that press freedom is an important conditioning variable concerning the influence of democratic elections on corruption. Results of their study suggest a collaborative effect of democratic reforms and freedom of the press to provide unbiased information to the voters. Only in countries with high press freedom, voters are able to examine the corrupt behavior of politicians [98]. In this respect, scholars highlight three key democratic institutional factors that deter corruption: first, an increased number of veto players in the form of multiple legislative houses, independent executive branches, and constitutional courts; second, heightened transparency that enables exposure of corrupt behavior and activates vertical and horizontal accountability; and third, strong and large ruling coalitions that disable monopoly [99]. Similarly, data indicate that democracy empowers electorate to remove leaders from office and thus mitigate the impeding effect corruption has on economic growth. Therefore, leaders of many democracies refrain from growth-damaging corruption because they are afraid of punishment at the upcoming election [100, 101].
Based on the preceding discussion, it is obvious that press freedom and democratization have a cooperative relationship. As countries become more democratic, the critical investigative role of the press is intensified. Subsequently, press role in curbing corruption increases [102]. Empirical studies that are based on cross-sectional analyses confirm that free press role is intensified if it is accompanied with powerful horizontal political institutions able to hold corrupt official accountable. The most obvious agency is the independent judiciary system that works to sustain the critical role of the press. The picture, then, is that no single factor can fight corruption alone. This fight requires a collaborative role of all accountability mechanisms [63, 103]. The picture, now, will be more confusing if we know that democracy may have dual effects on perception of government corruption. Results obtained from the study of democracy and citizens’ perception of government corruption find a significant relationship between macro institutional democracy and micro individual perceptions of government corruption. When conditional effects of rationality including both instrumental calculations and intrinsic values on corruption perceptions were considered, the opposite effect exists. Democracy reduces the perception of government as corrupt [104].
The main reason for the inconsistency among scholars can be partially explained in the light of the multidimensionality of the concept of “democracy” or “democratization.” Whereas free and competitive election deepens corruption, other aspects such as freedom of speech, free press and civil liberties control it. To tackle such issues, Hung-En Sung examined democracy-corruption relationship using the three major statistical forms in social sciences (linear, quadratic, and cubic) utilizing up-to-date data covering a larger number of countries. In general, he finds that democratization reduces corruption [92]. As well documented, the level of corruption is more likely to decrease in countries with strong democratic institutions, for many reasons. Democracy mitigates the negative consequences of corruption when it allows the voters through election to expel politicians who engage in corrupt practices [100]. Democratic governments, accordingly, facilitate economic growth and receive the political support they deserve. However, in many cases democratic governments can exploit democratic institutions, and manipulate a network of political support through buying the votes and providing bribes to voters [105].
The comparison between democratic and dictatorial systems extends to cover election campaigns. Researchers prove that since elections are often accompanied with the need to buy votes and bribe voters, it is likely that democratic systems are more vulnerable to corruption than military, authoritarian and autocratic system. For sure, the incentive to finance political campaigns might be a good reason to the prevalence of corruption that never exists in dictatorial governments [106]. For me, this argument may need another look at the definition of corruption itself. Dictatorial political systems that threaten the freedom and dignity of human beings are the worst form of corruption regardless of whether they accommodate elections. Though the corrupt behavior of democratic election campaigns is unjustifiable, it is very naïve harm if compared to the negative consequences of the military and dictatorial systems that deprive citizens from their freedom and dignity. What is the privilege one can earn if he/she lost his dignity and personal freedom? What is the positive economic advantage the whole society can enjoy, if its citizens and institutions live under a dictatorial regime suppressing their basic human rights including the right in life? The narrow approach to political corruption is, then, misleading and has to consider dignity, human freedom, and self-determination issues.
Electoral rules, as another political dimension, are also not alike in their effect on corruption. Results suggest that the ballot structure, district magnitude, and the electoral formula have a strong influence on political corruption [75]. However, countries with higher electoral participation irrespective of the rules according to Adsera and his colleagues have lower levels of corruption [107]. In a similar vein, literature extensively examined the impact of political institutions and specifically political accountability mechanisms on good governance and corruption. Three main features have been identified in the political system that heavily affect corruption: the degree of competition in the political system, the existence of checks and balance mechanisms across different branches of government, and the transparency of the system. Results show that political institutions are extremely significant in determining the level of corruption: democracy, parliamentary systems, political stability, freedom of the press are all associated with lower corruption [108].
There is no direct and straightforward relationship between political competitiveness and corruption. The level of corruption is higher in countries with intermediate levels of political competition than in fully democratic or authoritarian countries.
The influence of the electoral institutions on corruption depends on the plurality voting system that enables higher level of the individual accountability.
Prevalence and persistence of corruption depend on the interaction between three major factors: (1) a discretionary power that enables an authority to tailor the policies and regulation in a discretionary way, (2) extraction of rents by the abuse of the discretionary power, and (3) lack of or weak horizontal and vertical accountability agencies.
Political stability does not influence corruption directly. It leaves its effect on both the quality of political institutions and the efficiency of judicial authority, which decrease the degree of compliance with regulations.
Literature does offer contradicting results of the causal relationship between party system and corruption. High political parties’ competition may cause corruption and corruption may heighten political parties’ competition.
The likelihood of corruption development increases where state capability in the areas of law enforcement and control is imperfect especially in times of social and political transformation.
The institutional historical contextual approach to political transformation provides evidence that democratization does not serve as a mechanism against corruption.
Democracy may reduce corruption indirectly through the creation of voters’ enabling environment that allows them to remove corrupt regime from office.
In general, democratization lowers the level of corruption; however, an increase in corruption is expected during the early stages of democratization.
The effect of democratization in curbing corruption depends largely on the integrity of the society and the strength of both the state and society.
In many cases, corrupt governments manipulate government bodies and officials to the extent they can gain the public support through illegal networks.
The cultural level analysis of corruption means that it is rooted in the long-term historical structural determinants that reside beyond the current occurrences and events. It also acknowledges the fact that corruption results from noneconomic and nonpolitical factors that include cultural and religious determinants. Thirdly, it indicates that attitudes toward corruption vary across cultures. Where some cultures totally reject corruption, some others may justify it. As Alejandro Moreno states, justification of corruption is based on different cultural basis. It is highly accepted in post-Communist societies, followed by Latin American and South Asian countries [109]. This result bears some implications to the link between the degree of permissiveness toward corruption, which has a cultural reference, and level of democracy. It says that justification of corruption is wider in nondemocratic cultures than in democratic ones. Finally, the cultural level analysis directly or indirectly implies some sort of ethical violation to the norms as accepted standards and behaviors that stand for ideals of good and virtue [110].
Education, for example, has been proven to be a real cause behind reduction of corruption [111]. It shapes other factors responsible for promoting honesty, and a sense of identity with the entire country rather than with specific cliques or groups [112]. In addition, higher levels of education has been found to generate greater levels of wealth and equality for countries, both of which are associated with lower levels of corruption [113]. Sociologists in contrast to political scientists, economists, and journalism scientists focus on cultural variables including trust in public institutions and a generalized trust as a social capital, dominance of religious values versus nonreligious values, unequal distribution of power and wealth, acceptance of nepotism, level of education, role of religion, and many other cultural factors.
Cultural values are very difficult to change over time and thus as Hofstede explains are uncontrollable and it is unwise to fight corruption through a cultural change process [114]. Based on his results, Husted draws a profile of the corrupt society as one that enjoys high power distance, high uncertainty avoidance, and high masculinity [86]. Power distance is the extent to which powerless people perceive and accept the unequal distribution of power in a culture. In such a culture, the inferiors rely on their superiors in the form of paternalism, which is a main cause of corruption in a society. Uncertainty avoidance refers to the extent to which members of a culture feel threatened by unpredictable environment where corruption can be seen as a way to minimize uncertainty and avoid threat. Masculinity refers to, among other things, a materialized society where the basic measure of success is money as opposed to interest to the quality of life. The more the society is materialized, the more tendency it has to corruption [86].
Religion as a cultural component defining societies receives little attention as a determinant of corruption with radically contradicted results. It is my conviction that all religions prohibit corruption and view it as a dangerous crime, but the eventual impact of the religion depends on its ability to shape social norms and the role of the latter to control behaviors, especially, those in power. In her study, Shadabi uses data of 174 countries in 2010 and all of the economic and noneconomic control variables were considered in its cross-sectional estimations. The results show that religion has no effect on corruption [115]. The neutral position of religion in the fight against corruption has to be extended by more comparative studies across religions. Does Islam, for example, have the same neutral effect similar to Judaism and Christianity? What about Hinduism and Buddhism? Do they have the same neutral effect on corruption? Are disbelievers or seculars more or less corrupt than believers? I do believe that the neutral effect of religion is due to the fact that corruption is committed more by the elite, those who hold the authority, who are less committed to the religious values if compared to the religious grassroots who are the victims.
Interestingly, is the effect of women’ participation in government on corruption where higher rates of women’ involvement in politics lead to lower levels of corruption. The justification is given by two different studies conducted by Robert Gatti and associate and Swamy and associates. Both suggest that women have on average a less tolerant attitude toward corruption [116, 117]. The problem with cultural factors is that it changes slowly and the value system may take decades to bring about very little changes. As such, it is very difficult to rely on cultural changes to fight corruption. Culture consists of orientations to action in particular ways. People acquire cultural values through lifelong socialization. Therefore, if a society experiences dramatic changes in terms of its politics and economy, the persistent cultural values may hamper the expected impact of economic and political liberalization on corruption. Communism, for example, had produced a culture of corruption to the extent that the entire populations had been socialized into values and traditions making corruption an integral part of their life style. Those cultural heritages of communism were unlikely to merely disappear with the new political values that produced them [118]. This obvious problem does not deny the role of culture in determining corruption and its decisive influence. Society is built on norms. Norms are standards of anticipated behaviors that also control the way we interact with each other. Our behavior is mainly influenced by our perception of norms. Our rejection or acceptance of the corrupt behavior depends largely on the norms that cultivate our worldview [71]. Another relevant cultural determinant is income inequality that creates an atmosphere in which corruption develops and flourishes. Whereas the rich have many opportunities to enter into corrupt behaviors and abuse their power to gain personal benefits, the poor struggle to stand against the rich. The ultimate result is the production of public policies that favor the interests of the powerful elites at the expense of marginalized people. The relationship of income inequality with corruption is complex. On the one hand, corruption intensifies inequalities in income distribution [119] and on the other, income distribution inequality significantly increases the level of corruption [120]. The empirical evidence of the influence of inequality comes from the study of Jong-sung and Khagram who found that inequality is as significant as economic factors in determining and explaining corruption [121].
There is an association between the levels of trust among the people and the level of corruption. Higher trust leads to lower corruption.
Religion has a neutral effect on corruption, with other things equal.
All religions prohibit corruption; yet, its potential impact is little and insufficient as a single factor in the matrix of corruption fighting.
Level of corruption is more affected by the long-lived sociocultural structures than the current state policies.
Increasing level of education without well-developed civil monitoring institutions leads to higher level of corruption as it increases agents’ rent-seeking capacity.
Income inequality is likely to be a significant and no less central determinant of corruption than economic and political factors.
Empowerment of women through increasing female participation in politics and decision-making circles would result in less corruption.
The conventional wisdom says that the natural cure for corruption is the existence of competition, which is a natural product of international openness. In perfectly competitive markets, outcomes of economic revenues are not subject to the exploitation and manipulation by market actors and thus there is no room for corruption [122]. The standard expectation is that more openness through international trade curbs corruption because states competing globally have to have the norms and culture of global business environment, mainly the rule of law, accountability agencies, and transparency to attract business [123]. The empirical analysis of the relationship between trade openness and corruption is rare. Ades and Di Tella find that corruption is higher in countries where domestic firms are protected by natural and administrative barriers to trade [74]. Similarly, Larrain and Tavares provide evidence supporting the negative effect of openness on corruption, that is, more openness leads to less corruption [122]. Sandholtz and Gray reach the same conclusion when they provide evidence supporting their hypothesis stating that greater degree of international integration lowers levels of corruption. They analyze data from 150 countries that support the justification of the role of international integration in importing cultural norms that deter corruption and alters the costs and benefits of engaging in corrupt acts [124].
In a parallel vein, other empirical findings lend significant support to the positive relationship between openness and good governance [125, 126, 127, 128]. Statistical analysis proves that openness to foreign trade significantly hinders corruption [126, 129]. However, the size of the effect is very small. A real difference to a country’s level of perceived corruption would require a substantial integration in global trade rather than a little change [130]. One measure of competitive pressures is the integration of a country into the global economy. If competition reduces corruption, then increased openness to international trade and investment should go along with less corruption [8]. According to an empirical study, it has been found that globalization is a powerful weapon against corruption only for middle- and high-income countries, while for low-income countries it has no significant impact. For such countries, fighting corruption requires additional global action aiming at the reduction of poverty [131]. There are good reasons for why globalization minimizes corruption as it exposes the globalized country to anti-corruption norms. The international networks of Western countries transmit the anti-corruption values to countries connected to globalization [124]. Sandholtz and Gray report that the more international organizations a country belongs to and the longer it has been a part of the major international institutions, such as the United Nations, the General Agreement on Tariffs and Trade/World Trade Organization (GATT/WTO), and the International Monetary Fund (IMF), the lower its level of corruption [124]. There is no doubt that social and political openness enhance information availability to a number of new players in politics. Yet, according to the study of [91] Charron, impact of social and political openness on corruption is conditioned by domestic factors.
In a slightly different thread of research, Mukherjee concludes that greater economic globalization does not reduce bureaucratic corruption. However, he argues that this finding does not necessarily deny the importance of global trade engagement. Rather, it reflects that curbing corruption is not only an outcome of integration in global economy that stems from a nexus of complicated and hierarchical bureaucracy [132]. Consistent with this view, Gatti tested the conventional wisdom that international openness reduces corruption by analyzing whether the presence of obstacles to international trade and capital flows is correlated with higher level of corruption and found no evidence to support his hypothesis. Instead, his conclusion states that the main impact stems from the incentives of collusive behaviors between the two partners: individuals and customs officials, rather than from the restrictive trade policy that lowers the openness and foreign competition [127]. Another international factor that seems to affect the level of corruption is the colonial heritage. Studies show that countries that were British colonies have significantly lower perceived corruption. This is because most former British colonies have common law systems [130]. In the light of the debate of global trade and corruption, it seems that the only verified result of international openness and corruption is simply it depends on the wider cultural and sociopolitical context.
The most dangerous international source and determinant of corruption, I argue, is the double standards employed by the United States and other powerful European countries against the weak and developing countries. If corruption as Gerald Caiden argues takes place when things are not what they ought to be [14], then, violation of international law by any state should be seen as corruption. In this context, the Israeli occupation of Palestine since 1948 right now with full support of United States and several European countries is by definition the worst form of corruption [133]. Within the past 70 years or so, Israel has occupied Palestine and was permitted to invade and attack numerous neighboring countries with full support of the United States and several European countries, without any true positive interference from the U.N or Security Council [134]. The illegitimacy of the Israeli occupation provides the legal justification for defending and interpreting all other issues pertaining to the dilemma of the Palestinians, including all acts of resistance since they are in line with the right of self-determination [133].
In a similar vein, Karen Del Biondo provides evidence that there have been double standards in the EU’s reactions to the violations of democratic principles in 10 African countries. The similar violations of democratic principles by Eritrea, Ethiopia, Kenya, Chad, Niger, Nigeria, Rwanda, Guinea, Côte d’Ivoire, and Zimbabwe received dissimilar reactions to protect the self-interested objectives of the EU [135]. An up-to-date example of the international corruption according to my suggested definition is the intervention of USA and several European countries to suppress the Arab Spring revolutions. The serious consequences of such interference are reflected in the decline of press freedom and civil liberties, lack of rule of law and accountability agencies which, in turn, worsen the level and magnitude of corruption. In other words, the systemic corruption of the developing countries could be partially attributed to foreign policies of some Western countries that seek to serve their own interests at the expense of the rights of the marginalized peoples of the East. Hindering democratic transformation in developing countries under any justification may not serve the developed countries themselves. Corruption is one of the main causes behind poverty, unemployment, poor quality of life, depression, and all social and political and economic problems the whole society, especially youth suffer from [136]. What I like to stress is the fact that some of Western countries through their foreign policies that work against the aspirations of peoples of developing countries toward freedom, democracy, and dignity increase corruption in such countries, which eventually harms the West. Supporting nondemocratic governments equals defending corruption as dictators make no distinction between their own wealth and that of their countries [24]. Nondemocratic governors are above the law and cannot be held accountable. As such, the best international policy for fighting corruption is to promote real democratic systems that respect the rule of law, enhance accountability, press freedom, civil liberties, and social and economic justice.
Adding the international domain in the analysis of corruption is obviously justified by the current research that has tended to be fragmented. Scholars often exhibit little familiarity in areas of research other than their own fields [24, 137, 138]. As a result, progress in explaining this cancer or coronavirus pandemic that is damaging the fabric of any hope for stability, democracy, and welfare will continue without a real cure. I therefore, suggest that the starting point is to reconsider a new definition of corruption embracing the dynamic collaboration among the five hierarchal layers with emphasis on the highest level, the international. I also assume that: (1) The double standards policies of some powerful Western states are in stark contrast with any international anti-corruption policy the World Bank, IMF and other international and regional organizations adopt to fight corruption. (2) The incredible illegal support of USA to Israeli’s occupation of Palestine is the main source of corruption in Arab countries that delay projects of political and economic development over seven decades with the hope to free Palestine. Unfortunately, their efforts in the two fronts lead to a big failure. (3) Western countries’ position against the aspirations of developing countries for freedom, rule of law, dignity, and democracy perpetuates the systemic corruption and helps export terrorism and migration to the West. (4) I, therefore, presume that emphasis on the missing part of corruption studies, the international dimension, will provide a perfect insight on how to understand the mechanisms through which corruption works. It is a vicious cycle through which causes of corruption trickle down from the upper to the lower level and to the bottom, journalism as depicted in the graph of the hierarchal universal theory. The ultimate result of this cycle is a type of journalism that enters into strong and permanent alliance with corrupt and dictatorial governments. Journalism is a key factor affecting vertical and horizontal accountability institutions. Not only this, but it defends the wrongdoing of corrupt officials and serves against any peaceful means to change them or hold them accountable. Since, corruption as reviewed here is an economic, political, and cultural issue expressing a big failure of the whole society, journalism performance also decreases the risks and costs of corruption and publicizes the impunity culture that tolerates the corruptible.
The corrupt journalism serves mainly to suppress diversity, particularly, the opposition voices while maintaining and strengthening its ties with corrupt alliances, supporting monopoly, discretion and attacking accountability. This analysis illustrates to a large extent the penetration of journalism influences into the fabric of the three major ingredients of formula of corruption suggested by Klitgaard who see corruption as monopoly + discretion – accountability ([25], p. 75).
Globalization exerts a powerful impact on decreasing corruption in high- or middle-income countries; however, it has no impact in low-income countries.
A substantial opening to foreign trade is required to lower corruption significantly, while a marginal shift does not make a difference.
The level of corruption is negatively correlated with the legal cultures of the former colonial heritage.
International quantitative trade constraints shift the economy from directly productive activities to unproductive rent seeking activities.
Corrupt behaviors grow and flourish in closed economies, while countries involved in international economy expose themselves to all types of controls that minimize corruption.
In many cases, globalization has increased corruption as it involves a low level of risk discovery and penalty which encourages a high benefit of bribery and profit.
Occupation of Palestinian state by Israel represents the worst from of international corruption that violates the international law and the international humanitarian laws.
Defending the Israeli occupation for Palestinian state by USA and some powerful European states works against the aims of all international agencies that fight corruption including World Bank and IMF.
Any effort from USA and some powerful European states to hinder the revolutions of developing countries is an effort to perpetuate corruption and increase the likelihood of migration and terrorism that they are currently suffering from.
“The hierarchical universal theory of journalism/corruption determinants” intends to accommodate the various variables and underlying relations affecting corruption organized in a continuum from macro-international to micro-journalistic or individual level. In our effort to build the theory, we went—right now—through three steps: (1) The first step identifies the five interactive hierarchical levels of influences. (2) The second step reviews the most relevant empirical studies carried out in each level. (3) The third step introduces the generalizations/the results obtained from the empirical studies/existing literature. (4) The remaining step (the fourth) intends to synthesize the main cross-border hypotheses that create linkages capable to explain corruption, predict it, direct the future studies, and finally contribute to reducing it.
The challenging question is how to study variables pertaining to several levels interacting together to restrain or spread corruption. This question suggests a conceptual universal cross-cultural, multidisciplinary perspective beyond the traditionally single studies dedicated to examining a direct liner relationship within a specific level or sublevel. A levels-of-analysis perspective, as suggested by Thomas Hanitzsch, has been promising in sketching a universal framework for large-scale comparative analysis [139]. In this respect, Stephen Reese argues-in his conceptualization of the hierarchical influences approach—that is dedicated only to global journalism studies—that most research is not planned to examine variables attached to all levels of influence once. However, scholars can consider a multilevel interpretation of their results or actually take a further step to account for interaction among hierarchical levels [140]. The hierarchal theory shows to what extent there is a need to redirect corruption research to understand how it works to help them contribute to policies and initiatives of corruption fighting.
Before stating such hypotheses and closing this chapter, it is important to emphasize some cautions. (1) As is obvious, it is beyond my capacity, time and space limit to review all relevant theoretical and empirical works that fit into each level of analysis. Given the richness and unlimited scholarship produced on the subject, it would be impossible to cover all at once. The aim of my attempt is to redesign a new theory that aims at drawing a universal map for what has been carried out and what is still missing. What is important is the conceptual framework and methodological underpinnings that future research can consider. (2) Despite the fact that multidisciplinary international comparative studies are the recommended type of research to test the cross-border hypotheses, other types of research studies and methods, quantitative and qualitative, single cases using different indexes measuring corruption through one point of time or longitudinal studies are of added value for understanding corruption. (3) The approach we adopt in building this theory is based on the concept of science as a dynamic process of critical thinking, raising questions, and formulating hypotheses and not a body of knowledge. It is a matter of identifying the possible relationships between variables we can empirically observe and test [141]. (4) The following list of hypotheses is just initial step in the ongoing research and conceptual work that helps understand journalism-corruption determinants in their comprehensive framework. They are not by any definition a comprehensive view.
As journalism institutions become more restricted in nondemocratic countries that exhibit the least competitive markets, along with the least international economic integration and the lowest level of education, corruption will expand and flourish in all spheres of life.
The more democratic institutions are, and the more rule of law and accountability mechanisms exist, the more free and independent journalism institutions become and the less corruption levels prevail.
Journalism conditions and specifically its freedom, diversity, and independence are closely related to higher levels of economic and political competitions and higher levels of social capital and international integration and lower levels of corruption.
The watchdog role of journalism enhances good governance, rule of law, accountability, less levels of income inequality and hence lower levels of corruption.
Alliances between USA, powerful European nations, and dictators in developing countries are related to diffusion of state-owned and captured journalism, centralized governments, lower levels of transparency, and, hence, higher levels of corruption.
As totalitarian and authoritarian systems prevail, monopoly and centralization dominate, bureaucracy and public sector increase, the closed economies exist, and corruption diffuses in all domains of life.
As double standards in international politics dominate, sources of corruption develop, and alliances between ruling elites in developed and developing countries strengthen, journalism institutions are more likely to serve the interests of the elites at the expense of the general public, and the divide between the rich and the poor widens, leading to higher levels of corruption.
As educational and cultural levels of the general public increase, journalism ethical performance prevails, its watchdog role intensifies, democratic and accountability institutions and practices are more likely to exist, and corruption levels decrease.
As social networks penetration increase, vertical accountability dominates, rule of law enhances, the cost of corrupt behavior grows, and incidence of corruption reduces.
Watchdog journalism is more likely to have a preventive effect of corruption in a context where vertical and horizontal accountability exist, anti-corruption norms prevail, discretionary power of the elites is at its minimum, and finally where the judicial system offers higher level of corruption penalty.
Journalists’ autonomy and safety are prerequisites in the fight against corruption as independent investigative reports threaten and damage the horizontal and vertical cooperation between the corrupt agencies in the corrupt states. However, without independent judiciary system, and strong civil society, the corrupt authority will suppress the independent and free voices of journalism.
Perception of corruption as a proxy for actual corruption should not be taken for granted. In corrupt regimes where journalism is owned, controlled, and operated by corrupt ruling elites, corruption crimes and accusations are used as conspiracy tool in the hands of dictators to manipulate the public mind and distract the attention from focusing on efforts of regime change.
Though systemic corruption is rooted in the historical, cultural, and political structure, policy changes and definitely mass education and press freedom can help in reducing corruption.
Press freedom, democracy, rule of law, horizontal and vertical accountability, women empowerment, global openness, and education are complements rather than substitutes in their fight against corruption.
Press freedom causes less corruption; however, lower corruption level is an indicator of a healthy social, cultural, political, and economic environment that serves as a real cause for enhancing press freedom. As such, the direction of causation runs from lower corruption to higher press freedom as well.
IntechOpen publishes different types of publications
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