Sex Trafficking Victims at Their Junction with the Healthcare Setting-A Mixed-Methods Inquiry

Recommendations to Improve Services and Supports for Domestically Sex Trafficked Persons Derived from the Insights of Health Care Providers

Health care providers are highly likely to encounter persons who have been domestically sex trafficked and, therefore, possess valuable insights that could be useful in understanding and improving existing services and supports. In-depth interviews were conducted with 31 health care providers residing and working in Canada's largest province, Ontario. Results were analyzed using Braun and Clarke's analytical framework. Across providers, a key theme was identified: "Facilitators to improve care", which was comprised of two sub-themes, "Address needs in service provision" and "Center unique needs of survivors". From these results, eight wide-ranging recommendations to improve services and supports were developed (eg, Jointly mobilize an intersectoral, collaborative, and coordinated approach to sex trafficking service provision; Employ a survivor-driven approach to designing and delivering sex trafficking services). These recommendations hold the potential to enhance services in Canada and beyond by reducing barriers to access and care, facilitating disclosure, aiding in recovery, and empowering those who have been domestically sex trafficked.

Improving Nurse Practitioner Students' Knowledge and Confidence in the Identification and Management of Human Trafficking Victims

Human trafficking is a global public health problem affecting millions of people worldwide. In the United States, many trafficking victims seek medical care for physical, sexual, and mental health concerns. Unfortunately, many of these individuals go unrecognized by health care providers as being victims of human trafficking and return to their trafficker without interventions for their safety and protection. To provide effective quality care for this patient population, health care providers must be knowledgeable regarding the identification of signs of trafficking, trauma-informed interventions to ensure the safety and protection of the victim(s), and methods to collaborate with interprofessional partners for the provision of appropriate medical and socioeconomic care following the exit from their trafficking situation. The purpose of this pilot study was to evaluate best practices in teaching Family Nurse Practitioner (FNP) students to identify and implement appropriate interventions for victims of human trafficking. The study was conducted in two phases using a mixed-method research design with repeated measures. In the first phase, education was provided through the validated HOPE Training modules produced by the Safe House Project using a pretest, posttest design. In the second phase, the students observed an interprofessional simulation followed by focus groups using a phenomenological approach to explore students' perceptions. Knowledge and confidence increased significantly following the implementation of this study. The results provide essential information regarding incorporating human trafficking education into FNP curricula. This study also contributes to the body of knowledge regarding the vital role that nurse practitioners play in the interprofessional management of human trafficking victims.

Healthcare providers' experience of identifying and caring for women subjected to sex trafficking: a qualitative study

BACKGROUND

Men's violence against women, including human trafficking for sexual exploitation, is a severe threat to global health. Healthcare providers are uniquely positioned to identify and care for women subjected to human trafficking for sexual exploitation. They are among the few professionals the women interact with while being exposed to human trafficking for sexual exploitation. This study aims to describe healthcare workers' experience of identifying and caring for women subjected to human trafficking for sexual exploitation seeking women's healthcare.

METHOD

A qualitative design was chosen and nine qualitative interviews with healthcare providers were conducted and analyzed using the content analysis method.

RESULTS

Three main categories were revealed: (1) the importance of being attentive, (2) the importance of providing safety, and (3) the importance of collaborating, followed by a number of subcategories: behavioral and physical signs, limited time to interact, security measures, value of confidence building, organizational collaboration, essential external network, and information transmission.

CONCLUSIONS

As the women subjected to sex trafficking have limited time in healthcare, it is important for healthcare providers to be attentive and act immediately if suspecting human trafficking for sexual exploitation. It may be the only possibility for the healthcare providers to care for these women and reach them. They must endeavor to provide the women with safety due to their vulnerable position at the hospital. However, these women may leave the healthcare setting unidentified and unaided, which highlights the importance of collaboration on multiple levels.

Human trafficking risk factors, health impacts, and opportunities for intervention in Uganda: a qualitative analysis

BACKGROUND

Human trafficking is a global public health issue that is associated with serious short- and long-term morbidity. To address and prevent human trafficking, vulnerabilities to human trafficking and forces sustaining it need to be better understood among specific subpopulations. We aimed to explore risk and protective factors for human trafficking, the health impact of exploitation, and barriers and facilitators of seeking help throughout the human trafficking trajectory among forced labor and sex trafficking victims in Kampala, Uganda.

METHODS

Between March and November 2020, in-depth, semi-structured qualitative interviews were conducted with 108 victims of forced labor and sex trafficking who had completed a human trafficking survey conducted by the Uganda Youth Development Link (UYDEL). Participants who experienced various forms of exploitation were purposively invited for qualitative interviews and a convenience sample was interviewed. Interviews explored personal history, trafficking recruitment, experiences of exploitation and abuse, and experiences seeking help. Interviews were analyzed using a combination of deductive and inductive thematic analysis. Themes and subthemes were organized using an adapted conceptual framework of human trafficking.

RESULTS

Poverty and an abusive home life, frequently triggered by the death of a caretaker, underpinned vulnerability to human trafficking recruitment. Limited education, lack of social support, and survival needs pushed victims into exploitative situations. Victims of human trafficking were systematically exploited and exposed to dangerous working conditions. Victims suffered from sexually transmitted diseases, incontinence, traumatic fistulae, musculoskeletal injuries, and mental health symptoms. Lack of awareness of resources, fear of negative consequences, restrictions on movement, and dependence on the trafficker and exploitation income prevented victims from seeking help. The police and healthcare workers were the few professionals that they interacted with, but these interactions were oftentimes negative experiences.

CONCLUSIONS

To address and prevent human trafficking, localized interventions are needed at all stages of the human trafficking trajectory. Health impacts of human trafficking are severe. As some of the few professionals trafficking victims interact with, police and healthcare workers are important targets for anti-trafficking training. Improved understanding of human trafficking drivers and barriers and facilitators to seeking help can inform the design of necessary interventions.

Qualitative Assessment of a Human Trafficking Module Intervention in Pharmacy Education

Description of the Problem: Human trafficking is a critical public health threat in the United States, yet education on human trafficking for pharmacy students has not been evaluated despite pharmacists being the most accessible health care professionals. Description of the Innovation: To evaluate the most valuable aspects of an introductory module on human trafficking, pharmacy students participated in a human trafficking module, and their perception of human trafficking was evaluated after the module. Content on human trafficking was delivered through an asynchronous online presentation followed by a synchronous Zoom class discussion. Fifty-three third-year pharmacy students from the Women's Health elective in the fall semester of 2020 at the University of Minnesota - College of Pharmacy were included. Consensual Qualitative Research methodology was used for qualitative data analysis. Critical Analysis: Students' perceptions of the value of this learning module was evaluated through consensual qualitative research. The findings suggest the module held significant value for students to better understand human trafficking and the role of pharmacists. Implications: A hybrid model on human trafficking involving discussions, case examples, and questions posed by students was found to have a positive impact on their knowledge on human trafficking. The results of this study will provide direction for future modules, classes, or adaptations to the curriculum on human trafficking for pharmacy students and may prove beneficial for other health care professionals.

Slipping through the cracks-detection of sex trafficking in the adult emergency department: An integrative review

INTRODUCTION

Current research estimates that over 24 million individuals experience human trafficking worldwide. There is a growing prevalence of sex trafficking in the United States. An estimated 87% of trafficked persons visit the emergency department during their captivity. Emergency departments across the United States use differing screening methods for sex trafficking. Current screening tools return a high rate of false negatives, and the appropriate use of tools or standardised lists remains unclear.

AIMS

To explore best practices for identifying sex trafficking among adults who visit emergency departments. We sought to answer the practice question: How does the implementation of a multifaceted screening model for sex trafficking, versus the use of a list of standardised screening questions, improve the detection of trafficked persons?

METHODS

We conducted an integrative review of articles published after 2016 in PubMed, CINAHL, Embase, SCOPUS, and Web of Science databases. PRISMA checklist and guidelines were used. Whittemore and Knafl's method was used to review the literature.

RESULTS

A final selection of 11 articles were reviewed and appraised using the Johns Hopkins nursing evidence-based practice model. The synthesis of evidence yielded four themes: (1) Provider and personnel education; (2) Protocol establishment; (3) Legal consultation; and (4) Multidisciplinary teamwork.

CONCLUSION

Through this process, we learned the importance of using multifaceted screening tools for identifying persons who are experiencing sex trafficking. In addition to using multifaceted screening tools, detection is improved when all emergency department personnel receive training on sex trafficking. There is a recognised lack of education on sex trafficking recognition nationwide.

RELEVANCE TO CLINICAL PRACTICE

Notably, emergency department nurses play an essential role in sex trafficking identification due to their maximised interaction with patients and the increased perception of trust that patients have with nurses. Steps include the development of an education program to improve recognition.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement in the design or drafting of this integrative review.

Exploitation, Labor and Sex Trafficking of Children and Adolescents: Health Care Needs of Patients

Exploitation and labor and sex trafficking of children and adolescents is a major public health problem in the United States and throughout the world. Significant numbers of US and non-US-born children and adolescents (including unaccompanied immigrant minors) are affected by this growing concern and may experience a range of serious physical and mental health problems associated with human trafficking and exploitation (T/E). Despite these considerations, there is limited information available for health care providers regarding the nature and scope of T/E and how providers may help recognize and protect children and adolescents. Knowledge of risk factors, recruitment practices, possible indicators of T/E, and common medical, mental, and emotional health problems experienced by affected individuals will assist health care providers in recognizing vulnerable children and adolescents and responding appropriately. A trauma-informed, rights-based, culturally sensitive approach helps providers identify and treat patients who have experienced or are at risk for T/E. As health care providers, educators, and leaders in child advocacy and development, pediatricians play an important role in addressing the public health issues faced by children and adolescents who experience exploitation and trafficking. Working across disciplines with professionals in the community, health care providers can offer evidence-based medical screening, treatment, and holistic services to individuals who have experienced T/E and assist vulnerable patients and families in recognizing signs of T/E.

Modern slavery and labor exploitation during the COVID-19 pandemic: a conceptual model

BACKGROUND

Modern slavery is a complex global health problem that includes forced labor exploitation. An ecological systems perspective is needed to understand how contextual upstream and midstream factors contribute to labor exploitation, and how disruptive societal challenges, such as infectious disease pandemics, may exacerbate established pathways leading to exploitation. Accumulation of familial and societal risk factors likely heightens vulnerability; for instance, economic precarity for an individual interacts with poor livelihood options and lack of social welfare supports increasing their likelihood of accepting exploitative labor. However, few frameworks exist that account for the accumulation of and interdependence between risk factors at different levels and across contexts.

OBJECTIVE

Using an ecological systems framework, we review literature on the pathways leading to labor exploitation, with the aim of developing a conceptual model grounded in existing research. Next, we discuss how pathways in this conceptual model are likely exacerbated by the COVID-19 pandemic. This conceptual model can guide future research to detect modifiable factors and strategic points of intervention.

METHODS

A critical review of research articles and gray literature was performed with a primary focus on sub-Saharan Africa. The review utilized various scholarly databases to identify perspectives from multiple disciplines and to more fully account for complex processes linked to labor exploitation.

RESULTS

A conceptual model of these pathways was developed that emphasizes established determinants and risk factors for labor exploitation in sub-Saharan Africa. The model highlights how the COVID-19 pandemic may have exacerbated these pathways.

CONCLUSIONS

Future studies should carefully examine the direct and indirect pathways, accumulation of and interactions between factors, and specific external and personal stressors. Interdisciplinary research on multilevel interventions is needed to guide solutions to prevent the persistent problem of labor exploitation.

Youth survivor perspectives on healthcare and sex trafficking

PURPOSE

This study aimed to assess the perspectives of youth survivors of sex trafficking on healthcare to improve care for this vulnerable and often unrecognized population.

DESIGN AND METHODS

Semi-structured focus groups were conducted with eight survivors in Southern California who interacted with the healthcare system while being sex trafficked. Interviews were audio- and/or video-recorded and transcribed verbatim. The analysis utilized a grounded theory approach, where researchers reviewed the data collected, then inductively generated codes and themes based on the findings from the interviews.

RESULTS

The focus group interviews revealed the following themes: unequal treatment, barriers to patient care, risk identifiers, support, and survivor recommendations.

CONCLUSIONS

Youth survivors seeking healthcare reported multiple barriers based on their interaction with healthcare providers, such as the lack of provider awareness, education, training, feelings of shame, judgment, fear, racial biases, and lack of empathy. Improving patient outcomes relies on understanding the complexities of human trafficking and implementing an approach to decrease barriers to care.

PRACTICE IMPLICATIONS

This study resulted in invaluable survivor recommendations with practical solutions on addressing human trafficking and exploitation in the healthcare system. The solutions proposed by participants included strengthening relationships and experiences with healthcare providers by increasing awareness, establishing rapport, creating a safe space, asking questions about their safety and situation, using a non-judgmental approach, and providing resources.

Confusing Terms: A Concept Analysis of Naming Youth Trafficking

Human trafficking is a growing population health problem. More than half of all persons experiencing trafficking are youth, with many in the United States unrecognized despite experiencing exploitation. Available peer-reviewed articles report a myriad of descriptions of trafficking, yet the concept and operational definition of youth trafficking, specifically, is lacking and unclear. Youth trafficking is described differently across multidisciplinary researchers and clinicians working with trafficked youth. Furthermore, labor trafficking of youth is largely excluded from the conversation surrounding trafficking. This article presents a concept analysis of naming trafficking of persons under the age of 18 years to clarify the concept specific to youth experiencing all forms of trafficking and approaches professionals can take with this specific subpopulation of trafficked persons and survivors.

Assessing healthcare provider knowledge of human trafficking

BACKGROUND AND OBJECTIVES

Human trafficking is a significant problem in which healthcare workers are in a unique position to intervene. This study sought to determine the self-reported knowledge levels of healthcare providers most likely to come in direct contact with victims of human trafficking.

METHODS

An anonymous survey assessing self-reported knowledge of human trafficking was developed and distributed online. Demographic information and questions pertaining to training and knowledge of trafficking in a healthcare setting were asked. The primary outcomes were descriptive statistics and secondary outcomes were comparisons among demographic groups. Qualitative methodology via content analysis was implemented on an open-ended question.

RESULTS

The 6,603 respondents represented all regions of the country. Medical, nursing, and physician assistant students comprised 23% of the sample, while 40% were either physicians, fellows, or residents. Less than half the respondents (42%) have received formal training in human trafficking, while an overwhelming majority (93%) believe they would benefit by such training. Overall, respondents thought their level of knowledge of trafficking was average to below average (mean = 2.64 on a 5-point scale). There were significant differences in knowledge of trafficking by age group (p < .001), region (p < .001), and educational training level (p < .001). 949 respondents (14.4%) provided free-text comments that further described their opinions.

CONCLUSION

Most respondents stated they have not received training but felt they would benefit from it. There were significant differences between demographic groups. Further innovation is needed to design a universally appropriate curriculum on human trafficking that is accessible to all healthcare providers as well as mandatory training programs for healthcare institutions.

Sex trafficking screening and intervention in the emergency department: A scoping review

INTRODUCTION

Human sex trafficking is a global public health crisis. Emergency departments (EDs) are important access points for trafficked persons who seek medical care. However, because of victims' hesitancy to disclose their situation and health care practitioners' lack of training and institutional protocols, many trafficked persons go unrecognized.

METHODS

We performed a scoping review of current literature. PubMed, SCOPUS, and reference lists were searched to identify articles for inclusion. We aimed to identify gaps in knowledge and shortcomings to assist this vulnerable population. Two reviewers independently screened literature search results and abstracted data from included studies. Descriptive analysis was conducted.

RESULTS

We selected and analyzed 23 studies that focused on adult human sex trafficking identification, screening, interventions, or education in the ED. Eight (35%) of the publications used a survey model to quantitatively assess outcomes. Many of the other publications were descriptive or qualitative in nature, with some using a structured interview approach. We have observed that no validated or consistent screening tool exists for the identification of possible adult trafficked patients in the ED. However, we found that educational interventions and screening tools can improve health care practitioners' confidence, victim identification, and knowledge of "next steps" for victims.

CONCLUSIONS

We found that most ED clinicians and staff have little or no formal training in sex trafficking victim identification, support, institutional protocols, or available local resources. Our review demonstrates a paucity of formal training programs, validated adult screening tools, and standardized institutional protocols to aid in the care of trafficked patients in the ED.

Human Trafficking in Correctional Institutions: A Survey of Correctional and Anti-Trafficking Leaders

Growing awareness of the overlap between justice involvement and human trafficking victimization has led to calls for correctional institutions to prevent, identify, and respond to trafficking. However, it is unclear how correctional facilities (i.e., jails and prisons) are responding to such calls to action. To examine current efforts to address human trafficking in U.S. correctional facilities, this study surveyed correctional and anti-trafficking leaders (n = 46) about their perceptions and experiences with human trafficking screening, response, and training in correctional facilities. Although the majority of leaders (89%) agreed individuals in their state's correctional facilities have experienced human trafficking, they generally did not perceive that correctional staff were prepared to respond. Bivariate tests revealed that correctional and anti-trafficking leaders differed on their perceptions regarding correctional staffs' knowledge about human trafficking risk factors (p = .014), identification ability (p = .006), and response knowledge (p = .036), with anti-trafficking leaders perceiving correctional staff to be less prepared in these areas. Approximately 16% of leaders reported strategies to identify and respond to trafficking in correctional facilities, and about 27% reported human trafficking training for corrections staff. To promote a just society, study findings offer preliminary guidance for anti-trafficking correctional initiatives and future research.

Human Trafficking in Rehabilitation: What Nurses Need to Know

ABSTRACT

Violence and human trafficking are frequently paired and violate human rights. Human trafficking is a complex, global health issue. Trafficking survivors report seeking medical care for women's services, physical abuse, mental health, and gastrointestinal issues while being held in captivity. However, the majority of healthcare providers are unaware or unprepared to intervene, thus missing the chance to identify victims during these encounters. Rehabilitation nurses are no exception. Trafficking victims may come in contact with rehabilitation nurses because of injuries or chronic diseases caused by trafficking abuse. This article shares human trafficking red flags, victims' access to services, barriers to identification, and nursing interventions and implications.

Forced labour in supply chains: Rolling back the debate on gender, migration and sexual commerce

This article makes a conceptual contribution to the broader literature on unfree labour by challenging the separate treatment of sexual and industrial labour exploitation both by researchers and in law and policy. This article argues that the prevailing focus of the supply chain literature on industrial labour has inadvertently posited sexual labour as the ‘other’ of industrial labour thus obfuscating how the legal blurring of boundaries between industrial and service labour is engendering new modalities of the erosion of workers’ rights that are increasingly resembling those typical of sex work. This article advances the debate on unfree labour both conceptually and empirically. Conceptually, it highlights the relevance of social reproduction in understanding forms of labour unfreedom. Empirically, it demonstrates the similarities in forms of control and exploitation between sex work and industrial work by illustrating how debt and housing operate in both settings.

Compassionate Care-Going the Extra Mile: Sex Trafficking Survivors' Recommendations for Healthcare Best Practices

Human Trafficking (HT) persists in the US, despite multi-level measures designed to mitigate its societal costs. HT instruction for healthcare providers is growing, but there is a dearth of resources and training presenting obstacles for victims accessing suitable healthcare services. Voices of survivors are also scant in the literature, despite the fact that their recommendations would appear essential when designing best practices. This study aimed to methodically gather recommendations from sex trafficking (ST) survivors who sought medical care during their victimization. An exploratory concurrent mixed-methods design was used, and semi-structured interviews (N = 22) were conducted between March 2016 and March 2017, in San Diego, CA, and Philadelphia, PA. Data were analyzed through a coding system to identify meaningful analytical themes. Study participants were recruited through survivor-centered organizations, and their identification was kept anonymous and confidential. Findings included three main themes: (A) Red Flags; (B) supportive healthcare practices; and (C) resources for ST-patient study participants’ recommendations aimed to improve healthcare practice in response to their medical needs in a compassionate and caring manner, with trust building, rapport, and an opportunity to instill hope among ST-patients. Implementing Compassionate Care approaches when caring for ST-patients could positively impact patient–provider interactions, while creating opportunities for intervention.

Combatting human trafficking in the United States: how can medical informatics help?

OBJECTIVE

Human trafficking is a global problem taking many forms, including sex and labor exploitation. Trafficking victims can be any age, although most trafficking begins when victims are adolescents. Many trafficking victims have contact with health-care providers across various health-care contexts, both for emergency and routine care.

MATERIALS AND METHODS

We propose 4 specific areas where medical informatics can assist with combatting trafficking: screening, clinical decision support, community-facing tools, and analytics that are both descriptive and predictive. Efforts to implement health information technology interventions focused on trafficking must be carefully integrated into existing clinical work and connected to community resources to move beyond identification to provide assistance and to support trauma-informed care.

RESULTS

We lay forth a research and implementation agenda to integrate human trafficking identification and intervention into routine clinical practice, supported by health information technology.

CONCLUSIONS

A sociotechnical systems approach is recommended to ensure interventions address the complex issues involved in assisting victims of human trafficking.

The Impact of Human Trafficking Training on Healthcare Professionals' Knowledge and Attitudes

OBJECTIVES

The objective of this study was to evaluate a CME-accredited human trafficking didactic and discussion-based training for healthcare professionals by comparing participant knowledge and attitudes on human trafficking before and after attending the training.

METHODS

A novel 18-item survey was developed to test the knowledge of and attitudes towards human trafficking. Participants of 17 standardized trainings delivered by 4 physician-trainers over a two-year period were invited to take a pre-test and 2 post-tests at 1-week and 6-months post training. Surveys were anonymously collected and linked to each participant with a de-identified number. Data were analyzed using SPSS software with scores given to the overall and knowledge and attitude subscales. Data are presented as mean ± standard deviation. Comparisons were made using paired t-tests or ANOVA, as appropriate.

RESULTS

Total of 424 participants submitted the pre-test and were predominantly female (81%) and students in healthcare fields (55%). Of these participants, 237 (56%) submitted the 1-week post-test. Scores increased from pre-test to 1-week post-test in both knowledge (54.7 ± 18.7%-84.5 ± 12.8%, P = .001) and attitude (49.4 ± 14.7%-71.0 ± 12.8%, P < .001) subscales. Forty-seven participants (11%) submitted the 6-month post-test, which demonstrated a decrease in knowledge score from the 1-week post-test (84.5 ± 12.8%-50.0 ± 13.6%, P < .001). However, improvements in attitude scores were sustained across time (71.0 ± 12.8%-68.8 ± 12.4%, P < .001).

CONCLUSIONS

Among health professionals, the CME-accredited LIFT training leads to a short-term improvement in knowledge of human trafficking and a sustained improvement in awareness and attitudes about human trafficking.