Running head: PROJECT FINAL REPORT An Education for Mental Health Care Providers: Sex Trafficking Victim Identification Project Final Report Lillian Chang Arizona State University 1 PROJECT FINAL REPORT 2 Project Final Report Background and Signficance According to the National Trafficking Hotline (2017), last year there were over 5,000 cases of sex trafficking reported. Lederer & Wetzel (2014) discuss that more than 88% of victims interact with a health care provider while being trafficked at least once. A majority of cases, mental health care providers were informed that their patient was a sex trafficking victim through collaboration of other health care team members. Without this collaboration, may providers report that they would have never known that they had interacted with a victim (Domoney, Howard, Abas, Broadben, & Oram, 2015). Mental health care providers are in an especially challenging position as victims present with multiple comorbidities that often involve complex history taking. Many victims are at high risk for posttraumatic stress disorder (PTSD), anxiety, depression or a combination of all three (Abas, et al, 2013). Unfortunately, a knowledge gap exists when it comes to mental health care providers and their awareness of sex trafficking victim presentation. Mental health care providers report that they do not have adequate training when it comes to recognizing a sex trafficking victim, how to screen for them, provide the necessary care and resources that they need (Domoney, et al., 2015). There are currently national initiatives taking place that provide free training and education on treating trafficking victims. This includes the online education program SOAR or Stop, Observe, Ask and Respond, that has been implemented by the federal government. This provides educational for all health care professionals on how to recognize and treat trafficking victims. This program though addresses human trafficking in general and not specifically sex trafficking. It also targets all health care professionals and not just mental health providers. PROJECT FINAL REPORT 3 Problem Statement Does a change in attitude and knowledge occur in mental health care providers towards sex trafficking victim identification, after an educational intervention is given on how to identify sex trafficking victims? Search Strategy The key words used to search for articles included sex trafficking, health care and sex trafficking, mental health and sex trafficking, health policies and sex trafficking. The databases used to search include PubMed, SAGE, PsycINFO, Science Direct and CINAHL. Inclusion criteria included articles that were 5 years or less in publication, specifically discussed sex trafficking with health care and mental health, as well as recommendations for policies or procedures. The number of articles found totaled 34 and the number of articles selected was 20. Evidence Synthesis The research literature discusses that there are numerous gaps in knowledge and awareness from mental health care providers on treating sex trafficking victims. Many are not aware of the prevalence of sex trafficking within the country or within their geographical area in which they practice. Providers are also unsure of how to screen victims, how to approach them in a trauma sensitive manner and what is considered mandated reporting when treating these victims (Domoney, et al, 2015). In order for mental health care providers to provide effective quality care for these victims, it is essential that they receive the education and training needed to do so. Purpose Statement PROJECT FINAL REPORT The purpose of this project was to increase awareness and educate mental health care providers on sex trafficking victim identification. This was to help mental health care providers understand the prevalence of sex trafficking, the clinical presentation of a victim and the resources that victim’s need in order to recover. Evidence Based Practice Model The star model of knowledge transformation was used to guide the entire project. This model provides a way in which to organize evidence based practice processes. It depicts five different stages in which knowledge is discovered, transformed and then implemented into practice (Steven, 2012). The first stage is discovery research. This is where the knowledge is gathered from research inquiries and results are created from a study that is conducted. This stage is where the research is built upon in order to support clinical actions (Stevens, 2012). In this project, the research gathered was looking at the knowledge gap that mental health care providers have, towards providing care for sex trafficking victims. The study that was conducted was the pretest survey component that asked mental health care providers their knowledge of sex trafficking victim care. The second stage is evidence summary. This is where all the evidence and research gathered is synthesized into a “meaningful statement”, that can produce new knowledge and assess inconsistencies or biases within the research findings (Stevens, 2012). In the project, all the research articles were viewed and tallied up on the amount of consistent information provided on mental health care provider gaps in knowledge. Based on this summary, the foundation of what should be presented to mental health care providers was created. 4 PROJECT FINAL REPORT 5 The third stage is translation to guidelines. The purpose of this stage is to summarize the evidence that mental health care providers need to know, in order to be able to understand how to implement this knowledge into practice (Stevens, 2012). The educational intervention given to the providers was a summary of the research gathered, that addressed the knowledge gaps present in providing care for sex trafficking victims. The fourth stage is practice integration. This is where individuals and organizations must now implement changes into their practices, which incorporate the research and evidence gathered in the previous stages (Stevens, 2012). In the project, the resources provided incorporated both an individual aspect of how providers can treat victims, as well as guidelines for facilities to create polices and procedures to address victim care. The final stage is process, outcome evaluation. This is where an evaluation is performed to assess the impact of the evidence-based practice on to patient care. This evaluates overall the patient outcomes and quality of care that was implemented (Stevens, 2012). This project provided recommendations in which providers can follow up on their training and update their knowledge in sex trafficking victim care. It also recommended that providers be encouraged to reach out to their organizations or facilities on implementing protocols or procedures into the practice settings to address victim needs. Theoretical Model The Betty Neuman systems model was used to guide the intervention of this project. Specifically the reaction and tertiary prevention sections of the systems model were used to frame the educational presentation. Tertiary prevention is based upon the reaction and intervention areas of the system. The reaction is towards a problem or issue that is occurring in which the individual is resistant to or unable to manage. In this project, the reaction is the PROJECT FINAL REPORT 6 prevalence of sex trafficking and the inability of mental health care providers to be able to provide effective care in treating victims. Interventions occur after the reaction phase and are based on the type of reaction that occurred, what resources there are, the goals and anticipated outcomes (Ume-Nwagbo, Dwan, &Lowry, 2006). The intervention that took place within this project was to educate and provide resources for mental health care providers, so that they can provide effective trauma informed care for all victims. The tertiary prevention phase looks at the individual readapting and being reeducated in order to prevent any future occurrences towards the problem or issue that occurred. The individual is able to rehabilitate and adjust towards healthy functioning (Ume-Nwagbo, et al., 2006). Mental health care providers after receiving the educational intervention are able to implement this knowledge within their practice and apply their skills towards future patient care. Project Methods The target population for the project consisted of mental health care providers made up of nurse practitioners, psychiatrists and psychologists. Recruitment consisted of personally emailing and inviting participants to take part in the educational intervention. All participants were given an introductory letter explaining the purpose of the project and how to participate. Pre and posttest surveys were given to assess their knowledge and attitudes towards sex trafficking victim identification. Participants were told that all data gathered would be anonymous with survey IDs personally created by each participant to match pre and post survey responses. All surveys were created through the secure Red Cap software and database. The educational intervention consisted of a voice over power point presentation video. The surveys and video were available online and all participants could access them through a private link at any time. PROJECT FINAL REPORT 7 The survey questions used to assess the participants’ knowledge and attitudes were modified and adopted from the sex trafficking attitudes scale (Houston-Kolnik, Todd, & Wilson, 2016). Collaboration for the educational intervention and survey were done with Dr. Angela Chia-Chen Chen, faculty mentor at ASU. Data collection spanned three months to allow participants time to complete the surveys and view the educational presentation on their own time. Data analysis was done in collaboration with Dr. Angela Chia-Chen Chen and Dr. Jennifer Mensik, faculty and statistical consultant at ASU. Outcomes The total participants were nine (n=9), which were those that completed both the pretest and posttest surveys. The sample as a whole mainly consisted of psychiatric mental health nurse practitioners (85.7%). Over half of the participants worked in outpatient clinical settings (64.3%). The average years that participants practiced in mental health were 2.11 years (M= 2.11, SD= 0.93). Over half of the participants worked with adult populations 18 years and older (55.6%). The pre and post test surveys (Appendix A) consisted of the same questions asked in regards to knowledge and attitudes towards identifying as well as treating sex trafficking victims. The Wilcoxon signed ranks test was done to analyze the data that was collected over the threemonth period (Appendix B). All participants reported that they were aware of sex trafficking that is occurring within the US, but only 77.8% were aware that this was occurring within Arizona. The participants’ knowledge significantly increased in the posttest score compared to the pretest (Z= -2.694, p< 0.007). The confidence that participants’ had on treating sex trafficking victims was higher in the posttest score than the pretest (Z= -2.565, p< 0.01). PROJECT FINAL REPORT 8 The confidence that participants had on the ability to protect themselves as well as the victim during screening, against potential harm from the trafficker was higher in the posttest score than the pretest (Z= -2.251, p< 0.024). The participants’ attitudes towards advocating for victim care did not change pre and post test. All participants agreed that advocating for this high-risk vulnerable population is needed. Discussion The results of this project illustrate that there is a need for education and training of mental health care providers on being able to recognize, screen and provide care for sex trafficking victims. For victims, this provides increased reassurance to trust providers in being able to provide trauma informed care and have the awareness of the resources that victims may need. Mental health care providers based on this educational intervention will be able to implement the knowledge that they were given easily into their practice. The impact of this project on policy is that it provides resources that are freely available to access on how to implement policies or procedures in any patient setting on caring for sex trafficking victims. The recommendations of this project is that mental health care providers continue to maintain and update their training on sex trafficking victim care. It is important that providers be able to maintain their knowledge in order to provide effective care to victims that they may come across in practice. Much of the literature has shown that it is important that providers continue with updating and maintaining their training in order to refresh their memory on providing care to victims. The strengths of this project were that the research on the importance of health care awareness on treating sex trafficking victims was abundant. Participants who took part in the surveys all agreed that advocacy for this population is needed and that all the information given PROJECT FINAL REPORT 9 was helpful for them to be able to implement it into practice. The limitations of this project were that the sample size was small and all survey data gathered was anonymous. This was due to the challenges of recruiting available providers to be able to take part in an educational intervention on their own free time. Therefore, the statistical significances found were small due to the small sample size. The anonymity of the data was challenging in that it was not known which participants had not completed their posttest surveys. This made follow up challenging with not knowing which participants to reach out to if they were having any difficulties in completing the educational intervention. Conclusion Overall, this project illustrated the need for increased awareness and education of mental health care providers to be able to identify as well as treat sex trafficking victims. Many providers were shown to be uncomfortable or unsure of how to go about treating this population and what to be aware of in terms of recognizing who is a victim. As the prevalence and awareness grows on sex trafficking within the US, it will become more important than ever for mental health care providers to be able to provide effective care for these victims. PROJECT FINAL REPORT 10 References Abas, M., Ostrovschi, N. V., Prince, M., Gorceag, V. I., Trigub, C., & Oram, S. (2013). Risk factors for mental disorders in women survivors of human trafficking: a historical cohort study. BMC Psychiatry, 13(1), 1-11. Domoney, J., Howard, L. M., Abas, M., Broadbent, M., & Oram, S. (2015). Mental health service respones to human trafficking: a qualitative study of professionals' experiences of providing care. BMC Psychiatry. doi:10.1186/s12888-015-0679-3 Houston-Kolnik, J. D., Todd, N. R., & Wilson, M. (2016). Preliminary validation of the sex trafficking attitudes scale. Violence Against Women, 22(10), 1259-1281. Lederer, L. J., & Wetzel, C. A. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilties. Annals of Health Law, 23(1), 61-91. National Human Trafficking Hotline. (2017). Sex trafficking. Retrieved from https://humantraffickinghotline.org/type-trafficking/sex-trafficking Stevens, K. R. (2012). Star Model. Retrieved from http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp Ume-Nwagbo, P. N., DeWan, S. A., & Lowry, L. W. (2006). Using the neuman systems model for best practices. Nursing Science Quarterly, 19(1), 31-35. PROJECT FINAL REPORT 11 Appendix A PROJECT FINAL REPORT 12 PROJECT FINAL REPORT 13 PROJECT FINAL REPORT 14 Appendix B