\r\n\tSQL is worth learning because it’s a programming language that’s in demand in the tech industry and in other sectors that need technology. Most software developers who know SQL earn respectable salaries. Learning SQL can not only enhance your skills, but it can also give you a better understanding of the applications you work with daily. In this book, we will go through the details of SQL and how to use it effectively. The goal of this book is to have many practical application examples that will help learners easily acquire and self-study SQL.
",isbn:"978-1-83969-946-7",printIsbn:"978-1-83969-945-0",pdfIsbn:"978-1-83969-947-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"d1d908cd61561c1e813552fbd6cb9ed1",bookSignature:"Ph.D. Duc-Man Nguyen and Dr. Van-Loi Nguyen",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11919.jpg",keywords:"Database Classification, Types of Databases, SQL Basic, Drop Statement, Aggregate Functions, Conversion Function, Date Function, Mathematical Functions, User-Defined Types, User-Defined Functions, String Data Type, Pivoting Data in SQL",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 3rd 2022",dateEndSecondStepPublish:"July 6th 2022",dateEndThirdStepPublish:"September 4th 2022",dateEndFourthStepPublish:"November 23rd 2022",dateEndFifthStepPublish:"January 22nd 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"a month",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Nguyen Duc Man is a member of the DSA-Da Nang Software Association, Vietnam. He was awarded the Award for Excellent effort in Training and Management by the Duy Tan University, Vietnam for several years in a row, and received the Certificate of Merit for Excellent effort in Training and Management by the Ministry of Education and Training, Vietnam. His current research interests are software testing, mobile testing, test automation, test case generation, context-driven testing, and ML for testing.",coeditorOneBiosketch:"Dr. Van-Loi Nguyen received his Master of Engineering in Computer Science from the University of Danang, Vietnam in 2010, and a Ph.D. degree from Soongsil University, Korea, in 2017. He is currently a lecturer at the Vietnam - Korea University of Information and Communication Technology, the University of Danang. He has over 18 years of experience teaching and researching programming, databases, machine learning, information retrieval, multimedia, and artificial intelligence.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"227628",title:"Ph.D.",name:"Duc-Man",middleName:null,surname:"Nguyen",slug:"duc-man-nguyen",fullName:"Duc-Man Nguyen",profilePictureURL:"https://mts.intechopen.com/storage/users/227628/images/system/227628.jpg",biography:'1.\tName:\tNguyen Duc Man\n\tOffice: Room 601, 254 Nguyen Van Linh, Danang, Vietnam\n\tTel: +84-2363 650 403 (Ext 601)\n Mobi: 0904 235 945\n\tEmail: mannd@duytan.edu.vn\n\n2.\tEducation:\nBSc.\tInformation Technology\tDuy Tan University, Vietnam\t1999\nMSc.\tComputer Science\tDanang University, Vietnam\t2009\nPhD.\tComputer Science\tDuy Tan University, Vietnam\t2020\n\n3.\tAcademic experience:\nDuy Tan University, Vietnam\tTeaching\tLecturer\t2004- Present\tFT\n\t\n4.\tNon-academic experience:\nHSD Corporation, Ho Chi Minh, Vietnam\tAnalysis, Design and Code, DB Design\tSoftware Developer\t1999-2001\tFT\nDuy Tan Software Center, Vietnam\tTeam leader, Planning, A&D\tProject Lead\t2001-2003\tFT\n\n5.\tCertifications or professional registrations:\n-\tCertificate for completion of Train the Trainer courses (Software Capstone Project, Requirements Engineering, Software Architecture, Software Project management, software Process and Quality management, Software Integration Practices). Institute of Software Research, Carnegie Mellon University, USA. (2010, 2014, 2016, 2017, 2018, 2019).\n-\t7 Professional Development Hours for participation in the Fundamentals of Program Assessment Workshop, ABET Symposium (2017)\n-\t7 Professional Development Hours for participation in the Self-Study Development Workshop ABET Symposium (2017)\n-\t14 Professional Development Hours for participation at the 2017 ABET\nSymposium, ABET Symposium (2017)\n-\tSoftware Testing and Automation Conference. VISTACON 2011, Ho Chi Minh, Vietnam (2011).\n-\tFagan Software Inspection Method. ECCI Group, Vietnam (2011).\n-\tHP Train the Trainer courses: HP QTP, LoadRunner, Quality Center (2011).\n\n6.\tMembership in professional organizations:\n-\tMember of DSA-Da Nang Software Association, Vietnam.\n\n7.\tHonors and awards:\n-\tAwards for Excellent effort in Training and Management. Duy Tan University, Vietnam (2003, 2006, 2007, 2008, 2009, 2010, 2012).\n-\tCertificate of Merit for Excellent effort in Training and Management. Ministry of Education and Training, Vietnam (2008- 2009, 2010- 2011, 2013- 2014).\n-\tCertificate of Merit of the People Committee of Da Nang. Danang, Vietnam (2011-2012).\n\n8.\tService activities:\n-\tInstitutional service: \n•\tStudents’ Awards Committee \n•\tFaculty Development Committee \n•\tScholarship Committee \n•\tFaculty Council \n\n9.\tPublications and presentations from the past five years:\n\n1.\t\tCheng, Y. H., Chang, P. C., Nguyen, D. M., & Kuo, C. N. (2020). Automatic Music Genre Classification Based on CRNN. Engineering Letters, 29(1).\n2.\t\tHuynh, Q. T., Pham, L. T., Ha, N. H., & Nguyen, D. M. (2020). An Effective Approach for Context Driven Testing in Practice—A Case Study. International Journal of Software Engineering and Knowledge Engineering, 30(09), 1245-1262.\n3.\t\tNguyen, D. M., Huynh, Q. T., Ha, N. H., & Nguyen, T. H. (2020). Automated test input generation via model inference based on user story and acceptance criteria for mobile application development. International Journal of Software Engineering and Knowledge Engineering, 30(03), 399-425.\n4.\t \tNguyen, D. M., Do, H. N., Huynh, Q. T., Vo, D. T., & Ha, N. H. (2018, August). Shinobi: A Novel Approach for Context-Driven Testing (CDT) Using Heuristics and Machine Learning for Web Applications. In International Conference on Industrial Networks and Intelligent Systems (pp. 86-102). Springer, Cham.\n5.\t\tHoang-Nhat, D. O., NGUYEN, D. M., HUYNH, Q. T., & Nhu-Hang, H. A. (2018). One2Explore-Graph Builder for Exploratory Testing from a Novel Approach.\n6.\t\tNguyen, M. D., Huynh, T. Q., & Nguyen, T. H. (2016, November). Improve the Performance of Mobile Applications Based on Code Optimization Techniques Using PMD and Android Lint. In International Symposium on Integrated Uncertainty in Knowledge Modelling and Decision Making (pp. 343-356). Springer, Cham.\n7.\t\tBao Le Nguyen, Nguyen Duc Man, Minh Nguyen Cong and Luong Vo Van (2013). Difficulties in the Operation of an International Program in Vietnam. FICAP-1 Proceedings, BrownWalker Press, 2013, ISBN-13: 9781612337043.\n8.\t\tDuc Nguyen Duc Man, Tien Vu Truong, Nguyen Bao Le (2013). Deployment of Capstone Projects in Software Engineering Education at Duy Tan University as Part of a University-wide Project-based Learning Effort. Learning and Teaching in Computing and Engineering (LaTiCE), IEEE Computer Society -CPS, 2013, E-ISBN :978-0-7695-4960-6 (pp. 184 -191).\n9.\t\tGia Nhu Nguyen, Nhat Tan Tran, Thanh Trung Nguyen and Nguyen Duc Man (2014). The Benefits of CDIO for ABET Preparation from a Hands-on Study in Vietnam. Proceedings of the 10th International CDIO Conference. Barcelona \n10.\t\tVu T Truong, Bao N Le, Man N Duc, Thang M Nguyen (2014). Accessing the Maturity of Teamwork Capabilities through CDIO Projects. Proceedings of the 10th Annual International CDIO Conference. Universitat Politècnica de Catalunya, Barcelona, Spain.\n11.\t\tPhuong A Pham, Man D Nguyen, Long Q Nguyen, Thang M Nguyen, Bao N Le (2014). Learning Computer Programming In Cdio’s Team Settings. Proceedings of the 10th Annual International CDIO Conference. Universitat Politècnica de Catalunya, Barcelona, Spain.\n12.\t\tVo, Q. N., Tran, N. P., Van Dat Ngo, V. H. T., Huynh, Q. T., Ha, N. H., & Nguyen, D. M. LEVERAGE THE BLOCKCHAIN TECHNOLOGY TO MANAGE SMART CONTRACT IN ASSET TRADING. Kỷ yếu Hội nghị KHCN Quốc gia lần thứ XII về Nghiên cứu cơ bản và ứng dụng Công nghệ thông tin (FAIR); Huế, ngày 07-08/6/2019 DOI: 10.15625/vap.2019.00032\n\n13.\t\tHa, N. H., Nguyen, D. M., Liu, C. A., Van Van, T., Nguyen, A. D., & Huynh, Q. T. AN EMPIRICAL STUDY OF THE IMPACT OF THE MPOS SYSTEM ON THE PROCESS CHANGE OF RESTAURANTS. Kỷ yếu Hội nghị KHCN Quốc gia lần thứ XII về Nghiên cứu cơ bản và ứng dụng Công nghệ thông tin (FAIR); Huế, ngày 07-08/6/2019 DOI: 10.15625/vap.2019.00032\n\n14.\t\tNguyễn Thanh Hùng, Nguyễn Đức Mận, Huỳnh Quyết Thắng (2019), Thử Nghiệm Đánh Giá Áp Dụng Một Số Kỹ Thuật Kiểm Thử Để Nâng Cao Độ Tin Cậy Cho Ứng Dụng Di Động Trong Môi Trường Phát Triển Linh Hoạt. Section on Information and Communication Technology (ICT) - No. 13, Journal of Science and Technique - Le Quy Don Technical University - No. 199, ISSN 1859-0209\n15.\t\tHuỳnh Quyết Thắng, Nguyễn Đức Mận, Nguyễn Thị Bảo Trang, Nguyễn Thị Anh Đào (2016). Kỹ thuật kiểm thử hồi qui hiệu quả cho phát triển ứng dụng di động. Kỷ yếu Hội nghị khoa học công nghệ quốc gia lần thứ IX, ngày 4-5/8/2016 - "Nghiên cứu cơ bản và ứng dụng Công nghệ thông tin" (FAIR 2016), trang 255-265. Nhà xuất bản Khoa học tự nhiên và Công nghệ. ISBN 978-604-913-472-2\n\n10.\tRecent professional development activities:\n-\tCoordinator and Assistant Director of ACM/ICPC Asia Regional Contest, Danang, Vietnam (2013). \n-\tParticipated in the 7th National Conference on Fundamental and Applied IT Research (2014).\n-\tAttended the 7 Professional Development Hours the Fundamentals of Program Assessment Workshop (2017).\n-\tParticipated in the 12th National Conference on Fundamental and Applied IT Research (2019).\n-\tINISCOM 2018, INISCOM 2019, KSE 2019, CITA2021, CITA2022\n-\tAttended the CDIO Regional Meeting - Asia-Pacific (2019).',institutionString:"Duy Tan University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Duy Tan University",institutionURL:null,country:{name:"Vietnam"}}}],coeditorOne:{id:"473326",title:"Dr.",name:"Van-Loi",middleName:null,surname:"Nguyen",slug:"van-loi-nguyen",fullName:"Van-Loi Nguyen",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003Sa5QKQAZ/Profile_Picture_2022-05-10T10:01:50.jpg",biography:"Dr. Van-Loi Nguyen received his Master of Engineering in Computer Science from the University of Danang, Vietnam in 2010, and a Ph.D. degree from Soongsil University, Korea in 2017. He is currently a lecturer at the Vietnam - Korea University of Information and Communication Technology, the University of Danang. He has over 18 years of experience teaching and researching in the fields of programming, databases, machine learning, information retrieval, multimedia, and artificial intelligence.",institutionString:"University of Danang",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"9",title:"Computer and Information Science",slug:"computer-and-information-science"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"429342",firstName:"Zrinka",lastName:"Tomicic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/429342/images/20008_n.jpg",email:"zrinka@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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1. Introduction
Poverty is a serious economic and social problem that afflicts a large proportion of the world’s population and manifests itself in diverse forms such as lack of income and productive assets to ensure sustainable livelihoods, chronic hunger and malnutrition, homelessness, lack of durable goods, disease, lack of access to clean water, lack of education, low life expectancy, social exclusion and discrimination, high levels of unemployment, high rate of infant and maternal mortality, and lack of participation in decision making [1, 2, 3]. Because poverty has deleterious impacts on human well-being, its eradication has been identified as an ethical, social, political and economic imperative of humankind [1, 3, 4]. Thus, the eradication of poverty and hunger were key targets in the Millennium Development Goals that the United Nations adopted in September 2000, and continue to be a priority in the pursuit of the Sustainable Development Goals that the United Nations General Assembly subsequently adopted in January 1, 2016 [5, 6, 7, 8, 9]. Although poverty exists in all countries, extreme poverty is more widespread in the countries in Sub-Saharan Africa and South Asia [8, 10]. The causes of poverty in these countries are complex and include the pursuit of economic policies that exclude the poor and are biased against them; lack of access to markets and meaningful income-earning opportunities; inadequate public support for microenterprises through initiatives such as low interest credit and skills training; lack of infrastructure; widespread use of obsolete technologies in agriculture; exploitation of poor communities by political elites; inadequate financing of pro-poor programs; low human capital; conflicts and social strife; lack of access to productive resources such as land and capital; fiscal trap; and governance failures. Liu et al. [11], Beegle and Christiaensen [12], and Bapna [13] note that although considerable progress has been made to reduce poverty in the last two decades, more needs to be done to not only reduce the rate of extreme poverty further, but to also reduce the number of those living under extreme poverty. This is an important aspect of poverty reduction given that the rate of poverty can fall while the number of the poor is increasing simultaneously. For example, the poverty rate in Africa decreased from 54% in 1990 to 41% in 2015 but the number of the poor increased from 278 million in 1990 to 413 million in 2015. This constitutes a compelling case for robust well-thought out policies that not only stimulate economic growth but also produce outcomes that are inclusive and sustainable and address other dimensions of well-being such as education, health and gender equality [1, 8, 12, 14, 15, 16, 17, 18, 19, 20]. Examples of poverty reduction initiatives that various countries have adopted are Ghana’s poverty reduction strategy, Ethiopia’s sustainable development and poverty reduction program, Kenya’s economic recovery strategy for wealth and employment creation, Senegal’s poverty reduction strategy, and Uganda’s poverty eradication action plan. Toye [21] notes that the measures outlined in these strategic policy documents have not been effective in reducing poverty because they were initiated as a condition for development assistance under the debt relief initiative of the International Monetary Fund and the World Bank. A critical analysis of the poverty reduction measures contained in these documents, however, reveals that to a large extent their failure to significantly reduce the incidence of poverty can be largely attributed to factors such as how the programs were designed, how the poverty reduction policies were targeted, and how they were implemented. This chapter is based on the premise that success in poverty reduction can be achieved by identifying who the poor are, assessing the extent of poverty in the different regions of developing countries, determining both the root causes of poverty and the opportunities that exist for reducing the incidences of poverty and improving the standards of living, and removing the various obstacles to poverty reduction [1, 3, 6, 15, 22]. The assumption that economic growth automatically results in a reduction of poverty also needs to be re-examined given the existence of empirical evidence that shows that economic growth can occur while poverty is worsening [8, 16, 17, 23, 24, 25, 26, 27]. The focus needs to be on inclusive growth that addresses the unique needs of the poor and increases their access to basic services, employment and income generating opportunities, reliable markets for their products, information, capital and finance, and adequate social protections that remove the causes of the vulnerability of the poor [3, 7, 14, 19, 25, 28, 29, 30, 31]. The experience of diverse rapidly growing developing countries demonstrates that with political will and visionary leadership that is committed to justice, equality, and rule of law, the goal of reducing poverty and improving the living standards of the poor is achievable. Sachs [4] notes that through such leadership the downward spiral of impoverishment, hunger, and disease that certain parts of the world are caught in can be reversed and the massive suffering of the poor brought to an end. Sachs is categorical that although markets can be powerful engines of economic development, they can bypass large parts of the world and leave them impoverished and suffering without respite. He advocates that the role of markets be supplemented with collective action through effective government provision of health, education and infrastructure. The World Bank [1, 32, 33], Acemoglu and Robinson [34], and Beegle and Christiaensen [12] argue that in much of Sub-Saharan Africa where agriculture is the main occupation, low agricultural productivity is a primary cause of poverty. They assert that the low agricultural productivity is a consequence of the ownership structure of the land and the incentives that are created for farmers by the governments and the institutions under which they live. More recently, the COVID-19 global pandemic has significantly increased the number of the newly poor. The World Bank [16] estimates that in 2020, between 88 million and 115 million people fell into extreme poverty as a result of the pandemic and that in 2021 an additional between 23 million and 35 million people will fall in poverty bringing the new people living in extreme poverty to between 110 million and 150 million. But the World Bank also points out that even before the pandemic, development for many people in the world’s poorest countries was too slow to raise their incomes, enhance living standards, or narrow inequality. Coates [35] contends that in February 2020, poverty was in fact increasing in several countries while many others were already off track to achieving Sustainable Development Goal 1. In what follows, I explore these issues and identify practical measures that can be applied to stimulate inclusive growth and reduce extreme poverty in developing countries. I also present some case studies to demonstrate how these measures have been successfully applied in various developing countries.
2. Some definitions and statistics
A clear definition of poverty is vital to identifying the causes of poverty, measuring its extent, and in assessing progress towards its eradication. The World Bank defines poverty in terms of poverty lines that are based on estimates of the cost of goods and services needed to meet the basic subsistence needs. Thus, the poor are regarded as those whose incomes is at or below specific poverty lines. The most commonly used international poverty line is $1.90 per day [5, 17]. A concept that is closely related to the poverty line is the head count index which is the proportion of the population below the poverty line. Table 1 shows that Sub-Saharan Africa made significant progress in poverty reduction between 1990 and 2018 as indicated by the decrease in the head count index from 55–40%. Over this period, the population of Sub-Saharan Africa increased by 112% from 509.45 million to 1078.31 million and the population of the poor increased by 55% from 280.95 million to 435.56 million. This increase in the number of the poor by about 154.61 million is significant and suggests an urgent need to intensify poverty reduction efforts.
Poverty line of US$ 1.90
Poverty line of US$ 3.20
Head count index
Number of the poor
Head count index
Number of the poor
1990
0.55
280.95
0.76
385.50
1995
0.60
352.76
0.79
463.37
2000
0.58
388.27
0.79
526.33
2005
0.52
393.57
0.76
574.25
2010
0.47
412.49
0.72
626.12
2015
0.42
417.60
0.68
679.09
2018
0.40
435.56
0.67
718.76
Table 1.
Head count index (%) and the number of the poor (millions) in sub-Saharan Africa.
Source: PovCalNet, World Bank.Online.
The rate of poverty in Sub-Saharan Africa is significantly greater if it is assessed using a $3.20 a day poverty line. Several researchers argue that $3.20 a day is a more realistic yardstick for assessing poverty and are critical of the commonly used $1.90 a day poverty line that they regard as being too low for standard of living assessments. As expected, Table 1 shows that over the period under consideration the poverty rates in Sub-Saharan Africa were higher using a $3.20 a day poverty line as compared to poverty rates estimated using a $1.90 a day poverty line. Specifically, using the $3.20 a day poverty line shows that the poverty rates were 76% in 1990 and declined to 67% in 2018. However, over 1990–2018 period, the number of those living in poverty increased by 333.26 million from 385.5 million to 718.76 million (Figures 1–3).
Figure 1.
Headcount index (%) sub-Saharan Africa. Source: PovCalNet [36], World Bank. Online.
Figure 2.
Number of the poor (millions) in sub-Saharan Africa. Source: PovCalNet [36], World Bank. Online.
Figure 3.
Poverty gap in sub-Saharan Africa. Source: PovCalNet [36], World Bank. Online.
A useful metric in analyzing poverty issues is the poverty gap which is the ratio by which the mean income of the poor fall below the poverty line. The poverty gap is an indicator of the severity of the poverty problem in any context and provides an estimate of the income that is needed to bring the poor out of poverty. The squared poverty gap is also an indicator of the severity of poverty and is computed as the mean of the squared distances below the poverty line as a proportion of the poverty a line. Its usefulness stems from the fact that it gives greater weight to those who fall far below the poverty line than those who are close to it. Estimates of the squared poverty gap can be used to more effectively target poverty alleviation policies to segments of communities that are more severely impacted by poverty and thus bring about better and more equitable outcomes. Some values of the squared poverty gaps for Sub-Saharan Africa are presented in Table 1 and depicted in Figure 4. They corroborate the overall picture of the severity of poverty declining in sub-Saharan Africa between 1990 and 2018 (Table 2).
Figure 4.
Squared poverty gap in sub-Saharan Africa. Source: PovCalNet [36], World Bank. Online.
Pov. Gap ($1.90)
Sq. Pov. Gap ($1.90)
Pov. Gap ($3.20)
Sq. Pov. Gap ($3.20)
1990
0.25
0.15
0.42
0.28
1995
0.29
0.17
0.46
0.31
2000
0.27
0.16
0.45
0.30
2005
0.22
0.13
0.40
0.25
2010
0.19
0.10
0.36
0.22
2015
0.16
0.08
0.32
0.19
2018
0.15
0.08
0.31
0.18
Table 2.
Poverty gap and squared poverty gap (%) in sub-Saharan Africa.
Poverty is a challenge that developing countries can overcome through, among others, good economic and social policies, innovative and efficient use of resources, investments in technological advancement, good governance, and visionary leadership with the political will to prioritize the needs of the poor. Sachs [4] notes that these elements are vital in enabling the provision of schools, clinics, roads, electricity, soil nutrients, and clean drinking water that are basic not only for a life of dignity and health, but also for economic productivity. In several countries measures are already being implemented to combat extreme poverty and improve the standards of living of the impoverished communities with steady progress being realized in several cases. Policy makers can learn important lessons from these poverty reduction measures and replicate and scale them up in other regions. Some strategies that developing countries can apply to reduce both the rate of poverty and number of the poor are:
3.1 Stimulating inclusive economic growth
Economic growth is vital in enabling impoverished communities to utilize their resources to increase both their output and incomes and thus break the poverty trap and be able to provide for their basic needs [1, 4, 19, 20, 22, 23, 25, 37, 38]. However, for economic growth to be effective in reducing poverty, it needs to be both inclusive and to occur at a rate that is higher than the rate of population growth. The fact that agriculture is the dominant economic sector in most poor communities implies that efforts to combat extreme poverty need to be directed towards increasing agricultural production and productivity [28, 30, 39, 40, 41, 42]. Some concrete ways for achieving this overall goal include promoting the adoption of high yielding crop varieties and use of complementary inputs such as fertilizers and pesticides; intensifying the use of land through technological improvements such as increased use of irrigation where water is a constraint to agricultural production; and, adoption of post-harvesting measures that reduce the loss of agricultural produce. These measures are costly and are likely to be unaffordable to poor households. Their increased adoption requires the provision of cheap credit on terms that are flexible and aligned to the unique circumstances of the poor. How credit programs are designed is critical because it can have a significant impact on poverty reduction and livelihood outcomes [35, 43]. When well designed, these programs can stimulate economic growth and enable poor communities to access financial capital for investment in income-generating activities. If poorly designed (e.g. if the interest rates are high and the repayment periods are short), credit programs can be not only exclusionary and inequitable, but the credit can also be misapplied, the poor entrapped in debt cycles, and economic growth and poverty reduction undermined.
Stimulating economic growth also requires public investments in infrastructure such as roads, electrical power, schools, hospitals, and water and sanitation systems [23]. These investments are important for several reasons. Good roads reduce transportation costs and generate diverse economic benefits that include increased ease of transporting agricultural produce to markets, ease of accessing agricultural inputs, and an increase in the profitability of income-generating businesses [23]. Providing electric power to impoverished areas not only results in improved standards of living but also stimulates the establishment of small-scale industries that process agricultural produce and thus contribute to value addition, in addition to creating much needed jobs. Providing safe, good-quality water for drinking and domestic use is vital in reducing incidences of debilitating water-borne diseases that are expensive to treat, saving time used to fetch water and enable the time and effort saved to be employed in more productive activities. More generally, investment in infrastructure will make rural economies more productive, increase household incomes, contribute to meeting basic needs, and enable greater saving for the future thus putting the economy on a path of sustainable growth [4, 35, 40].
A key challenge that developing countries face in providing the infrastructure they need is financing. On this issue several researchers advocate for increased use of foreign aid to finance public infrastructure in poor developing countries. According to Sachs [4], the rationale for this policy proposal is that developing countries are too poor and lack the financial resources for providing the infrastructure that they require to break the poverty trap and enable the provision of basic needs. He argues that if the rich world had committed $195 billion in foreign aid per year between 2005 and 2025, poverty could have been entirely eliminated by the end of this period. Moyo [44], Easterly [45, 46], and Easterly and Levine [47] are however critical of foreign aid and assert that it not only undermines the ability of poor communities to develop solutions to their problems but also fosters corruption in governments and results in the utilization of the aid funds on non-priority areas. Banerjee and Duflo [43] and Page and Pande [23] opine that foreign aid can foster economic growth if well-targeted and used efficiently. They however point out that in most cases foreign aid is a small fraction of the overall financing that is required and that developing countries must increasingly rely on their own resources that are generated through taxes. Successful financing of critical infrastructure and social services will therefore require more efficient expenditures of public resources and the eradication of corruption in governments.
3.2 Economic and institutional reforms
An important step in reducing poverty in developing countries is the implementation of economic and institutional reforms to create conditions that attract investment, enhance competitiveness, ensure increased efficiency in the use of resources, stimulate economic growth, and create jobs. If well designed and implemented, these reforms can be instrumental in strengthening governance and reducing endemic corruption and poor accountability that have contributed to the poor economic performance of several developing countries [23, 27]. Some reforms that are needed include the strengthening of land tenure systems to encourage risk-taking and investment in productive income-generating activities; improving governance to ensure greater inclusivity, transparency and accountability; reducing the misuse of public resources and unproductive expenditures; ensuring a greater focus on the needs and priorities of the poor; maintaining macroeconomic stability and addressing structural constraints to accelerating growth e.g. by reducing the high costs of doing business and excessive regulatory burdens; and involving the poor, women, and the youth in decision-making [8]. These reforms can benefit the poor by improving their access to land and other productive resources and by ensuring that their needs and priorities are adequately considered in policy making. Developing countries also need to reform their tax systems to make them more efficient and pro-poor.
3.3 Promoting microfinance institutions and programs
Lack of finance is a major constraint to the establishment of small scale businesses and other income generating activities in impoverished communities in several developing countries [48, 49]. Through microfinance institutions, this constraint can be removed and the much-needed credit provided to small businesses that are often unable to access credit from formal financial institutions. In this way, micro-credit can be instrumental in stimulating economic activity, creating jobs in the informal sector, increasing household incomes, and reducing poverty [1, 3, 28, 43, 48, 50, 51, 52]. Vatta [53] has noted that microfinance institutions have good potential to reach the rural poor and to address the basic issues of rural development where formal financial institutions have not been able to make a significant impact. Some advantages of obtaining credit from microfinance institutions include less stringent conditions with regard to providing collateral thus easing access to credit; the possibility of the poor obtaining small amounts of loans more frequently thus enabling the credit needs for diverse purposes and at shorter time intervals to be met; reduced transaction costs; flexibility of loan repayment; and an overall improvement in loan repayment. The small informal self-help groups that are often the units for microcredit lending are also valuable for social empowerment and fostering learning, the development of skills, entrepreneurship, exchange of ideas and experiences, and greater accountability by the group members [49, 54]. Sachs [4] supports microfinance as a viable and promising path to poverty alleviation and cites Bangladesh as a country where micro-credit has contributed to a reduction in poverty through group lending that enabled impoverished women who were previously considered unbankable and not credit worthy to obtain small loans as working capital for microbusiness activities. He further notes that by opening to poor rural women improved economic opportunites, microcredit can be instrumental in reducing fertility rates and thus improve the abilities of households to save and provide better health and education for their children.
3.4 Improving the marketing systems
According to Karnani [55], the best way to reduce poverty is to raise the productive capacity of the poor. Efficient marketing systems are vital in enabling the poor to increase their production because they permit the delivery of products to markets at competitive prices that result in increased incomes. This is also the reason why developing countries need to explore ways of expanding export markets. The plight of cotton, rice, tea, coffee, and cashew nut farmers in Kenya demonstrates the importance of improving the marketing systems. Weaknesses and inefficiencies in the marketing of these commodities has resulted in the impoverishment of the farmers who face problems such as damage to their harvests, low commodity prices and thus low profits and incomes, and exploitation by middlemen. By improving the marketing system, the growers of these commodities can benefit from better storage that would cushion them from price fluctuations, the pooling of their resources that would enable a reduction of their costs, and the processing of their products to enable value-addition and an improvement on the returns. The implementation of these measures can stimulate local, regional, and national economies; underpin the establishment of a robust agro-industrial sector; create jobs; increase production and incomes; and, contribute to equitable and sustained reduction of poverty.
3.5 Cash/income transfer programs
The fight against poverty needs to consider the fact that among the poor are those who cannot actively participate in routine economic activities and are therefore likely to suffer exclusion from the benefits of economic growth. This category of the poor include the old and infirm, the sick and those afflicted by various debilitating conditions, families with young children, and those who have been displaced by war and domestic violence. Special affirmative actions that transfer incomes to these groups are required to provide for their basic needs and ensure more equity in poverty reduction. In impoverished regions where children contribute to the livelihoods of their families by supplying agricultural labor and participating in informal businesses, income transfer programs can provide families with financial relief and enable regular school attendance by children. Such investment in the education of the children is vital in improving their human capital and prospects for employment and can therefore play an important role in long term poverty reduction [7, 8, 56]. Kumara and Pfau [57] analyzed such programs in Sri Lanka and found that cash transfers in the country significantly reduced child poverty and also increased school attendance and child welfare. Barrientos and Dejong [58], Monchuk [59], Banerjee et al. [60], Page and Pande [23], Hanna and Olken [61], and World Bank [8] strongly support cash transfer programs and contend that these programs are a key instrument in reducing poverty, deprivation, and vulnerability among children and their households. They cite South Africa, Bangladesh, Brazil, Mexico and Chile as examples of countries where cash transfer programs have significantly reduced poverty and vulnerability among poor households. They also point out that cash transfer programs are beneficial to households because they are flexible and enhance the welfare of households given that households are free to use the supplemental income on their priorities.
Cash transfer programs are central to social protection that is much needed in developing countries that face heightened social and economic risks due to structural adjustments driven by globalization. As noted by Sneyd [2], Monchuk [59], Barrientos et al. [62], and Barrientos and Dejong [58], globalization has resulted in greater openness of developing economies and exposed them to changes in global markets leading to a greater concentration of social risk among vulnerable groups. They regard social protection as the most appropriate framework for addressing rising poverty and vulnerability in the conditions that prevail in developing countries. They recommend that if significant and sustained reduction in poverty is to be achieved, cash transfer programs be accompanied by complementary actions that extend economic opportunities and address the multiple dimensions of poverty such as food, water, sanitation, health, shelter, education and access to services. Fiszbein et al. [29] strongly support the increased use of social protection programs such as cash transfers to alleviate extreme povery and estimate that in 2014 these programs prevented about 150 million people from falling into poverty. It needs to be noted that although well designed cash transfer programs can be effective in reducing poverty, they are expensive and may be difficult to finance in a sustained manner [23]. However, by reducing wasteful expenditures and instituting tax reforms, the required resources can be freed for investment in cash transfer programs [29]. The viability of this approach is evident in the case of Bangladesh and a number of central Asian countries that have been able to successfully finance cash transfers from their national budgets. Countries that are not able to finance cash transfer programs from their own resources need to explore the possibilities of securing medium-term support from international organizations [4, 7, 29, 58, 63].
A major concern that several researchers have expressed regarding cash transfer programs is that they have a short term focus of alleviating only current poverty and have thus failed to generate sustained decrease in poverty independent of the transfer themselves. Critics of cash transfers also argue that they are a very cost ineffective approach to poverty alleviation and an unnecessary waste of scarce public resources. Furthermore, they claim that many cash transfer programes are characterized by unnecessary bureaucracy, high administrative costs, corruption, high operational inefficiencies, waste, and poor targeting. The overall result of these weaknesses is that program benefits have to a large extent failed to reach the poorest households. Where these shortcomings exist, they need to be identified through rigorous audits and addressed through improved program design. But more fundamentally, it also needs to be recognized that cash transfer programs are not simply handouts but are investments in poor households that regard the programs as their only hope for a life free from chronic poverty, malnutrition and disease.
4. Selected case studies on poverty reduction in developing countries
The goal of poverty reduction can be achieved through sound policies that address the root causes of poverty, promote inclusive economic growth, prioritize the basic needs of the poor, and provide economic opportunities that empower the poor and enable them to improve their standards of living [6, 8, 64]. In what follows we present a few case studies from sub-Saharan Africa, Asia and Latin America to illustrate real world examples of policies that have resulted in significant reduction in poverty. Policy makers can learn important lessons from these case studies in their attempts to combat poverty in different contexts.
4.1 Sub-Saharan Africa
Several countries in Sub-Saharan Africa have developed poverty reduction plans that are currently being implemented to improve the standards of living of the poor and vulnerable. In Kenya where poverty is widespread and is estimated to exceeed 60 percent, the key elements of the poverty reduction strategy are facilitating sustained and rapid economic growth; increasing the ability of the poor to raise their incomes; improving the quality of life of the poor; improving equity and the participation of the poor in decision-making and in the economy; and improving governance and security [65]. The government has also implemented macroeconomic reforms to reduce domestic debt burden and high interest rates - this is expected to promote higher private-sector led growth and thus contribute to poverty reduction. An important action that is being carried out to reduce poverty in Kenya is promoting agricultural production. This focus is underpinned by the fact that the majority of Kenyans derive their livelihoods and income from agriculture and live in rural areas. Some specific poverty reduction measures in Kenya that target the agricultural sector include providing subsidized fertilizers and seeds; encouraging the growing of high value crops; rehabilitation and expansion of irrigation projects; and, provision of subsidized credit to alleviate capital contraints. To support agricultural production, the government has also prioritized the strengthening and streamling of the marketing system and the expansion of rural roads to improve the access of the poor to markets, increase economic opportunities, and create employment. Robust efforts are also underway to increase agricultural exports as a means for stimulating domestic agricultural production and increasing the country’s foreign exchange earnings. Other poverty reduction measures that are being implemented in Kenya are the promotion of small scale income generating enterprises; subsidization of education and health care to reduce the costs to poor households; school-feeding programs; rural employment schemes through public works projects; investments in technical and vocational training to enable the youth acquire skills in areas such as carpentry, masonry, and, auto mechanics; and, family planning programs to reduce the fertility rates.
In collaboration with international development partners, Kenya and other low and middle income countries in Sub-Saharan Africa have been implementing cash transfer programs on a limited scale to address extreme poverty and assist vulnerable households. The cash transfers were unconditional in the intial phases with disbursements made to all applicants. Subsequently however, and based on the lessons learned from the earlier phases, several countries have redesigned their cash transfer programs and made them conditional and contingent on means-testing. This is important given the severe budget contraints that developing countries face, the need to target the cash transfers on the poorest and most vulnerable households, and the need to ensure that social protection expenditures are efficient and result in the greatest reduction in poverty. Egger et al. [66] conducted an empirical study of a cash transfer program in rural western Kenya between mid-2014 and early 2017 and concluded that the program had several positive effects on both the households that received the cash transfers and those that did not. Some specific benefits attributable to the cash transfer program were an increase in consumption expenditures and holdings of durable assets by households; increased demand-driven earnings by local enterprises; increased food security; improved child growth and school attendance; improvement in health of members of the recipient households; female empowerment; and, enhanced psychological well-being. Furthermore, the cash transfer program had a stimulatory effect on local economic activities and these effects persisted long after the cash disbursements. The experience with cash transfer programs demonstrates that they can contribute significantly to a reduction in extreme poverty if they are scaled up, and if they are well designed and targeted at the poorest households.
Since March of 2020, Kenya’s progress in poverty reduction has been adversely affected by the COVID-19 pandemic that is estimated to have increased the number of the poor by an additional 2 million through adverse impacts on incomes and jobs [24, 67]. The containment measures that were implemented in response to the pandemic significantly slowed economic activity, reduced revenues from household-run businesses, exacerbated food insecurity, and posed a serious threat to the lives and livelihoods of large segments of the population. Some of the actions that the government of Kenya took to address these challenges included allocating more resources to the healthcare sector to combat the pandemic; instituting taxation and spending measures to support healthy firms from permanent closure in order to protect jobs, incomes and the productive capacity of the economy; and, scaling-up social protection programs to offset the increase in poverty and protect the most vulnerable households [24, 67].
4.2 Asia
A number of countries in Asia have developed and implemented programs that have been impactful in significantly reducing extreme poverty. According to the Asian Development Bank (ADB) [68], these programs were predicated on rapid economic growth driven by innovation, structural reform, and the application of private sector solutions in the public sector. Asia’s progress in raising prosperity and reducing poverty is evident from the fact that since 1990 over a billion people have emerged from extreme poverty and also from the fact that in the decade spanning 2005–2015 more that 611 million people were lifted out of extreme poverty – four-fifths of these were in China (234 million) and India (253 million) [68]. The general approach that governments of Asia have taken to poverty reduction include accelerating economic growth, increasing the delivery of social services, developing lagging areas, increasing investments to generate jobs, promoting small and medium-sized enterprises, redistributing incomes, balancing rural–urban growth, and developing social protection interventions [68, 69].
An example of a successful poverty reduction initiative in Asia is the Shanxi Integrated Agricultural Development Project (SIADP) that was implemented between 2009 and 2016 in the Shanxi province in China with a $ 100 million loan from the ADB. The goal of the SIADP was to improve agricultural production in the region as a way to stimulate economic growth and reduce the level of poverty. Prior to the implementation of the SIADP most farmers in Shanxi province mainly grew wheat and corn that generated low incomes and required extensive use of water and agrochemicals. The farmers in the region also engaged in free-range livestock grazing, an environmentally unsustainable practice that resulted in soil and water pollution from uncontrolled disposal of untreated animal waste. They were also unorganized and did not have good access to markets and finance, and the participation of women in the economy was marginal and their social and economic rights ignored. According to the ADB [68], the SIADP was implemented by first training farmers in improved production techniques that resulted in the development of a sustainable agricultural sector with the farmers starting to grow high-value crops, and forming contract farming agreements with agro-enterprises that enabled the farmers to gain access to stable markets and premium prices for their produce. The farmers also started breeding and raising livestock under more controlled conditions that enabled not only an increase in livestock output but also the turning of animal waste into compost or biogas which is a source of clean energy. These measures were instrumental in stimulating the region’s bioeconomy, improving the quality of the environment, increasing farm incomes, and reducing the level of poverty in Shanxi province.
Social protection programs are vital in cushioning poor and vulnerable households from crises they are unable to cope with and that are likely to cause an overall reduction and degradation of their physical and social assets [68]. This is exemplified by the food stamp program that was implemented in 2008 through a partnership between the Government of Mongolia and the ADB. The food stamp program was put in place at a time when the overall poverty rate in Mongolia was 32.6 percent of the population with about 5 percent of the population being categorized as extremely poor. There was also a high level of food insecurity in the country and a high inflation rate that had reached 32.2 percent [68]. To help reduce the adverse impact of food insecurity and high inflation, the government of Mongolia established a food subsidy program that targeted poor households. The program was very effective in assisting the poor to buy enough floor, rice and other basic commodities and also freed up money that the poor could then spend on other necessities. Following the introduction of this program, school attendance by children increased and their mean grades improved [68]. The program also supported the poor households in developing alternative food sources. The ADB [68] notes that the participants in the food stamp program also learned valuable skills in backyard gardening, food storage and food preservation with many of them reporting significant earnings from vegetable production. Thus, the program contributed directly to poverty reduction by mitigating the adverse effects of the food and financial crises on the poor and is a strategy that developing countries need to seriously consider in their efforts to reduce povery and improve living standards.
4.3 Latin America
As a region, Latin America has performed reasonably well in reducing extreme poverty and boosting shared prosperity [70]. A country-specific assessment however reveals a significant heterogeneity across and within the countries in the region. The countries that have performed well include Argentina, Bolivia, Brazil, Panama, Uruguay, and Peru while those that have performed poorly include Guatemala, Mexico, Honduras, Nicaragua and the Dominican Republic. For the well-performing countries, the reasons include rapid and inclusive economic growth, and the adoption of redistributive policies such as improved access to education, healthcare, and social protections. In these countries, there has been a significant increase in the participation of the poor in labor markets thus enhancing their ability to generate labor income. Cord et al. [70] assert that the growth in female labor force participation in particular has been strong and has contributed to the substantial drop in poverty rates that has been observed in the well-performing countries. It is worth noting that these gains in poverty reduction and promotion of shared prosperity have been aided by prudent macro fiscal economic policies and positive terms of trade. These countries have also benefitted immensely from remittance flows that have not only complemented the expansion of government transfers and the broadening of pension coverage but have also enabled greater macroeconomic stability, higher savings, more entrepreneurship and better access to healthcare and education. In a country like El Salvador which is one of the largest remittance-receiving countries in the region, these private remittances have played a major role in poverty reduction [70]. Although, the income transfer programs that several countries in Latin America have implemented have been effective in reducing persistent intergenerational poverty, the incidence of poverty in the region has remained high due, in part, to the limited scale of these programs and weaknesses in their design [71]. By supplementing household consumption, these programs are playing a key role in human development and preventing future poverty because present consumption improves productive capacity through the expected positive impact of improved nutrition and health status on labour productivity [71]. Further reduction in poverty in the region requires not only the scaling up of the income transfer programs and improvements in their design to ensure greater efficiency in service delivery, but also the redressing of other critical drivers of poverty such as the long-standing inequalities in access to land and other productive resources [71]. A problematic issue that needs to be addressed is the over-reliance of these programs on external financing; it poses to policy-makers the challenge of identifying and crafting alternative sources of financing to ensure the sustainability of these programs.
5. Conclusions and policy implications
Poverty is a serious challenge that developing countries are facing today and requires focused and sustained action to significantly reduce it, break the cycle of poverty, and improve the standards of living. Although income is the yardstick that is most commonly used to measure and assess it, poverty is multidimensional and entails diverse aspects of well-being that include food, water, sanitation, health, shelter, education, access to services and human rights [20]. According to the World Bank, the extent of poverty is highest in Sub Saharan Africa, South Asia, and Latin America where the number of the poor has been increasing due to high population growth and modest economic performance in these regions. Various reports also indicate that the youth are the majority of the population in these countries so that targeting them can be effective in reducing poverty. Developing countries are currently in various stages implementing policies aimed at reducing poverty and vulnerability, and improving the standards of living. Promoting inclusive economic growth is vital not only in increasing output and incomes but also in ensuring that the benefits of economic growth are broadly shared. Some ways of promoting inclusive economic growth are investing in infrastructure and technology; liberalizing trade and expanding export markets; providing incentives to small and medium businesses; providing fiscal stimulus to the economy; ensuring macroeconomic stability; and improving public management and governance [8, 26, 33]. The implementation of these measures in an integrated manner can have positive economy wide effects, incentivize the private sector, create the much needed employment opportunities, and reduce the levels of poverty.
Poverty reduction can also be enhanced through microfinance institutions that not only provide credit to small borrowers who are often unable to access credit from formal financial institutions, but also mobilize domestic savings and channel these savings towards income generating activities [43]. This role of microfinance institutions is particularly important in developing countries where most businesses are small scale and face severe financing constraints [43, 48, 51, 52]. The available empirical evidence demonstrates that microfinance has been instrumental in supporting income generating activities in impoverished regions and thus contributed to the provision of basic needs and reduction of poverty. Developing countries can also address the challenge of poverty by improving the efficiency and competitiveness of their economies. This can be accomplished through economic and institutional reforms that reduce the cost of doing business, strengthen the linkages between various sectors of the economy, protect property rights, reduce corruption, and foster greater accountability in public management. Tax regimes also need to be reformed to make them more efficient, provide incentives to small businesses, effect redistribution in favor of the poor, and generate more resources that can be used to finance critical services such as education, health, water and sanitation, and shelter for the poor. Furthermore, through tax reforms employment opportunities can be expanded as a key step in poverty reduction. Finally, carefully designed affirmative actions and social protection programs need to be included as a key pillar of the poverty reduction strategies of developing countries given that there will invariably be groups in society whose unique circumstances result in their exclusion from the economic and social benefits of conventional poverty reduction measures. This is the rationale for the cash transfer programs that several developing countries are increasingly implementing to reduce poverty and vulnerability. The private sector and international development institutions can play an important role in poverty reduction in developing countries by providing expertise and the supplemental resources and assistance that are needed to implement poverty reduction plans. Success in poverty eradication requires a focus on areas where poverty is widespread and the use of innovative and practical policy instruments that are most likely to lift the greatest number of the poor out of poverty. It is a goal that is attainable through collaboration among all stakeholders, prioritization of the basic needs of the poor, the determination to improve economic performance to realize inclusive economic growth and break the vicious cycle of povery, empowering the poor to take control of their future, and by mainstreaming poverty reduction into national policies and actions.
\n',keywords:"poverty, poverty reduction, inclusive economic growth",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79838.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79838.xml",downloadPdfUrl:"/chapter/pdf-download/79838",previewPdfUrl:"/chapter/pdf-preview/79838",totalDownloads:330,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,introChapter:null,impactScore:0,impactScorePercentile:34,impactScoreQuartile:2,hasAltmetrics:0,dateSubmitted:"June 1st 2021",dateReviewed:"November 2nd 2021",datePrePublished:null,datePublished:"February 2nd 2022",dateFinished:"December 29th 2021",readingETA:"0",abstract:"The existence of extreme poverty in several developing countries is a critical challenge that needs to be addressed urgently because of its adverse implications on human wellbeing. Its manifestations include lack of adequate food and nutrition, lack of access to adequate shelter, lack of access to safe drinking water, low literacy rates, high infant and maternal mortality, high rates of unemployment, and a feeling of vulnerability and disempowerement. Poverty reduction can be attained by stimulating economic growth to increase incomes and expand employment opportunities for the poor; undertaking economic and institutional reforms to enhance efficiency and improve the utilization of resources; prioritizing the basic needs of the poor in national development policies; promoting microfinance programs to remove constraints to innovation, entrepreneurship, and small scale business; developing and improving marketing systems to improve production; providing incentives to the private sector; and, implementing affirmative actions such as targeted cash transfers to ensure that the social and economic benefits of poverty reduction initiatives reach the demographics that might otherwise be excluded.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79838",risUrl:"/chapter/ris/79838",book:{id:"10227",slug:"rural-development-education-sustainability-multifunctionality"},signatures:"Collins Ayoo",authors:[{id:"224658",title:"Dr.",name:"Collins",middleName:null,surname:"Ayoo",fullName:"Collins Ayoo",slug:"collins-ayoo",email:"collins.ayoo@carleton.ca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/224658/images/system/224658.jpg",institution:{name:"Carleton University",institutionURL:null,country:{name:"Canada"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Some definitions and statistics",level:"1"},{id:"sec_3",title:"3. Poverty alleviation strategies",level:"1"},{id:"sec_3_2",title:"3.1 Stimulating inclusive economic growth",level:"2"},{id:"sec_4_2",title:"3.2 Economic and institutional reforms",level:"2"},{id:"sec_5_2",title:"3.3 Promoting microfinance institutions and programs",level:"2"},{id:"sec_6_2",title:"3.4 Improving the marketing systems",level:"2"},{id:"sec_7_2",title:"3.5 Cash/income transfer programs",level:"2"},{id:"sec_9",title:"4. Selected case studies on poverty reduction in developing countries",level:"1"},{id:"sec_9_2",title:"4.1 Sub-Saharan Africa",level:"2"},{id:"sec_10_2",title:"4.2 Asia",level:"2"},{id:"sec_11_2",title:"4.3 Latin America",level:"2"},{id:"sec_13",title:"5. Conclusions and policy implications",level:"1"}],chapterReferences:[{id:"B1",body:'World Bank. World Development Report 1990: Poverty. 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Does microfinance affect income inequality? Applied Economics. 2014;46(9):1021-1034'},{id:"B53",body:'Vatta K. Microfinance and poverty alleviation. Economic and Political Weekly. 2003;38(5):32-33'},{id:"B54",body:'Si S, Yu X, Wu A, Chen S, Chen S, Su Y. Entrepreneurship and poverty reduction: A case study of Yiwu, China. Asia Pacific Journal of Management. 2015;32(1):119-143'},{id:"B55",body:'Karnani A. Marketing and poverty alleviation: The perspective of the poor. Markets, Globalization & Development Review. 2017;2(1):1. DOI: 10.23860/MGDR'},{id:"B56",body:'Toye J, Jackson C. Public expenditure policy and poverty reduction: Has the World Bank got it right? Institute of Development Studies Bulletin. 1996;27(l):56-66'},{id:"B57",body:'Kumara AS, Pfau WD. Impact of cash transfer programmes on school attendance and child poverty: An ex ante simulation for Sri Lanka. The Journal of Development Studies. 2011;47(11):1699-1720'},{id:"B58",body:'Barrientos A, Dejong J. Child poverty and cash transfers. In: CHIP Report, No. 4. London: Childhood Poverty Research and Policy Centre; 2004'},{id:"B59",body:'Monchuk V. Reducing Poverty and Investing in People: The New Role of Safety Nets in Africa. Washington, DC: World Bank; 2013'},{id:"B60",body:'Banerjee AV, Hanna R, Kreindler GE, Olken BA. Debunking the stereotype of the lazy welfare recipient: Evidence from cash transfer programs. The World Bank Research Observer. 2017;32(2):155-184'},{id:"B61",body:'Hanna R, Olken BA. Universal basic incomes versus targeted transfers: Anti-poverty programs in developing countries. Journal of Economic Perspectives. 2018;32(4):201-226'},{id:"B62",body:'Barrientos A, Hulme D, Shepherd A. Can social protection tackle chronic poverty? The European Journal of Development Research. 2005;17(1):8-23'},{id:"B63",body:'Coady D. Alleviating Structural Poverty in Developing Countries: The Approach of Progresa in Mexico, mimeo. Washington DC: International Food Policy Research Institute; 2003'},{id:"B64",body:'Ravallion M. Growth and poverty: Evidence for developing countries in the 1980s. Economics Letters. 1995;48:411-417'},{id:"B65",body:'Republic of Kenya. Poverty Reduction Strategy Paper 2001-2004 Vols. I & II. Nairobi: Government Printer; 2001'},{id:"B66",body:'Egger D, Haushofer J, Miguel E, Niehaus P, Walker MW. General Equilibrium Effects of Cash Transfers: Experimental Evidence from Kenya. National Bureau of Economic Research Working Paper 26600. Cambridge Massachusetts; 2021. Available from: https://www.nber.org/system/files/working_papers/w26600/w26600.pdf [Accessed on December 12, 2021]'},{id:"B67",body:'World Bank. Kenya Economic Update: Rising Above the Waves. Washington, DC; 2021 Available from: https://openknowledge.worldbank.org/handle/10986/35946'},{id:"B68",body:'Asian Development Bank (ADB). Effective Approaches to Poverty Reduction: Selected Cases from the Asian Development Bank. Manila, Philippines : Asian Development Bank Institute; 2019'},{id:"B69",body:'Glauben T, Herzfeld T, Rozelle S, Wang X. Persistent poverty in rural China: Where, why and how to escape? World Development. 2012;40:784-795'},{id:"B70",body:'Cord L, Genoni ME, Rodríguez-Castelán C. Shared Prosperity and Poverty Eradication in Latin America and the Caribbean. Washington, D.C.: World Bank; 2015'},{id:"B71",body:'Barrientos A, Santibañez C. Social policy for poverty reduction in lower-income countries in Latin America: Lessons and challenges. Social Policy and Administration. 2009;43(4):409-424'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Collins Ayoo",address:"collins.ayoo@carleton.ca",affiliation:'
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1. Introduction
In the United States, national data has shown that cardiac surgical procedures utilize somewhere between 10 and 15% of the approximately 15 million units of packed red blood cells received by surgical patients annually [1]. To this point, the Society of Thoracic Surgeons (STS) published a series of blood conservation guidelines in 2007 and 2011 aimed at cardiac surgery procedures [2, 3]. These guidelines developed a risk profile of factors associated with increased post-operative blood transfusion such as: advanced age, reduced preoperative red blood cell volume, utilization of antiplatelet or antithrombotic drugs, procedural factors (including the complexity, urgency, or re-operative nature of the surgery), and non-cardiac patient comorbidities. With these high risk factors identified, a set of evidence-based blood conservation guidelines were establish to include: utilization of medications to increase preoperative blood volume (eg, erythropoietin) or decrease post-operative blood loss (eg, anti-fibrinolytics), intra-operative blood salvage or sparing techniques, autologous pre-donation to reduce stress upon the patient’s own blood, transfusion algorithms and recommendations for a multimodality approach that utilizes all of the above. The subsequently revised guidelines in 2011 included: pre-operative management of dual-antiplatelet therapy, utilization of drugs that augment blood volume or limit blood loss, use of blood derivatives (eg, fresh frozen plasma, coagulation factor concentrates, etc.), updates in the management of blood salvage techniques, consideration for minimally invasive techniques to limit blood loss or transfusion, recommendations for blood conservation in conjunction with extra-corporeal membrane oxygenation and cardiopulmonary bypass, and implementation of topical hemostatic agents. Despite these measures, there has been an increase in blood product utilization by patients undergoing cardiac surgery procedures over the last decade. The reasons likely being multifactorial but include a rise in number of patients undergoing complex, multiple component cardiac surgeries (e.g., CABG and valve procedure), increased number of patients exposed to clopidogrel or similar strong anti-platelet medications, and removal of aprotinin from the US market in 2007. Aprotinin is an anti-fibrinolytic serine protease that has been shown to decrease blood product transfusion in CABG patients by nearly 39% [4]. However, further research demonstrated increased patient morbidity and mortality and it was subsequently removed from the market. Subsequent studies have shown increased transfusion requirements in cardiac surgery patients since its removal [5].
The effect of blood product transfusion on cardiac surgery patients has been well studied in the literature and associated with incremental morbidity as defined by renal failure, prolonged ventilator support, serious infection, cardiac complications or neurologic events for each unit transfused [6]. Recent data investigating patients undergoing coronary surgery associated intra-operative transfusion with a more than three-fold increase in 30-day mortality [7]. By comparison, less has been written about blood product transfusion in general thoracic procedures. However, the available data echoes much of what has been described in cardiac surgery. A large retrospective study by Ferraris, et al. analyzed 8728 patients undergoing non-vascular thoracic procedures. The study found an adverse, dose-dependent relationship between intra-operative blood transfusions and morbidity, pulmonary complications, sepsis, wound complications, and length of stay [8]. Given the increased utilization of blood products in cardiac patients and the associated risks of transfusion, it is important to identify patients at risk for bleeding complications following cardiac surgery.
Bleeding is a significant complication of open cardiac surgery, with an incidence ranging from approximately 5–15%. Cardiac surgery procedures are associated with significant alterations in physiology compared to non-cardiac thoracic surgery. Cardiopulmonary bypass (CPB) and exposure of the patient’s blood to a non-endothelialized circuit has been associated with stimulation of both intrinsic and extrinsic coagulation pathways. To counteract this, patients are systemically heparinized. Cardiopulmonary bypass is likewise associated with platelet dysfunction and consumption secondary to platelet adhesion to surfaces, hemodilution, and platelet aggregation. CPB associated thrombocytopenia is further exacerbated by the process of intra-operative red blood cell salvage. After blood is aspirated from the surgical field, it is collected in a sterile reservoir and processed. The process of centrifugation separates red blood cells from platelets and plasma which are both removed as waste. The isolated red blood cells are then washed of debris in anticipation of reinfusion and therefore without a component of plasma or platelets. Following initiation of CPB, cardioplegia is achieved and patients are cooled for the cardioprotective effects of hypothermia which impair the enzymatic reactions of the coagulation cascade. In a recent study, aortic procedures were associated with the highest bleeding complication rate (15.0%) and isolated CABG with the lowest risk (5.1%). Complications from bleeding were associated with increased LOS and critical care utilization. Patients undergoing re-exploration for bleeding demonstrate larger increases in both LOS and days spent in critical care [9]. Naturally, the significant consumption of healthcare resources following these complications translates to an incremental economic burden on both the patient and the healthcare system. In adult cardiac surgery patients undergoing re-exploration for bleeding, a meta-analysis by Biancari, et al. sought to characterize sources of bleeding identified at the time of re-exploration. They collected data from 18 different studies, a total of 51497 patients where 2455 had undergone reoperation for bleeding/tamponade. Of these patients, surgical sources of bleeding were identified in 65.7% of patients in comparison to diffuse bleeding which can be more troublesome. Bleeding was further delineated as cardiac/bypass graft (40.9%) or mediastinal (pericardial, sternal, etc.) (27.0%). The predominant sites identified were: the body of the graft (20.2%), the sternum (17.0%), vascular suture lines (12.5%), the internal mammary harvest site (13.0%) and anastomoses (9.9%) [10]. Alternatively, diffuse bleeding, often attributed to coagulopathy secondary to anti-thrombotic agents can represent a significant challenge in achieving hemostasis with increased risk for residual blood loss and transfusion of blood products. Biancari et al., suggest that re-exploration for bleeding in cardiac surgery patients may be a preventable event with systematic evaluation of these areas and meticulous hemostasis prior to closure. Biosurgical hemostatic agents may serve as valuable adjuncts in this process and in the reduction of bleeding complications.
Topical hemostatic agents are useful adjuncts to reducing operative and post-operative bleeding and play an essential role in cardiothoracic surgery procedures. Patients presenting for cardiac surgery, as opposed to non-cardiac thoracic surgery, have likely been exposed to antiplatelet agents such as aspirin, clopidogrel, ticagrelor, apciximab or systemic anticoagulation agents such as warfarin or heparin (including intra-operative bolus dosing and subsequent reversal with protamine). Furthermore, patients undergoing cardiac procedures utilizing cardiopulmonary bypass are even more prone to bleeding and blood product transfusion [11]. In patients undergoing cardiothoracic surgery, non-surgical bleeding, defined as microvascular bleeding secondary to coagulopathy or capillary oozing can limit the utility of conventional surgical maneuvers in achieving hemostasis such as suture ligation, electrocautery, and surgical clips. The presence of non-surgical bleeding due to coagulopathy should be primarily directed at correction of the underlying abnormality but also presents an opportunity for the utilization of biosurgical hemostatic agents which can serve as useful adjuncts in gaining adequate hemostasis.
Selection of a hemostatic agent is often anecdotal and the following review seeks to clarify the available agents, their mechanisms, efficacy, and potential risks associated with their use. Conceptually, biosurgical hemostatic agents can be broadly classified as active, non-active, or a combination of both. A hemostatic agent is considered active if it contains agents directly involved in the clotting cascade such as thrombin in isolation or combined with a mechanical agent. In contrast, non-active agents contain no clotting factors, rather they provide a mechanical or synthetic seal to aid in achieving hemostasis. Lastly, there are a few available agents which utilize elements of both major categories that are known as flowable hemostatic agents.
2. Thrombin with or without gelatin carrier (Thrombin JMI®, Evithrom®, and Recothrom®)
Thrombin is an endogenous serum protease formed from its precursor prothrombin during activation of the intrinsic and extrinsic coagulation pathways. Thrombin is involved in the cleavage of fibrinogen to fibrin which polymerizes to serve as the basis of a hemostatic clot. Thrombin concurrently activates factor XIII which aids in fibrin crosslinking and strengthening the polymerized fibrin mesh to complete the clot atop the platelet plug, thereby achieving hemostasis. Historically, thrombin was isolated from bovine plasma with well documented reports of producing clinically significant antibody responses and hemorrhagic complications (excessive post-operative bleeding and re-operation for bleeding) following patient exposure. Typically, patients develop antibodies to bovine factor V and Va, with more than half of patients producing auto-antibodies to human coagulation proteins, specifically factor V which can produce life-threatening bleeding [12]. In response to these concerns, both human derived and recombinant human thrombin have been developed. An unpublished phase III, prospective randomized controlled double-blinded study demonstrated that human-derived thrombin was as effective as bovine-derived thrombin in providing effective hemostasis. In this study, human-derived thrombin was applied to a gelatin sponge and produced effective hemostasis in 93.6% of cardiovascular surgery patients within 6 minutes and 61.7% within 3 minutes when applied to oozing or bleeding of mild intensity that could not be controlled with other surgical techniques [13]. Recombinant human thrombin was examined in a similar study that did not include cardiovascular surgery patients, but did include vascular surgery procedures and demonstrated comparable results regarding efficacy [14]. Both human and recombinant thrombin boast reduced immunologic response compared to bovine thrombin. Recombinant thrombin has the added benefit of minimizing the theoretical risk of viral transmission compared to human thrombin that has been pooled from donor plasma.
An active hemostatic agent such as thrombin is particularly useful in cardiac surgery patients where innate coagulation is impaired secondary to systemic heparinization while on cardiopulmonary bypass. It should be considered for mild to moderate non-surgical bleeding (not amenable to suture ligation or electrocautery) or in a surgically inaccessible area such as the dome of the left atrium or raw myocardial edges from a deep intra-myocardial coronary following bypass grafting [15]. In non-cardiac procedures, instillation of thrombin, complexed with fibrinogen, has also been described as an efficacious hemostatic therapy in the management of severe hemoptysis (>150 cc/12 hrs) [16]. Although bronchial artery embolization (BAE) is the treatment of choice in these patients, this therapy may be unavailable and endoscopic fibrinogen-thrombin instillation can serve as a bridge to embolization or as primary therapy in its absence.
Thrombin can be delivered alone via a spray applicator, with an inert carrier such as a gelatin sponge, or in combination with fibrinogen (fibrin glue). When paired with a gelatin component, the sponge is capable of absorbing 45 times its own weight, expanding to nearly 200% of its initial volume and facilitating concentration of coagulation factors in the area of concern. Like bovine derived thrombin, the gelatin is derived from porcine or bovine sources and carries with it a theoretical risk of antigenicity [17]. Caution should be used in applying gelatin sponge based thrombin products to open arterial bleeding due to potential risk for embolization. Of note, thrombin spray is contraindicated in treating massive or arterial bleeding and caution should be exercised to avoid entry into large blood vessels as it can produce severe intravascular clotting.
An essential consideration in using thrombin as a topical hemostat, depending on its source, is its proper preparation and storage. Both bovine derived and recombinant thrombin are available in powder form meaning they require mixing with saline to reconstitute into solution for application. They should be stored at room temperature [18, 19]. Conversely, human thrombin is packaged in solution and stored frozen. It may be left refrigerated for up to 30 days and can be stored at room temperature for no more than 24 hours per the manufacturer.
Products such as FloSeal deliver human thrombin (previously bovine) in a gelatin-based matrix consisting of collagen microgranules to produce swelling and tamponade upon contact with blood. Compared to other fibrin sealants, it requires blood as a source of fibrinogen. Similar to standalone pooled human thrombin, a theoretical risk of viral transmission exists with utilization of FloSeal despite manufacturer efforts to reduce viral load during production. Regarding efficacy, a prospective randomized study compared FloSeal with Gelfoam thrombin after conventional surgical methods failed to control bleeding and demonstrated that FloSeal had superior hemostatic efficacy with a comparable safety profile to Gelfoam thrombin [20]. The aforementioned study group consisted of patients undergoing cardiac surgery and demonstrated that FloSeal achieved hemostasis in 94% of patients compared to 60% in the Gelfoam thrombin control group within 10 minutes. This difference was even more pronounced at 3 minutes where hemostasis was successful in 72% of the FloSeal group compared to 23% of the control. Similarly, a prospective randomized study by Nasso, et al. compared FloSeal to a control group of Surgicel or Gelfoam and included patients undergoing cardiac and thoracic aortic procedures. They demonstrated statistically higher rates of successful hemostasis, shorter times to hemostasis, and lower rates of post-operative transfusion of blood products, in the FloSeal group [21]. Common sites of cardiac bleeding treated in the study included coronary bypass anastomoses, cardiotomy sites, and anastomotic sites involving a prosthesis. The trial likewise found that FloSeal was associated with a statistically significant higher rate of successful hemostasis and shorter time to hemostasis when compared to the control group. Lower rates of blood product transfusion, incidence of re-exploration, and shorter ICU LOS were also appreciated in the group treated with FloSeal, although not statistically significant.
3. Fibrin sealants (Tisseel®)
Fibrin sealants first gained FDA approval in 1989 with the commercial release of Tisseel. Fibrin sealants generally contain separated components of freeze dried coagulation proteins, mainly fibrinogen and thrombin but also fibronectin. They are typically supplied in a dual syringe system that admix the two agents immediately prior to application. Fibrinogen, of course if a precursor to fibrin, the very foundation of the clot and is activated by thrombin, which serves as a catalyst when delivered simultaneously. Fibronectin on the other hand, is a high molecular weight, extracellular matrix glycoprotein that is physiologically deposited at the site of injury along with fibrin and serves as a sealant to aid in wound healing [22]. The mechanical strength of the sealant is driven by the concentration of fibrinogen and the relative concentration of thrombin determines the rate of clot formation [23]. By understanding the individual components of fibrin sealants, it is relatively easy to understand how these products mimic the final stages of wound healing and can be especially useful in patients with coagulopathies from systemic heparinization or other anticoagulants. One prospective randomized clinical trial of fibrin sealant versus more conventional hemostatic agents in cardiac surgery patients undergoing re-sternotomy or re-exploration identified significant shorter time to hemostasis and decreased post-operative blood loss compared to patients in the control group [24]. A randomized controlled trial in pediatric patients undergoing cardiac surgery with known significant coagulopathy demonstrated intraoperative use of fibrin sealant significantly reduced the amount of bleeding and transfusion of blood/blood products but also decreased the time to hemostasis [25]. Caution should be used with fibrin sealants, especially in coronary artery bypass grafting where they have been reported to be associated with increased risk of myocardial injury when applied intra-operatively. Lamm, et al., describe several cases of acute occlusion of coronary bypass grafts after administration of a fibrin sealant near anastomotic sites [26]. In each reported case, embolectomy at that time demonstrated fresh fibrin clot within the graft. The aforementioned study specifically examined Tissucol (Baxter) in aortocoronary bypass operations.
Applications in general thoracic surgery include intra-operative application of fibrin glue for the prevention of prolonged air leak in patients undergoing pulmonary resection. Air leak can arise from pulmonary parenchyma secondary to surgical manipulation or stapling. Generally, these parenchymal air leaks resolve spontaneously in a few days. Prolonged air leak (greater than 7 days) is associated with increased length of stay and may ultimately require further intervention. Studies exploring the efficacy of fibrin glue in the prevention of post-operative air leak have yielded mixed results to support their routine use [27, 28, 29].
4. Progel ™
Progel (Bard) is a pleural air leak sealant consisting of polyethylene glycol and human serum albumin. It is the only FDA approved product to treat pleural air leaks in open thoracotomy, video-assisted, and robotic-assisted thoracic surgery. It is delivered in an adjustable syringe applicator providing either a stream for focal application to suture/staple lines or as a spray for increased surface area application. Progel’s intrinsic elasticity makes it an attractive option for application to the pleural surface of the lung with an ability to tolerate re-expansion within 2 minutes of use [30]. A multicenter, prospective, randomized control trial demonstrated that intra-operative application of Progel resulted in fewer post-operative air leaks compared to the control group (65% vs. 86%, respectively) and shorter median length of stay (6 vs. 7 days, respectively) [31].
5. Evarrest®
Evarrest (Ethicon), is a fibrin sealant patch made of oxidized regenerated cellulose covered with thrombin (human derived) and fibrinogen. Contact of the powdery, active side of the patch with bleeding tissue causes thrombin to activate fibrinogen to fibrin and form a stable clot. The newly formed clot subsequently integrates with the patch’s matrix design to assist in achieving hemostasis [32]. Advantages of Evarrest include that it is ready to use and bio-absorbable in about eight weeks. Contraindications to its use are comparable to other topical active agents in that it should not be applied to control bleeding from large vascular defects or intravascularly. Like most thrombin containing products, there is also risk of reaction to human blood products.
Evarrest has been successfully described in the control of major vascular injury during robotic assisted lobectomy and segmentectomy [33]. In the vignette provided by Gharagozloo et al., pulmonary artery/vein bleeding was controlled with direct pressure aided by a tightly rolled gauze sponge wrapped with an Evarrest fibrin sealant patch for 3 minutes while seeking to obtain proximal control. Should conversion to thoracotomy be required, pressure should continue to be held with a non-robotic instrument through the assistant port and allowing for complete removal of the robot from the field.
6. BioGlue®
BioGlue is a bovine serum albumin and glutaraldehyde tissue adhesive originally developed as an adjunct for hemostasis in cardiovascular surgery, gaining FDA approval in 2001. Similar to fibrin sealants, BioGlue’s components are provided in two separate vials and delivered via a two-chambered syringe. The two agents are mixed within the applicator tip immediately prior to application. When applied to tissue, the glutaraldehyde and albumin form strong covalent crosslinking with each other and the tissue at the site. The mechanical seal is not only independent of the patient’s intrinsic clotting mechanisms but polymerizes rapidly and adheres to synthetic graft materials, making it an attractive option for controlling anastomotic bleeding in cardiac and vascular surgery when utilizing synthetic (eg Dacron®, Gore-tex®, and polyurethane) grafts or patches. BioGlue requires a bloodless field to adhere unlike some other agents, limiting its utility for active bleeding. It is generally applied to an anastomotic site in a thin layer prior to unclamping and restoration of perfusion [34]. Specific applications in cardiothoracic surgery include [35]:
Repair of type A aortic dissections. Specifically, the re-approximation of dissected aortic arch layers.
Aortic root reconstruction. Bovine albumin-glutaraldehyde may be used to seal the proximal anastomosis of the LVOT and replaced aortic root. This can be a particularly difficult suture line to place repair sutures.
Left ventricular apical cannulation. BioGlue can be applied when sewing a left ventricular assist device cannula cuff to the apex of the left ventricle, an area known to be especially prone to bleeding. Sealing this area with bovine albumin-glutaraldehyde is particularly useful as it will be under the stress of systolic left ventricular pressures and constant motion.
Right/left ventricular tear or rupture repair. BioGlue can be used in conjunction with patches of oxidized regenerated cellulose (Surgicel) to support fragile repairs of the right ventricle. It can also be used in traumatic ruptures of the left ventricle with bovine pericardium instead of Surgicel.
Post-infarction ventricular septal defect repair. BioGlue can be used to seal the overlapping Dacron patches of the repair together.
Ensuring hemostasis of suture lines. Particularly when applied to aortic aneurysm repairs, coronary anastomoses, and arteriotomies.
Criticism of BioGlue includes its low viscosity and difficulty controlling its application. This can be mitigated by injecting slowly and allowing the glue to partially set prior to completely expelling the mixture from the applicator tip. Various reports of adverse events have described early failure of coronary artery bypass grafts, leaking of glue through needle holes causing embolization, and anastomotic stricture impairing aortic growth [36, 37, 38].
7. Bone wax and Ostene ®
Median sternotomy is the most common approach in cardiac surgery. It can also be used in non-cardiac thoracic surgery to access the lower trachea, mainstem bronchi, tumors of the anterior mediastinum, and retrosternal goiters. The sternum is primarily made of spongy, cancellous bone encased in a rim of cortical bone. Its high surface area to volume ratio make it no surprise that it is highly vascular and prone to osseous hemorrhage. Bleeding from the median sternotomy of a heparinized patient can be challenging to control. Mechanical hemostatic devices such as bone wax can greatly aid in providing an impenetrable barrier. The most classic formulation described by Sir Victor Horsley in 1885 consisted of beeswax, almond oil and salicylic acid [39]. In current use, most surgeons know medical grade bone wax as a non-absorbable mixture of sterilized beeswax and a softening agent such as Vaseline or paraffin with isopropyl palmate. In use, bone wax is quite malleable and can be worked to any desired consistency before application either manually or via submersion in warm, sterile solution before removing from the packaging. Despite its relative ease of use, there are several significant complications that one should consider.
First and foremost, experimental studies have demonstrated that bone wax significantly reduces the number of bacteria needed to initiate infection [40, 41]. For this reason, bone wax should never be utilized in a contaminated field. Secondly, bone wax is relatively inert, having been identified as remotely as 10 years following initial application. Histological studies have confirmed these suspicions on autopsy showing chronic granulomatous inflammation and foreign body reaction [42]. Given the above findings, it is understandable how bone wax could complicate healing of the sternum following median sternotomy by not only increasing risk of mediastinitis and osteomyelitis but impairing sternal edge apposition and inducing chronic inflammation.
Ostene, like bone wax, readily provides hemostasis without impairing bone healing. It was originally described in 2001 as an absorbable alternative to bone wax. Ostene is water-soluble and composed of hydrophilic alkylene oxide copolymers and is eliminated from the bone surface within 24–48 hours of application [43]. Several studies have compared Ostene to bone wax regarding sternal healing and favor its use to reduce sternal dehiscence and chronic inflammation [44, 45].
8. Surgicel®
The Surgicel family of products utilize oxidized, regenerated cellulose delivered in a loosely knit sheet, fibrillar sheet, or powder to aid in providing local hemostasis from capillary or minor venous bleeding. They are non-active mechanical hemostatic agents, meaning they do not contain specific coagulation factors and are best served in patients with intact innate coagulation (ie not on cardiopulmonary bypass). Once saturated with blood, Surgicel swells in to a brown-black gelatinous mass because of the decreased local pH initiating red cell lysis. It then serves as a scaffold for platelet aggregation and is generally absorbed completely within 4–6 weeks [46]. Surgicel has the added advantage of being bacteriostatic with some activity against MRSA reported [47, 48]. One underestimated feature of Surgicel is its ease of handling and non-adherence to instruments. However, like most hemostatic agents, caution should be exercised with its use. A key disadvantage of Surgicel is that by lowering the local pH, other active hemostatic agents may be rendered ineffective, namely thrombin [49]. Other authors have reported Surgicel remnants being misdiagnosed as an abscess, even mimicking mediastinitis that may be difficult or impossible to distinguish on imaging [50].
Surgicel is commonly applied in video-assisted thorascopic surgery during lymphadenectomy. In general, bleeding from lymphadenectomy can be avoided with careful dissection in avascular planes. However, occasional entry into the lymph node capsule introduces troublesome but non-life threatening bleeding that can easily be controlled using direct pressure with a topical hemostat such as Surgicel [51]. Typically bleeding improves following lymph node removal, but Surgicel may be left in the lymph node basin for any mild persistent bleeding.
Arista AH (Bard) is a microporous polysaccharide hemosphere (MPH) powder derived from purified plant starch with FDA approval for not only cardiothoracic but vascular, gynecological, urology, orthopedic, general, plastic and ENT surgeries as well. Notably, Arista has been FDA approved as a cell saver, or autologous blood salvage circuit, compatible hemostat. Arista rapidly dehydrates blood, causing the MPH particles to swell and concentrate blood solids such as platelets, RBCs, and coagulation proteins to form a gelled matrix [52]. This gelatinous matrix creates a scaffold for formation of the fibrin clot and provides a mechanical barrier to continued blood loss regardless of the patient’s coagulation status. Arista is typically enzymatically degraded by serum amylases and cleared from the body within 24–48 hours per the manufacturer. To apply, the area of concern should have as much excess blood removed as possible, Arista should be liberally applied to the site of bleeding, wound-appropriate pressure should be held, and excess Arista should be removed by irrigation. Like most hemostatic agents, it should not be placed in blood vessels or when there may be risk of embolization. A retrospective study by Bruckner, et al., compared the application of topical Arista to historical agents including FloSeal, Gelfoam thrombin, or Surgicel in cardiothoracic procedures. They found a decreased time to hemostasis, decreased post-operative blood loss, and reduced blood product transfusion requirement within the first 48 hours post-operatively without any identified adverse events.
10. Conclusion
Bleeding in the cardiothoracic surgery patient is well studied. Specifically, cardiac surgery patients are frequently subject to systemic heparinization and potentially multiple antiplatelet medications. Thus, significantly increasing their risk for nonspecific bleeding refractory to traditional surgical hemostatic maneuvers. Complications from uncontrolled bleeding are both costly to the patient in terms of outcomes and economically to the healthcare system as well. Selection of the proper hemostatic adjunct can reduce time to hemostasis, blood product transfusion, and improve patient outcomes. Frequently, selection of a hemostatic agent has been constrained by anecdotal experience and limited knowledge of the diverse array of agents presently available. Choosing a hemostatic adjunct relies on understanding of its mechanism of action, indications for use, and knowledge of potential complications surrounding its use. In addition, many topical hemostats have also found novel uses in non-cardiac thoracic surgery to reduce post-operative air leaks and length of stay following pulmonary resection. The prepared surgeon has familiarized themselves with these agents and can anticipate opportunities for their deployment.
\n',keywords:"cardiothoracic surgery, biosurgical agents, topical hemostatic agents, surgical hemostasis, blood conservation",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/74755.pdf",chapterXML:"https://mts.intechopen.com/source/xml/74755.xml",downloadPdfUrl:"/chapter/pdf-download/74755",previewPdfUrl:"/chapter/pdf-preview/74755",totalDownloads:258,totalViews:0,totalCrossrefCites:0,dateSubmitted:"November 2nd 2020",dateReviewed:"November 26th 2020",datePrePublished:"January 11th 2021",datePublished:null,dateFinished:"January 11th 2021",readingETA:"0",abstract:"Patients undergoing cardiothoracic surgery, especially open cardiac procedures requiring cardiopulmonary bypass, are exposed to several alterations in primary and secondary hemostasis. These derangements are associated with increased microvascular bleeding that is refractory to conventional surgical maneuvers aimed at achieving hemostasis. This poses a technical problem for the surgeon and exposes the patient to increased morbidity from uncontrolled bleeding and any associated transfusion of blood products. Use of biosurgical hemostatic agents, specifically in patients undergoing cardiac surgery, have been shown to be safe and effective in reducing time to hemostasis, decreasing transfusion of blood products, and improving patient outcomes. Despite their merits, selection of a topical hemostat is frequently based on anecdotal experience and limited knowledge of the available agents. 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J Thorac Cardiovasc Surg. 2004;128(3):442-448. doi:10.1016/j.jtcvs.2004.03.041'},{id:"B5",body:'Walkden GJ, Verheyden V, Goudie R, Murphy GJ. Increased perioperative mortality following aprotinin withdrawal: a real-world analysis of blood management strategies in adult cardiac surgery. Intensive Care Med. 2013;39(10):1808-1817. doi:10.1007/s00134-013-3020-y'},{id:"B6",body:'Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006;34(6):1608-1616. doi:10.1097/01.CCM.0000217920.48559.D8'},{id:"B7",body:'Vlot EA, Verwijmeren L, van de Garde EMW, Kloppenburg GTL, van Dongen EPA, Noordzij PG. Intra-operative red blood cell transfusion and mortality after cardiac surgery. BMC Anesthesiol. 2019;19(1):65. Published 2019 May 4. doi:10.1186/s12871-019-0738-2'},{id:"B8",body:'Ferraris VA, Davenport DL, Saha SP, Bernard A, Austin PC, Zwischenberger JB. Intraoperative transfusion of small amounts of blood heralds worse postoperative outcome in patients having noncardiac thoracic operations. Ann Thorac Surg. 2011 Jun;91(6):1674-80; discussion 1680. doi: 10.1016/j.athoracsur.2011.01.025. Epub 2011 Apr 23. PMID: 21514923.'},{id:"B9",body:'Al-Attar N, Johnston S, Jamous N, et al. Impact of bleeding complications on length of stay and critical care utilization in cardiac surgery patients in England. J Cardiothorac Surg. 2019;14(1):64. Published 2019 Apr 2. doi:10.1186/s13019-019-0881-3'},{id:"B10",body:'Biancari F, Kinnunen EM, Kiviniemi T, et al. Meta-analysis of the Sources of Bleeding after Adult Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018;32(4):1618-1624. doi:10.1053/j.jvca.2017.12.024'},{id:"B11",body:'Barnard J, Millner R. A review of topical hemostatic agents for use in cardiac surgery. 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Use of endoscopic fibrinogen-thrombin in the treatment of severe hemoptysis. Respir Med. 2003 Jul;97(7):790-5. doi: 10.1016/s0954-6111(03)00032-5. PMID: 12854628.'},{id:"B17",body:'Ham SW, Lew WK, Weaver FA. Thrombin use in surgery: an evidence-based review of its clinical use. J Blood Med. 2010;1:135-142. doi:10.2147/JBM.S6622'},{id:"B18",body:'Pfizer Inc. Prescribing information: Thrombin-JMI, 2019.'},{id:"B19",body:'Baxter. Prescribing information: Recothrom, 2019.'},{id:"B20",body:'Oz MC, Cosgrove DM 3rd, Badduke BR, et al. Controlled clinical trial of a novel hemostatic agent in cardiac surgery. The Fusion Matrix Study Group. Ann Thorac Surg. 2000;69(5):1376-1382. doi:10.1016/s0003-4975(00)01194-2'},{id:"B21",body:'Nasso G, Piancone F, Bonifazi R, et al. Prospective, randomized clinical trial of the FloSeal matrix sealant in cardiac surgery. Ann Thorac Surg. 2009;88(5):1520-1526. doi:10.1016/j.athoracsur.2009.07.014'},{id:"B22",body:'Pankov R, Yamada KM. Fibronectin at a glance. J Cell Sci. 2002;115(Pt 20):3861-3863. doi:10.1242/jcs.00059'},{id:"B23",body:'Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Shapiro ML, Lawson JH. A comprehensive review of topical hemostatic agents: efficacy and recommendations for use. Ann Surg. 2010;251(2):217-228. doi:10.1097/SLA.0b013e3181c3bcca'},{id:"B24",body:'Rousou J, Levitsky S, Gonzalez-Lavin L, et al. Randomized clinical trial of fibrin sealant in patients undergoing resternotomy or reoperation after cardiac operations. A multicenter study. J Thorac Cardiovasc Surg. 1989;97(2):194-203.'},{id:"B25",body:'Codispoti M, Mankad PS. Significant merits of a fibrin sealant in the presence of coagulopathy following paediatric cardiac surgery: randomised controlled trial. Eur J Cardiothorac Surg. 2002;22(2):200-205. doi:10.1016/s1010-7940(02)00271-3'},{id:"B26",body:'Lamm P, Adelhard K, Juchem G, et al. Fibrin glue in coronary artery bypass grafting operations: casting out the Devil with Beelzebub?. Eur J Cardiothorac Surg. 2007;32(4):567-572. doi:10.1016/j.ejcts.2007.07.020'},{id:"B27",body:'Fleisher AG, Evans KG, Nelems B, Finley RJ. Effect of routine fibrin glue use on the duration of air leaks after lobectomy. Ann Thorac Surg. 1990 Jan;49(1):133-4. doi: 10.1016/0003-4975(90)90371-c. PMID: 2297261.'},{id:"B28",body:'Fabian T, Federico JA, Ponn RB. Fibrin glue in pulmonary resection: a prospective, randomized, blinded study. Ann Thorac Surg. 2003 May;75(5):1587-92. doi: 10.1016/s0003-4975(02)04994-9. PMID: 12735583.'},{id:"B29",body:'Gagarine A, Urschel JD, Miller JD, Bennett WF, Young JE. Effect of fibrin glue on air leak and length of hospital stay after pulmonary lobectomy. J Cardiovasc Surg (Torino). 2003 Dec;44(6):771-3. PMID: 14994744.'},{id:"B30",body:'C.R. Bard. Prescribing information: Progel, 2018.'},{id:"B31",body:'Allen MS, Wood DE, Hawkinson RW, Harpole DH, McKenna RJ, Walsh GL, Vallieres E, Miller DL, Nichols FC 3rd, Smythe WR, Davis RD; 3M Surgical Sealant Study Group. Prospective randomized study evaluating a biodegradable polymeric sealant for sealing intraoperative air leaks that occur during pulmonary resection. Ann Thorac Surg. 2004 May;77(5):1792-801. doi: 10.1016/j.athoracsur.2003.10.049. PMID: 15111188.'},{id:"B32",body:'Ethicon. Prescribing information: Evarrest, 2018.'},{id:"B33",body:'Gharagozloo F, Meyer M. Technique of robotic lobectomy III: control of major vascular injury, the 5 “P”‘s.Mini-invasive Surg 2020;4:57. http://dx.doi.org/10.20517/2574-1225.2020.44'},{id:"B34",body:'Bhamidipati CM, Coselli JS, LeMaire SA. BioGlue in 2011: what is its role in cardiac surgery?. J Extra Corpor Technol. 2012;44(1):P6-P12.'},{id:"B35",body:'Zehr KJ. Use of bovine albumin-glutaraldehyde glue in cardiovascular surgery. Ann Thorac Surg. 2007;84(3):1048-1052. doi:10.1016/j.athoracsur.2007.01.012'},{id:"B36",body:'Khan H, Chaubey S, Desai J. Early failure of coronary artery bypass grafts: an albumin cross-linked glutaraldehyde (BioGlue) related complication. J Card Surg. 2011;26(3):264-266. doi:10.1111/j.1540-8191.2011.01208.x'},{id:"B37",body:'LeMaire SA, Carter SA, Won T, Wang X, Conklin LD, Coselli JS. The threat of adhesive embolization: BioGlue leaks through needle holes in aortic tissue and prosthetic grafts. Ann Thorac Surg. 2005;80(1):106-111. doi:10.1016/j.athoracsur.2005.02.004'},{id:"B38",body:'LeMaire SA, Schmittling ZC, Coselli JS, et al. BioGlue surgical adhesive impairs aortic growth and causes anastomotic strictures. Ann Thorac Surg. 2002;73(5):1500-1506. doi:10.1016/s0003-4975(02)03512-9'},{id:"B39",body:'Zhou H, Ge J, Bai Y, Liang C, Yang L. Translation of bone wax and its substitutes: History, clinical status and future directions. J Orthop Translat. 2019;17:64-72. Published 2019 Apr 11. doi:10.1016/j.jot.2019.03.005'},{id:"B40",body:'Nelson DR, Buxton TB, Luu QN, Rissing JP. The promotional effect of bone wax on experimental Staphylococcus aureus osteomyelitis. J Thorac Cardiovasc Surg. 1990;99(6):977-980.'},{id:"B41",body:'Johnson P, Fromm D. Effects of bone wax on bacterial clearance. Surgery. 1981;89(2):206-209.'},{id:"B42",body:'Sudmann B, Bang G, Sudmann E. Histologically verified bone wax (beeswax) granuloma after median sternotomy in 17 of 18 autopsy cases. Pathology. 2006;38(2):138-141. doi:10.1080/00313020600561732'},{id:"B43",body:'Ostene Bone Hemostasis Material [instructions for use]. Los Angeles, Calif: Ceremed Inc.PN-26 CF607 Rev. H 2011.'},{id:"B44",body:'Vestergaard RF, Jensen H, Vind-Kezunovic S, Jakobsen T, Søballe K, Hasenkam JM. Bone healing after median sternotomy: a comparison of two hemostatic devices. J Cardiothorac Surg. 2010;5:117. Published 2010 Nov 24. doi:10.1186/1749-8090-5-117'},{id:"B45",body:'Vestergaard RF, Nielsen PH, Terp KA, Søballe K, Andersen G, Hasenkam JM. Effect of hemostatic material on sternal healing after cardiac surgery. Ann Thorac Surg. 2014;97(1):153-160. doi:10.1016/j.athoracsur.2013.08.030'},{id:"B46",body:'Frantz VK. Absorbable cotton, paper and gauze: (oxidized cellulose). Ann Surg. 1943;118(1):116-126. doi:10.1097/00000658-194311810-00010'},{id:"B47",body:'Scher KS, Coil JA Jr. Effects of oxidized cellulose and microfibrillar collagen on infection. Surgery. 1982;91(3):301-304.'},{id:"B48",body:'Spangler D, Rothenburger S, Nguyen K, Jampani H, Weiss S, Bhende S. In vitro antimicrobial activity of oxidized regenerated cellulose against antibiotic-resistant microorganisms. Surg Infect (Larchmt). 2003;4(3):255-262. doi:10.1089/109629603322419599'},{id:"B49",body:'Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Shapiro ML, Lawson JH. A comprehensive review of topical hemostatic agents: efficacy and recommendations for use. Ann Surg. 2010;251(2):217-228. doi:10.1097/SLA.0b013e3181c3bcca'},{id:"B50",body:'Kaneyuki D, Mogi K, Sakata T, Takahara Y. Surgicel® packing remnants mimicking mediastinitis after adult cardiac surgery. Interact Cardiovasc Thorac Surg. 2018;26(6):1035-1036. doi:10.1093/icvts/ivy006'},{id:"B51",body:'White A, Swanson SJ. How to deal with benign hilar or interlobar lymphadenopathy during video-assisted thoracic surgery lobectomy-case report series. J Vis Surg. 2016;2:22. Published 2016 Jan 27. doi:10.3978/j.issn.2221-2965.2016.01.04'},{id:"B52",body:'Arista AH Absorbable Hemostatic Particles: The latest generation in hemostatis from BD. https://www.crbard.com/CRBard/media/ProductAssets/DavolInc/PF10133/en- US/PF10133_AristaBrochure-2018.pdf. Accessed July 27, 2020.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Zachary Frenzel",address:"zachary.frenzel@sluhn.org",affiliation:'
Department of Surgery, St. Luke’s University Hospital, Bethlehem, PA, USA
Department of Surgery, St. Luke’s University Hospital, Bethlehem, PA, USA
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This study addresses to define experimentally the self-healing ability and efficiency of the Araldite 2011 epoxy adhesive reinforced with the thermoplastic co-polyester (TPC). Heating the joint results in melting the co-polyester in adhesive, and then it is expected to repair the damaged region by the melted co-polyester. Firstly, before applying the self-healing process, a preliminary study was applied to define whether selected adhesive is compatible with the thermoplastic particles in terms of self-healing. From the initial results, it is seen that Araldite 2011 adhesive is suitable for use in the self-healing mechanism. In the healing cycle, initial crack in the reinforced adhesive was propagated until 30 mm during the double cantilever beam (DCB) testing. The fractured specimens were repeatedly healed in terms of the close-then-heal (CTH) scheme until no healing has taken place. After the healing process was completed, the healing efficiency was defined using the fracture energy values. In this study, the healing process was repeated two times with the acceptable healing efficiencies. 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Chemical modification reviewed includes chemical modification without introducing new atom such as cyclized natural rubber and deproteinized natural rubber (DPNR), modification by introducing a chemical group such as hydrogenated natural rubber (HNR), chlorinated natural rubber (CNR) and epoxidized natural rubber (ENR) and lastly modification by grafting on NR. Grafting can be carried out using DPNR latex to yield styrene‐grafted‐NR, methyl methacrylate‐grafted‐NR and styrene and methyl methacrylate‐grafted‐NR. 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Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. 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He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. 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He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. 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