EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Educating Healthcare Providers on Human Trafficking: A Small Intervention, Large Benefits Lisa A. Rosch Arizona State University, Edson College of Nursing & Health Innovation 1 EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 2 Abstract Human trafficking affects men, women, and children of all races and incomes. Healthcare providers can work directly with those who are trafficked when they come into the emergency room or clinic to seek care. The identification of those who are trafficked is key to assisting those who need help obtain resources and get the help they need to move forward in their lives. Unfortunately, many healthcare providers do not have the knowledge to identify or the time it takes to pick up on cues that a patient is being trafficked. Currently, there is no set education or curriculum to teach healthcare providers. This has resulted in increased lack of identification of those who are trafficked. An evidence-based quality improvement practice change was implemented. The purpose of this project was to educate healthcare professionals about the red flags that trafficked individuals might exhibit and to implement a screening tool in the emergency department. A brief educational Power Point on human trafficking was provided. A pre-test, post-test and a post-survey was utilized to evaluate awareness and knowledge. After the implementation of the human trafficking screening tool, 1,749 patients were screened, for a screening rate of 71%. Keywords: human trafficking, healthcare provider, education, training, resources, referral EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 3 Educating Healthcare Providers on Human Trafficking Human trafficking involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act (Department of Homeland Security [DHS], 2020; Centers for Disease Control and Prevention [CDC], 2020). Traffickers may use violence, manipulation, or false promises of well-paying jobs or romantic relationships to attract victims into trafficking. The damage and trauma caused by the traffickers can be so profound that many may not identify themselves as victims or ask for help, even in highly public settings (DHS, 2020). Problem Statement According to the most recent data from the Northern Virginia Human Trafficking Initiative (NOVA-HTI), human trafficking is the fastest-growing organized crime activity in the United States, making almost $32 billion a year for traffickers (NOVA-HTI, 2020). Human trafficking is a $150 billion industry globally (Toney-Butler & Mittel, 2019). It is estimated that 21 million adults and children are labor-trafficked or sex-trafficked through force, fraud, or coercion (Powell et al., 2017). Health and Human Services (HHS) reports human trafficking creates a wealth of health issues such as sexually transmitted infections (STI’s), unwanted pregnancy resulting from rape or prostitution, infections or mutilations caused by unsanitary and dangerous medical procedures, chronic back issues, hearing loss, cardiovascular or respiratory problems, malnourishment, serious dental problems, and undetected or untreated diseases, such as diabetes and cancer. Additionally, substance abuse problems and addictions either from being coerced into drug use by their traffickers or by turning to substance abuse to help cope or mentally escape their desperate situations endangers victims of human trafficking (https://www.acf.hhs.gov/otip). EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 4 Purpose The purpose of the project is to educate healthcare professionals about the red flags that trafficked individuals might exhibit and to implement a screening tool in the emergency department of a hospital in a large city in the southwest region of the United Sates. This paper reviews the evidence surrounding the education of health professionals and provides a report of an educational project that includes implementing a screening tool. Only 13% of healthcare providers can recognize a trafficked victim, and fewer than 3% are trained to care for victims of human trafficking (HT). Since healthcare providers have not been successful in recognizing or rescuing victims of HT in the past, they could benefit from education and training (Rollins et al., 2017). Rationale Healthcare providers are often the first line of care for those who are trafficked which poses a substantial opportunity to positively influence consequences in terms of health, overall quality of life and reintegration into society (Toney-Butler & Mittel, 2019; Chambers, 2019). Human trafficking is considered a gross violation of human rights (Rezaeian, 2016). A report indicated that 88% of human trafficking survivors experienced an interaction with a healthcare provider in some way, shape or form during their victimization (Toney-Butler & Mittel, 2019; Rollins et al., 2017). Background and Significance Human Trafficking Patients Human trafficking is becoming more apparent to those in clinical settings causing an increase in the need for education and training of health care providers. Healthcare providers are in a situation to recognize trafficking victims and intervene (Shandro et al., 2016). The provider EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 5 should be able to detect red flags quickly to be able to obtain information from those who are trafficked. Education for Healthcare Providers Various methods for training and education have been employed. The current state is that healthcare providers are not aware and are unprepared to identify and treat victims of human trafficking (Donahue, Schwien & LaVallee, 2019). The lack of human trafficking training and awareness of healthcare providers is detrimental to victims as they frequently need healthcare. Human trafficking affects the physical, psychological, and social needs that necessitate comprehensive, coordinated healthcare approaches (Chambers, 2019). A study by Donahue, Schwien & Lavallee looked at an evidence-based online training module. A pre-survey to identify learning needs was given and a post survey was used to demonstrate the effectiveness of the education. The online training module contained a power point presentation, guidelines for identification and treatment and two realistic case studies, 96% found the educational module to be useful in their work setting. (Donahue, Schwien & Lavallee, 2019). Grace et al., (2014) reported an increase in test scores from 7.2% to 59% in 75% of participants in ten emergency departments receiving education about HT, the relevance of HT to the health care system, clinical signs in victims of HT, and referral sources for victims of HT. A study by Egyud et al, 2019 demonstrated a 100% compliance with screening through the electronic medical record. This yielded total of 38 patients who were identified as having the potential to be trafficking victims. Medical red flags helped to identify 20 patients (53%), and 18 patients (47%) used the National Human Trafficking Hotline. EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 6 Healthcare Policy The Trafficking Awareness Training for Health Care Act of 2015 complements the HHS anti-trafficking efforts to increase the healthcare providers’ awareness, information, and training (Powell, Dickins & Stoklosa, 2017). Another act to combat trafficking is The Victims of Trafficking and Violence Protection Act of 2000, a federal statute passed into law in 2000 by the United States Congress (Congress.gov, 2000). The goal of these pieces of legislation is to help healthcare providers become more confident in identifying, screening, and assisting those who are being trafficked. Internal Data With the proper training and education, healthcare providers can identify and properly treat victims of human trafficking in the healthcare setting. Prior to the implementation of this practice change, emergency department patients in the facility where the project took place, were not being screened for trafficking by healthcare providers. Education programs for healthcare providers can teach the provider how to recognize those who have been trafficked, potentially resulting in improvement of the lives of many victims, and providing increased access to effective, accessible, long-term care for human trafficking survivors (Chambers, 2019). The lack of educational programs for healthcare providers leaves many potential victims unidentified and those patients often experience varying levels of re-traumatization by the healthcare provider (Chambers, 2019). An education program increases provider knowledge, and there is an increase in self-reported acknowledgement of human trafficking victims (Grace et al., 2014). Studies have shown that healthcare providers with training were more likely to have identified a victim, and reported human trafficking (Powell, Dickins & Stoklosa, 2017). There was no human trafficking EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 7 screening tool or education on human trafficking for healthcare providers in the ED where the project took place. PICO Question Preliminary interest in this problem led to an inquiry of current evidence to determine the best interventions for provider education in human trafficking. This literature review led to the clinically relevant PICO question, “In healthcare providers who serve victims of human trafficking, does education on human trafficking versus treatment as usual increase service utilization?” Search Strategy A comprehensive review of the latest evidence was conducted to answer the PICO question. Three databases were searched- PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and the Cochrane Library. These databases were chosen because of the nature of the topic, human trafficking. Inclusion Criteria, Exclusion Criteria, and Limitations The inclusion criteria included studies reported within the previous five years. Studies needed to be in English and available in full text. Each study had to include a component of education for healthcare providers. Studies that did not include primary research were excluded, as well as opinion articles. The inclusion and exclusion criteria were upheld for all databases. Search Yield The search of PubMed with the phrases human trafficking, education, healthcare provider and study yielded 21 results. Taking out the word healthcare and using the same phrases human trafficking, education and study yielded 139 results. When limiting the search to research articles, the results were easily reviewed and assessed for their pertinence to the PICO EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 8 question. When the limits to primary research of the past 5 years were applied, the total number of studies was 33 results. A database search of CINAHL utilizing the same key terms human trafficking, education, healthcare yielded only 4 results. Other keywords utilized included; study, which still only yielded 18 results. The word healthcare was omitted, and another search was conducted. Using search terms such as design, survey, mixed methods, quantitative, case study, qualitative, clinical practice, randomized control, cohort, systematic review and quasi experimental yielded up to 16 results. After the limitations were applied 2 studies were retained for review. A database search of Cochrane utilizing key terms human trafficking and education yielded 5 results. 3 of 5 articles were related to human trafficking. However, only one included human trafficking education, therefore, one article was reviewed. Rapid critical appraisal was performed on the entire yield of the search. Ten studies addressed the PICO question, and reviewed the correlation between human trafficking, healthcare providers, education, and the benefits that the patients reap from proper identification and treatment. Critical Appraisal & Synthesis Ten studies were retained for this review, including seven systematic reviews (SR), two qualitative analyses (QA), and one mixed methods (MM) study with a cross sectional survey. Most of the studies met level V evidence as they were systematic reviews (Melnyk & FineoutOverholt, 2019). The SR’s retained included a systematic search of databases and included multiple peer reviews and grey literature. Overall, the SR’s retained all addressed the lack of knowledge and education for healthcare providers, health needs/support services, aftercare and barriers associated with victims of human trafficking. There was no bias identified in any of the EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 9 studies. The only study that looked at registered nurses was done by Long et al., 2018. This study observed the RN and their perspective on victims of human trafficking. To evaluate the data, the information from each systematic review was placed in an evaluation table (Appendix A, table 1). The evidence from the qualitative reviews and mixed method study was also reviewed and placed in an evaluation table (Appendix A, table 2). The samples in all the studies were heterogeneous. The ages range varied from 14 to “adult,”- with no upper limit given. The studies spanned a time frame from 2000 to 2020. Most studies were conducted in an emergency department and one study was done in a mental health facility. While there are weaknesses in the evidence such as small sample sizes in some of the studies, there was evidence to move forward with a project to educate healthcare providers and screen patients for human trafficking. Evaluation of the studies demonstrated that more research should be conducted on validated screening tools to evaluate the effectiveness of education, and resource referrals. Additionally, research on the psychological aspects, medical needs and mental health associated with human trafficking needs to be more robust. Few studies address holistic views and effective interventions are needed but this was outside of the scope of this project. Lack of identification of trafficked victims by healthcare providers leave patients who are trafficked open to more problems in regards to mental health, physical health and emotional wellbeing. Increasing providers’ awarenss and education about those who are trafficked will help improve the care of those that are trafficked. After review of the studies, there is strong evidence that demonstrates increasing awareness, education, and screening will increase utilization of resources and referrals from those who have been trafficked. Based on the evidence reviewed, EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 10 training, incorportaing a human trafficking screening tool, education and resources directed towards the area of human trafficking could be the key in beginning to removing barriers to care. Further review of the synthesis of the literature for trafficking victims increases the quality of life and decreases depression which will be important going forward, psychological stress goes down, synthesis table (Appendix B). Theory Application The theoretical/conceptual framework plays an important role in human trafficking training and education. Kolb’s four-stage model consists of a learning cycle that shows how experience is translated through reflection into concepts, guides for active experimentation and assists in facilitation of new experiences (Healey & Jenkins, 2000). Kolb’s model includes four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation (Appendix C). They follow each other in a cycle formation, the cycle may be entered at any area, but the stages should be followed in sequence (Healey & Jenkins, 2000). Kolb’s learning cycle can offer feedback, which is the foundation for change and evaluation of the consequences of that action. The benefits of this theory include knowledge created through experience, effective as a means of developing clinical judgment, demonstrates learning as a continuous process and it can meet the needs of all learners (Murray, n.d.) Implementation Framework This project was guided by the Evidence Based Practice Change by Rosswurm and Larrabee (1999). The model utilizes theoretical and research literature connected with evidence‐based practice, research application, consistent language, and change theory (Rosswurm & Larrabee, 1999). This model strongly supports evidence‐based practice change. EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 11 The model starts with the appraisal of the need for the change and ends with the incorporation of evidence-based protocols which many of the systematic research and qualitative studies reviewed included. This model consists of six components: 1) Assess the need for change in practice; 2) Link problems with interventions and outcomes; 3) Synthesize best evidence; 4) Design a change in practice; 5) Implement and evaluate the practice change; and 6) Integrate and maintain practice change (Rosswurm & Larrabee, 1999) (Appendix D). Internal and external evidence on human trafficking establish that is a significant problem related to lack of healthcare provider awareness of victims of human trafficking throughout the world. There is a great need for provider awareness and education and referrals/resources are lacking to provide the victim of human trafficking the best care available. The problem, potential interventions, and desired outcomes become important variables for assessing the literature that has been reviewed for purposes of this project. The steps apply to providing an appropriate framework for designing an education/awareness program for healthcare providers. Using this model along with time and research support, and the synthesis of the best evidence for making changes in practice will guide practice change (Rosswurm & Larrabee, 1999). Implications for Practice Change Educating healthcare providers on warning signs of human trafficking that patients exhibit lead to increased identification and the ability to offer resources. The evidence supported healthcare provider education and screening for human trafficking and coupled with the internal evidence at the project site led to the initiation of this project. The stakeholders at the organization where the practice change was initiated: nursing leaders, the informational technology department and the unit manager concurred with the gap which led to the initiation of the project. The data collected included the pre and post-test via Survey Monkey (Appendix E) EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 12 taken by participants who viewed the education PowerPoint© presentation. Given the evidence and the need of the facility, a human trafficking screening tool was formatted and utilized in the electronic health record (EHR) in the emergency department. The number of patients screened with the newly implemented tool was also collected as data for this project. Methods The project was an evidenced based quality improvement project. The methods used to collect the data included a human trafficking screening tool in the electronic health record (Appendix F), and a pre-test and post-test. The trafficking screening tool was completed by the nurses in the emergency department after viewing an educational PowerPoint© presentation which included the signs of HT and how to complete the screening. The screening tool, developed by EPIC, the electronic health record vendor, was implemented and approved by the site and placed into the triage bar under the safety and screening tab in the electronic health record. An informational tip sheet offered on how to properly complete the screening tool and questions was available to the user. A link to Survey Monkey was sent out via email by the unit director so that staff could complete the pre-test and post-test. Participants performed the screening with the new human trafficking screening tool for a period of 8 weeks. Ethical Considerations Arizona State University Institutional Review Board (IRB) approval was obtained. A letter of support was received from the organization where the project was completed. A letter of approval has also been received from the facility Network Nursing Research Council. The IRB at the site of the project determined that the project is not human subject research per their policy. EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 13 Population and Setting Participants included registered nurses at a local emergency department in the greater Phoenix area. Participants must have been able to understand and read English. They had to be currently employed at the facility in which the project was being conducted and hold a professional nursing license by the state of Arizona. This project excluded any members of the healthcare team that do not provide direct care to the patient (Hospital Unit Coordinators, patient care technicians, registration personnel). Minors, those unable to consent, prisoners and economically/educationally disadvantaged individuals were not included. Consent was implied by the healthcare provider opting to take the educational PowerPoint© presentation. A pre-test and a consent to participate (Appendix G) was included with the pre-test. Project Description/Timeline This evidence-based practice change occurred over a period of 8 weeks from January 21, 2021 through March 27, 2021. The pre-test and PowerPoint© presentation were sent via email during week 1 and week 2. The email was sent by the unit director and site champion to retain anonymity. The link for the Virtual PowerPoint© education on human trafficking education was also sent via email with an explanation letter and the pre-test. The PowerPoint© included instructions on how to use the hospital’s triage bar in the EHR to assess for human trafficking during the intake triage visit in the emergency department. The educational offering should have taken the participant approximately 10 minutes to complete. The participants then used the human trafficking screening tool, which was subjective, and built into the triage bar in the electronic medical record and was to be completed while triaging the patient. The trafficking screening tool did not require direct questioning of the patient about trafficking. The questions asked the healthcare provider to assess the risk and answer ‘yes’ or ‘no’ to if the patient appeared EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 14 to be a victim of human trafficking. In the final two weeks of the project, participants had the opportunity to complete a post-test, which was also sent out via email by the unit manager. These dates were from March 13, 2021 through March 27, 2021. The post-test would take the participant approximately 7 minutes to complete. In addition to the post test, participants had the opportunity to complete a post education evaluation survey that consisted of 7 questions and would take the participant approximately 2-3 minutes to complete (Appendix H). The questions used a Likert scale 1 to 5 to determine knowledge, identification, ability to make referrals, confidence level, reporting, common signs, and thoughts on the training. Recruitment Recruitment of participants was done by placing posters and flyers (Appendix I) designed by the doctoral student, in the break room and staff bathrooms. The unit director placed the recruitment posters. The emergency department supervisor discussed the project in shift-to-shift report. Participants received information about the project in a letter from the unit manager. The unit manager sent out emails to staff regarding project participation and the educational opportunity. Instrumentation/Data collection SurveyMonkey was the resource selected for sending out surveys to the participants to guarantee anonymous responses. SurveyMonkey was of no cost and it is widely used. There was also an added benefit of customer support if problems arose with the survey. Email was the chosen method of dissemination of the survey both due to ease of use and participants could complete the pre-tests at their leisure. A site champion in the Information Technology (IT) department at the institution where the project was being conducted was able to pull the information and data for the project bi-weekly. The information included how many patients were triaged in the ED and the number that were screened for human trafficking. This data was EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 15 de-identified before being provided to the DNP student. The other data collected was the pre and post-test, and the post education evaluation. Data Analysis Descriptive statistics was used on data from the pre and post-test scores, all data was entered in Intellectus and analyzed as group data. A two-tailed paired t-test was completed to determine if the mean difference of the pre-test and post-test was significantly different from zero. The post-survey was only completed by one participant and there was no additional feedback. Given the small number of pre and post-tests, all planned data analysis was limited as statistical reporting of outcomes. Budget There was no financial cost to completing this training as participants were not paid for attendance. The emails were sent out by the unit manager and flyers were sent via email and printed at no cost to the author completing the project. Microsoft PowerPoint© was used for the presentation and SurveyMonkey for the questionnaire. Neither of these resources had a financial cost to use. There were costs associated with the time of the emergency department manager, the information technology department, and social work. There was no direct cost to the project manager, the DNP student, or to the participants who participated on regularly scheduled work time. Results The goal was for nurses to view the educational power point to increase knowledge of HT and learn how to complete the screening tool located in the EHR, and then go on to complete the human trafficking screening tool on patients in triage area of the ED. The recruitment emails sent by the unit manager was sent out to 69 people, n=69. As shown in Table 1, a total of 5 (n=5) EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 16 took the pre-test, the average score of the test was 88%. The lowest score was 75% and the highest score was 94%. A total of 3 (n=3) took the post-test, the average score was 94%. The lowest score was 81% and the highest score was 94%. It is unknown if more participants engaged in the PowerPoint education but declined to take the pre and post-tests. Table 1 Two-Tailed Paired Samples t-Test for the Difference Between pre-test and post-test Pre-test M 87.52 Post-Test SD 7.68 M 92.54 SD 2.82 T -1.21 p .294 d 0.54 Note. N = 5. Degrees of Freedom for the t-statistic = 4. d represents Cohen's d. A Shapiro-Wilk test was conducted to determine whether the differences in pre-test and post-test could have been produced by a normal distribution (Razali & Wah, 2011). The results of the Shapiro-Wilk test were not significant based on an alpha value of 0.05, W = 0.96, p = .782. This result suggests the possibility that the differences in pre-test and post-test were produced by a normal distribution cannot be ruled out, indicating the normality assumption is met. Levene's test was conducted to assess whether the variances of pre-test and post-test were significantly different. The result of Levene's test was not significant based on an alpha value of 0.05, F(1, 8) = 2.00, p = .195. This result suggests it is possible that pre-test and post-test were produced by distributions with equal variances, indicating the assumption of homogeneity of variance was met. The result of the two-tailed paired samples t-test was not significant based on an alpha value of 0.05, t(4) = -1.21, p = .294, indicating the null hypothesis cannot be rejected. This finding suggests the difference in the mean of pre-test and the mean of post-test was not significantly different from zero. It is difficult to draw any statistical conclusions regarding increased EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 17 knowledge given the small sample size, but it is encouraging to see that the mean knowledge score increased. The human trafficking screening tool was completed on total of 1749 patients. 1225 patients or 70% were selected as ‘no’ they are not a potential victim of human trafficking. 491 patients or 28% were not addressed/the question was left blank. 2% or 32 patients were identified by a ‘yes’ answer of being a potential victim of human trafficking. If a ‘yes’ was marked this triggered an additional 8 questions to be asked by the triage RN (Appendix F). Not one nurse completed the 8 additional questions once the patient was placed in an examination room. Outcomes The human trafficking screening tool was built into the EHR and patients who were between the ages of 9-35 were screened. The tool is sustainable and the foundation for future work. The educational offering is also sustainable, and the organization is implementing it into future education for their staff. If the awareness and educational interventions are used to change practice, the potential outcome is to increase healthcare provider awareness and increase identification of human trafficking victims thereby increasing resource utilization. Through continual education, there could potentially be fewer victims suffering in silence. There may be less people suffering alone, having thoughts of suicide and we may see a decrease in cost for the healthcare/mental health system. Impact of Project Many victims who are trafficked have a presumptive belief that no one cares to help them or wants to help them; often they have been conditioned to believe this by the trafficker (Polaris Project, n.d.). As first line providers for these victims, health care provider education can help to rebuke the misconception of lack of caring by the provider and allow patients to feel comfortable EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 18 and not be afraid to seek assistance. Victims of HT with a pre-existing or acquired drug addiction will have increased opportunity to obtain the help and assistance that they need. Healthcare providers can become the vehicle for change and assist in combating trafficking and the injustice that it places on these victims. The cost of assisting one victim is less than the cost of providing health services to that victim (Ellery, 2019). This project allowed development of a screening tool in the EHR which will allow screening to continue well past the duration of the project. Literature Findings Donahue, Schwein & Lavellee, 2019, indicated that 89% of participants in their study had not received previous human trafficking training. The site where this project was conducted offered no professional education on HT warning signs or any other topic related to HT. In the Donahue study, the training module significantly increased confidence in identification from an average confidence level of 4/10 to a 8/10 of human trafficking victims within the emergency department; 96% found the educational module to be useful in their work setting. This project demonstrated a small increase in pre-test vs. post-test scores. The implementation of a screening tool and HT education in this project yielded improved recognition of victims of trafficking as Egyud et al. (2014) did. To identify victims effectively, hospitals should be providing ongoing education, training, and screening tools. Sustainability/Future Research The site where the project was implemented would like to see this screening form added to the triage bar in all their ED’s throughout the city. To sustain this project, closer focus and exposure is necessary. It would be helpful to get input from the staff directly about the human trafficking tool and why it is not being completed. In addition, it is important to have close follow up and follow through by a project site champion; it would be beneficial to have a peer EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 19 leader to assist in further implementation. To obtain more participants, it is recommended that the human trafficking education and screening tool be addressed during the unit-based practice council committee meetings. Currently, education is not mandatory; it is highly recommended that education on human trafficking be added to the organization’s structured mandatory education. Strengths/Limitations/Barriers Leaders at this facility were motivated and supportive; therefore, a human trafficking screening tool built into the EHR to screen patients appropriately was completed in a relatively short amount of time. The facility was willing to share the data obtained and share emails with the healthcare providers to help with recruitment. Some of the limitations included the inability to follow through in person due to the COVID19 pandemic. The lack of presence most likely contributed to a low response rate. Another limitation included staff not following through on the required documentation. Not one nurse completed the additional 8 questions to further assess trafficking risk for the patient once the patient was seen in the back. Finally, there were some computer setbacks due to firewalls when the education was rolled out. The link had to be sent out to the employees three times before the link was successfully working. Conclusion In conclusion, the need to provide education for healthcare providers is essential to raise awareness, increase knowledge and provide the proper resources and referrals for victims of human trafficking. Current practice was changed in the emergency department by implementing a human trafficking screening tool. 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Retrieved from https://sigma.nursingrepository.org/bitstream/handle/10755/622943/1_Murray_A_p8701 4_1.pdf;jsessionid=DDF369FD9E6A29A9350EA882A11DE0B2?sequence=1 Northern Virginia Human Trafficking Initiative (NOVA-HTI). (2020). Trafficking statistics. EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 24 Retrieved from https://www.novahti.com/trafficking-statistics Ottisova, L., Hemmings, S., Howard, L., Zimmerman, C., & Oram, S. (2016). Prevalence and risk of violence and the mental, physical and sexual health problems associated with human trafficking: An updated systematic review. Epidemiology and Psychiatric Sciences, 25(4), 317-341. doi:10.1017/S2045796016000135 Polaris Project. (n.d.). Recognizing human trafficking. Retrieved from https://polarisproject.org/recognizing-human-trafficking/ Powell, C., Dickins, K., & Stoklosa, H. (2017). Training US health care professionals on human trafficking: where do we go from here? 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AMA journal of ethics, 19(1), 63–71. https://doi- EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 25 org.ezproxy1.lib.asu.edu/10.1001/journalofethics.2017.19.1.pfor2-1701 Rosswurm, M., & Larrabee, J. (1999). A model for change to evidence-based practice. Image— the Journal of Nursing Scholarship., 31(4), 317-322. Shandro, J., Chisolm-Straker, M., Duber, H.C., Findlay, S.L., Munoz, J., Schmitz, G… Wingkun, N. (2016) Human trafficking: a guide to identification and approach for the emergency physician. Annals of Emergency Medicine, 68(4), 501-508. Stoklosa, H., Lyman, M., Bohnert, C., & Mittel, O. (2017). Medical education and human trafficking: Using simulation. Medical Education Online., 22(1), 1412746. Toney-Butler TJ, Mittel O. Human Trafficking. (2019). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK430910/ Westwood, J., Howard, L., Stanley, N., Zimmerman, C., Gerada, C., Oram, S. (2016). Access to, and experiences of, healthcare services by trafficked people: findings from a mixedmethods study in England. British Journal of General Practice, 66, 794-801. https://doi: 10.3399/bjgp16X687073 EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 26 Appendix A Review Studies Table A1 Systematic Reviews Citation Fraley, H. E., Aronowitz, T., & Stoklosa, H. M. (2020). Systematic Review of Human Trafficking Educational Interventions for Health Care Providers. Western Journal of Nursing Research, 42(2), 131–142. https://doi.org/1 0.1177/0193945 919837366 Funding: The author received Conceptual Framework The use of theoretical framework was absent from the included studies. Design/Method Sample/Setting Design: SR of peer reviews. N=7 Purpose: Disseminate information learned through a SR of the literature. DS: CINAHL, MEDLINE, PsychINFO, ERIC Inclusion Criteria: Included an HT educational intervention targeting HCP’s, focused on increasing HCP’s awareness of HT, described instruments to measure the efficacy of the HT educational Major Variables & Definitions IV1: Healthcare Providers DV1: HT Education Synthesized retrospective and current knowledge and identified gaps in education interventions aimed at increasing providers awareness and attitudes toward trafficking. Measurement Analysis Findings The Cochrane Collaboration’ s Preferred Reporting Items for SR was followed. Studies were appraised and then rated with an overall study quality score of 28 points. Scores were then summarized, and overall study quality was appraised as excellent (26-28), good (20-25), fair (15-19) or PRISMA, systematic literature review completed to determine what HCP trafficking educational intervention s exist Findings: Across studies N=7 reveal providers (mostly social workers and physicians) have low awareness of trafficking and can have negative attitudes towards victims. Decision for Use LOE: V Strengths: clear methodology, following PRISMA guidelines, use of Downs and Black checklist to evaluate quality of included studies, and the PGF in appraisal of instruments used to measure effectiveness of HT educational interventions targeting HCP’s. Weaknesses: Survey responses were inconsistently reported among studies, study results cannot be generalized to the entire population of HCP’s Conclusions: Recommend that nurses focus Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation no financial support for the research, authorship and publication of this article. Bias: Response bias present within the studies as providers may have responded in a socially desirable way, low response rates, low number of completions of pre and posttest surveys. Conceptual Framework Design/Method Sample/Setting intervention. Exclusion: Did not address awareness of HT, did not describe and intervention, were purely qualitative and were not in the English language. Major Variables & Definitions Measurement poor (<14) 27 Analysis Findings Decision for Use on children at risk of child abuse and who are identified as abused as a population at greater risk of HT Feasibility/Applicability pt population: Limited studies measure HCP awareness and attitudes toward trafficking. A population at risk of HT are minors under age 18. Country: U.S.A., Middle East, Caribbean and Central Africa. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Hemmings, S., Jakobowitz, S., Abas, M., Bick, D., Howard, L., Stanley, N., . . . Oram, S. (2016). Responding to the health needs of survivors of human trafficking: A systematic review. BMC Health Services Research., 16, 320. Conceptual Framework CBT and TFCBT Design/Method Sample/Setting SR and QA of peer review and grey literature. N=44 Purpose: to synthesize evidence on current knowledge and practice in responding to the health needs of trafficked people, specifically exploring identification, referral and provision of care by the healthcare sector. DS: 16 biomedical and social science databases including MEDLINE, Embase and PsychINFO and 21 grey literature websites and databases Major Variables & Definitions IV1: Survivors of HT. DV1: Health Needs. A combination of controlled vocabulary index was used including terms related to HT, health services, health personnel, and care approaches and interventions. 28 Measurement Analysis Findings Checklists adapted from the Joanna Briggs Institute and varied by type of document, independently asses by two reviewers using appraisal checklists PRISMAData was extracted by two reviewers using framework analysis- a matrixbased method involving the construction of thematic groupings into which data can be categorized Findings: Importance of interviewing possible victims in private, using professional interpreters, and building trust. Key themes included the importance of comprehensiv e needs assessments, adhering to principles of traumainformed care and cultural sensitivity, necessity of multi-agency working strategies and well-defined referral pathways. Decision for Use LOE: V Strengths: The review used a comprehensive search strategy including electronic searches, reference list, screening, citation tracking and expert recommendations Weaknesses: Review was limited by a lack of evidence from primary studies. Limited conclusions can be drawn regarding best practice in responding to the healthcare needs of male victims. The review was restricted to materials reporting on high-income countries, and findings may not be generalizable to low- and middle-income country settings. Inclusion: Addressed (male or female) adults Funding: and/or children Support from the who were Department of currently or Health Policy previously been Research trafficked, Programme, Conclusion: HT survivors reported on National require healthcare that is health Instittue to trauma-informed and interventions or Health Research culturally sensitive to their service particular needs. Coordination provision, Bias: None is needed between HC and focused on recognized primary, statutory and voluntary Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Country: U.S.A Conceptual Framework Design/Method Sample/Setting secondary, tertiary or emergency health settings, specialist posttrafficking support services in either the statutory and voluntary sectors, or statutory, voluntary and private social care settings and reported World bank high income countries. Major Variables & Definitions Measurement 29 Analysis Findings Decision for Use organizations. Future research should be focused on evidence to develop trafficking indicators, validated screening tools and evaluate the effectiveness of psychological interventions. Feasibility/Applicability pt. population: Several policy and guidance documents describe assistance measures to respond to the needs of trafficked persons, and there is little evidence-based guidance available on how to plan, assess or provide for the health needs of trafficked adults and children. Exclusion: Editorials, opinion pieces and textbooks were excluded from the review. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting Design: SR of peer-reviewed publications N= 53 Major Variables & Definitions IV1: Survivors of HT Measurement 30 Analysis Findings Decision for Use Searches were PRISMA, a ST research is LOE: V tracked using statement strongly DS: an electronic concerning focused on Strengths: A comprehensive, DV1: Needs of spreadsheet, PsychINFO, information the physical systematic search of peer survivors. Social Services document the to report in a and mental review, published articles Purpose: To Abstract, Social Safety and number of SR. health needs were conducted. The team put synthesize the articles found and service every effort to review and existing research Work Abstracts, protection, educational, PubMed, Health in each search, outcomes of analyze each piece and create a economic, and the number survivors. systematically, scrutinizing compilation of immigration Psychosocial kept following Few studies each study, recorded finding constructs and housing, title and incorporate using a standard form, and measures used in Measures, language, PsychTESTS, abstract holistic views used multiple, independent trafficking legal, physical, review, and Sociological of well-being. coders. research to psychological, the amount collect date from Abstracts, and spiritual retained for Weaknesses: Studies were people trafficked Public Affairs needs. Information analysis. limited to English and peer for sex. One member Service, review studies; the review Focuses on the of the research CINAHL, does not capture the work of team physical and Family and practitioners in the field who conducted all Society Studies mental health engage in evaluation efforts in article needs and Worldwide, their work with people searches, and service Health Source trafficked for sex. two members outcomes of Nursing/Acade Practitioners' perspectives independently mic Edition and survivors. should be systematically reviewed the Web of included in future research. It identified Funding: Not Science. is possible that information studies to specified was missed, details Inclusion determine misunderstood, or studies Bias: No Criteria: eligibility for were excluded. conflicts Articles had to inclusion recognized have been based on the Conclusions: The study Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America Graham, L. M., Macy, R. J., Eckhardt, A., Rizo, C. F., & Jordan, B. L. (2019). Measures for evaluating sex trafficking aftercare and support services: A systematic review and resource compilation. Aggression and Violent Behavior. (47), Pages 117136. https://doi.org/1 0.1016/j.avb.201 9.04.001 Inferred to be the Chronic Care Model EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Country: The U.S.A. Conceptual Framework Design/Method Sample/Setting published in English in a peer-reviewed journal between January 2000 and July 2017, data collect pertinent to needs and outcomes of survivors of ST, acknowledged that some portion of their sample included or was likely to have involved survivors of ST and included specific details about the constructs and measures used in data collection efforts. Major Variables & Definitions Measurement predetermined criteria. 31 Analysis Findings Decision for Use findings give researchers and practitioners a compilation of measures and constructs to inform their service evaluation efforts with survivors of ST. Feasibility/Applicability pt. population: Consequences of delivering untested services can negatively affect an already highly vulnerable population. Exclusion Criteria: Nonempirical and review Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting articles as well as studies that used only medical procedures to gather data from participants. Major Variables & Definitions Measurement 32 Analysis Findings Decision for Use Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting Dell, N. A., Maynard, B. R., Born, K. R., Wagner, E., Atkins, B., & House, W. (2019). Helping Survivors of Human Trafficking: A Systematic Review of Exit and Post exit Interventions. Trauma, Violence, & Abuse, 20(2), 183–196. https://doiorg.ezproxy1.lib. asu.edu/10.1177/ 1524838017692 553 TF-CBT, and the Integrative Treatment of Complex Trauma for Adolescents model. Design: SR of 8 databases using Covidence, cloud-based software for an SR. N= 161 Purpose: The purpose of this study was to synthesize the evidence of exit and post-exit intervention programs for survivors of HT to inform practice and research. DS: Social science Citation Index, Social service Abstracts, PsychINFO, PubMed, Women’s Studies International, ProQuest Dissertations, Criminal Justice Abstracts, and Scopus. Major Variables & Definitions IV: Survivors of HT DV: mental health, social network, community reintegration, and employment Trafficked individuals age ranging from 14.8 to 36 33 Measurement Analysis Findings Two reviewers independently screened the full text of all retrieved articles to assess for eligibility. If two reviewers did not agree, a third reviewer was consulted. Coding categories included methods and procedures, intervention, characteristic, participant characteristics, bibliographic information, and source descriptors. The authors adhered strictly to the Campbell Collaboratio n and Preferred Reporting Items for SR and MA (PRISMA) guidelines. Researchers, NGO’s, governments, and advocacy groups need to advance intervention research so that services that are evidenceinformed and effective can be provided. Decision for Use LOE: V Strengths: Provided compelling insights about the state of evidence of interventions that are important in moving practice and research in this area, more work is needed on the issue of HT. Weaknesses: The study was limited to studies published in the English language, primarily out of necessity due to translation. The terms and definitions of HT are divers, and there is little agreement on consistency from authors and studies. The review is limited by the quality of the studies included in the analysis. Inclusion criteria: Studies must have addressed the effects of an Conclusion: The needs of exit or post-exit Funding: The trafficking survivors are intervention author received complex and range from the intended to no financial most basic needs (food, directly serve support for the clothing, shelter) to more survivors of HT research, complex emotional, on mental authorship, and psychological and physical health publication of (including needs that result from varied Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation this article. Bias: The authors' coded risk of bias using Cochrane’s Risk of bias tool. Conceptual Framework Design/Method Sample/Setting trauma), health, or psychosocial outcomes—no restrictions on age, gender, or ethnicity. Major Variables & Definitions Measurement 34 Analysis Findings Decision for Use abuses trafficking victims face. We can no longer ignore the need to provide adequate services to survivors of HT and need to build the evidence base for exit and post-exit interventions. Exclusion criteria: Not Applicability/ Feasibility pt quantitatively population: The needs of assessing the survivors of HT when exiting effects of an is complex and often intervention: all challenging to those who are forms of trying to help. Prior reviews qualitative have not focused on the effects research, of exit and post-exit literature and interventions. Synthesizing SR, conceptual effects of interventions is an essays, and important step to inform policy research practice and examine gaps in on suppressing literature and inform future trafficking or research punishing traffickers. Not meeting criteria as an intervention study: studies testing the validity and reliability of Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America Country: U.S.A, Asia, and Africa EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting measures for screening or evaluating the needs of victims of trafficking. Studies were not restricted by geographical setting or publication status but were limited to those written in English and authored in 2005 or later. Major Variables & Definitions Measurement 35 Analysis Findings Decision for Use Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Garg, A., Panda, P., Neudecker, M., Lee, S. (2020). Barriers to the access and utilization of healthcare for trafficked youth: A systematic review. Child Abuse & Neglect, 100, 111. https://doi: 10.1016/j.chiabu .2019.104137 Framework analysis in regard to trauma informed care. Design/Method Sample/Setting Design: SR of the literature. N= 8 Purpose: To examine the current evidence in the literature regarding barriers to healthcare faced by trafficked youth. DS: Ovid Medline, PubMed, EBSCO, CINAHL, EBSCO ERIC, EBSCO Social Work Abstracts, EBSCO SocINDEX with Full Text, EBSCO Sociological Collect, Elsevier Embase, Ovid PsychINFO and Web of Science Core Collection Major Variables & Definitions IV: Victims and survivors of child HT. DV: Extrinsic, Intrinsic and Systemic barriers. 36 Measurement Analysis Findings The articles were assessed for quality using the MMAT version 2018. Two reviewers (AG & AP) reviewed each article using the MMAT checklist. PRISMA, statement concerning information to report in a SR. Access to care is not only inhibited by intrinsic and extrinsic barriers but is significantly affected by systemic factors. Decision for Use LOE: V Strengths: All studies reviewed advocated for the training of healthcare providers on the recognition of trafficking victims and on trauma informed care. Differences in assessments of selected articles were discussed until a consensus was reached, if a consensus could not be reached, a third review was asked to assess the article. Extrinsictrafficker control, physical confinement, influence of peers. IntrinsicWeaknesses: Lack of discrimination, Funding: This evidence due to the secondary confidentiality, research did not analysis of primary research. trust in receive any Having only 8 articles, healthcare specific grant methodology could have failed providers, from funding to identify existing literature. Inclusion knowledge of agencies in the Gender based barriers exist criteria: the healthcare public, since focus was on female Studies had to system and commercial, or victims. All studies were be written in emotional not-for-profit qualitative, so the English, reluctance. sectors. generalizability of finding was addressed Systemic limited. victims or issues inherent Bias: None Conclusion: Extrinsic, survivors of to healthcare recognized child trafficking system intrinsic and systemic barriers Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Country: U.S.A Conceptual Framework Design/Method Sample/Setting or commercial sexual exploitation of children, focused on barriers to healthcare problems accessing healthcare and limited to dates between January 1, 1999 to January 30, 2019. Exclusion criteria: Editorials, review articles, opinion pieces, books and textbooks were excluded as well as any articles not meeting the inclusion criteria. Major Variables & Definitions including provider knowledge, complex registration process, language barriers, appointment times and service coordination. Measurement 37 Analysis Findings Decision for Use prevent access and reduce utilization of medical services for this vulnerable population. Systemic barriers can be mitigated through improving effective training for healthcare providers on the identification of victims and implementing trauma-sensitive care. Key steps such as increased minor victim recognition in a professional setting, training of staff and providers on trauma-sensitive care, and improvement of coordination of services provided would facilitate an environment for a holistic medical home. Applicability/ Feasibility pt population: A study using quantitative methods would be essential to generalize results to the larger child trafficking population. This review focuses solely on children; a comparative analysis may be useful for providers caring for adult and child survivors of HT. Future research should Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting Major Variables & Definitions Measurement 38 Analysis Findings Decision for Use focus on implementing and assessing interventions to removing barriers to care. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Muraya, D. N., & Fry, D. (2016). Aftercare Services for Child Victims of Sex Trafficking: A Systematic Review of Policy and Practice. Trauma, Violence, & Abuse, 17(2), 204–220. https://doi.org/1 0.1177/1524838 015584356 Conceptual Framework None specified Design/Method Sample/Setting Design: SR of databases, libraries, journal articles and grey literature N= 15 Purpose: To explore aftercare services provided to child victims of ST globally based on the results of a SR of published and unpublished research, organizational policy, and current practice. DS: A comprehensive search of four databases including PubMed/Medlin e, PsychINFO, SocINDEX and SSA. Major Variables & Definitions IV: Child victims of ST DV: Guiding principles, comprehensive CM systems, and aftercare services. Delivery practices such as CM and multidisciplina ry, multiagency and multinational coordination to ensure the child victims benefit fully from the service. 39 Measurement Analysis Findings A flow diagram of the document selection process was performed. If abstracts seemed to meet the inclusion criteria, the full article or document was retrieved and reviewed to determine if it continued to meet the inclusion criteria. Key organization websites and international and local government al organization s were assessed to identify the literature. No systematic quality assessment was undertaken of the included publications. Findings: Findings on aftercare for child victims are guiding principles for aftercare services and comprehensiv e and coordinated case management. In addition, there are three phases to aftercare service provision: rescue, recover and reintegration. Each of these is characterized by different needs and types of service provided. Decision for Use LOE: V Strengths: Every effort was made to reduce the risk of bias in this systematic review. Weaknesses: Inclusion criteria and search terms were kept broad to incorporate as many documents as possible. Inclusion Conclusion: There is a great criteria: Policy need for an evidence base on guidelines and which policies and guidelines other can be founded. This requires documents case management, tracking detailing tools, cooperation with aftercare organizations, and agreed Funding: The service definitions of rescue, recovers, author received provision for and reintegration. There is a no financial child ST great need for research on victims support for the aftercare services. published research, Applicability/ Feasibility pt between 2000authorship, population: There is a great May 2013, and/or need for further research and peer-reviewed, publication of better documentation of non-peer the article. service provision. The area of reviewed Bias: Every aftercare service provision for journal articles effort was made and research children who have been Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation to reduce the risk of bias in this SR. Country: Switzerland, Ireland, Nepal, USA, Serbia, Cambodia, and Germany. Conceptual Framework Design/Method Sample/Setting reports, global search/no geographic limitations, documents published in English. Exclusion criteria: Irrelevant documents, full text unavailable, non-English language documents, conference proceedings, and dissertations. Major Variables & Definitions Measurement 40 Analysis Findings Decision for Use trafficked has experienced phenomenal growth in the past ten years, more research and resources are being directed to the area, the achievement of international minimum standards of care provision is possible Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting Design: SR and MA N= 31 Major Variables & Definitions IV: Women and girls trafficked into the sex industry. Measurement 41 Analysis Findings Decision for Use Risk of LOE: V mental DS: Searches of disorder Strengths: The review used a Purpose: To 15 electronic appears to be comprehensive search establish the databases of increased by strategy, independent prevalence of peer reviewed multiple screening and quality appraisal DV: Mental, violence and articles and factors; of studies and adhered to physical and other health doctoral theses violence prior PRISMA reporting guidelines. sexual health risks were and during Weaknesses: These studies problems of experienced by supplemented trafficking, did not provide information on those that are trafficked by reference restricted the representativeness of their trafficked. people, the screening, freedom and samples, limiting prevalence and citation tracking poor living generalizability. It is unlikely types of of included and working that their experiences physical, mental articles and conditions represent those of all and sexual expert while health problems recommendatio trafficked and trafficked people. It is unclear among trafficked ns. social support if those accessing support represent more severe cases. It people and risk and unmet Inclusion is unclear how trafficking factors social needs criteria: identification criteria might associated with following have differed by location and physical, mental Included male escape. or female selfand sexual Physical pain time. The studies with clinical identified or health problems or discomfort populations might’ve differed by location/time. None of the among trafficked believed to have most been trafficked, studies reviewed people’s people. frequently Funding: looked at risk of psychological history prior to experienced Department of physical, trafficking. The comparability by trafficked Health Policy psychological and reliability is limited by people Research or sexual diversity of methods and tools include Programme, violence and headache, to assess violence and health Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America Ottisova, L., Hemmings, S., Howard, L., Zimmerman, C., & Oram, S. (2016). Prevalence and risk of violence and the mental, physical, and sexual health problems associated with human trafficking: An updated systematic review. Epidemiology and Psychiatric Sciences, 25(4), 317-341. doi:10.1017/S20 4579601600013 5 Inferred to be the Chronic Care model in regard to mental health and chronic health conditions. The CASP, 2014. The quality appraisal checklist included 15 items assessing study quality, including risk selection and measurement bias. Each item rated 0-2, given a max score of 30 and max subscore for risk of selection and measurement bias of 6 and 6 respectively. PRISMA guidelines and is registered with PROSPERO (registration CRD420150 23564) EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation NIHR Research Professorship and the NIHR, SLaM NHS Foundation Trust Biomedical Research Centre-Mental Health. Conceptual Framework Design/Method Sample/Setting Major Variables & Definitions Measurement 42 Analysis Findings Decision for Use reported on the stomach pain outcomes. prevalence or and memory risk of physical, problems. Conclusion: HT is a severe mental or Further, most form of abuse that occurs in sexual and experience many areas of the world and reproductive depression, has serious, and often longhealth or anxiety and lasting health problems disorder and postincluding enduring mental presented the traumatic distress. Trafficking is results of stress associated with an increased published peerdisorder and risk of violence and a range of Bias: None reviewed or women physical and mental health identified doctoral experience a issues. Further investigation is research based high needed to review the effective Country: on the prevalence of psychological interventions to London, UK following study sexually help the highly vulnerable designs, cross transmitted group move beyond their sectional study, infections. nightmares. case control study, cohort Applicability/ Feasibility pt study, case population: Men, children series analysis, and people who are trafficked experimental for labor exploitation are study with underrepresented in research baseline and health and HT. measures for Appropriate interventions and the outcomes of support services are needed to interest, or address the medical needs and secondary mental health of those who are analysis of trafficked. organizational Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Citation Conceptual Framework Design/Method Sample/Setting records. No restrictions on language, country setting or the method of measuring health risks and outcomes Major Variables & Definitions Measurement 43 Analysis Findings Decision for Use Exclusion criteria: Qualitative studies, editorials, opinion pieces and reviews were excluded. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 44 Appendix A Review Studies Table A2 Citation Conceptual Framework Design/Met hod Sample/Setting Qualitative Reviews and Mixed Methods Domoney, J., Howard, L., Abas, M., Broadbent, M., & Oram, S. (2015). Mental health service responses to human trafficking: A qualitative study of professionals' experiences of providing care. BMC Psychiatry., 15, 289. Funding: Not specified. Inferred to be the Matrix Model for mental health. Design: Qualitative study of electronic health records of trafficked people in contact with secondary mental health services in London, England. Purpose: To understand how people are identified as potential victims of trafficking within mental health services N= 131 DS: Free text search used to search the CRIS database for adults and children who had accessed care within SLaM between 2006-2012 and whose records documented concerns that they were a potential victim of trafficking. Inclusion Major Variables & Definitions IV: Trafficked patients facing mental health problems. DV: those receiving mental healthcare. Challenges relating to engagement were similar in both child and adult data. For example, nonattendance. Measurement Free text notes, which consisted of details of patient contacts and correspondenc e with other professionals involved in the patients’ care were downloaded for each case. For those with many entries, key words such as “asylum” “appeal” were Analysis Thematic analysis was used for clinicians’ notes and corresponde nce that involved three stages. First, random selection of case noted read and potential codes were noted. Second, full sample case notes were Findings Key challenges faced by staff included social and legal instability, difficulties in ascertaining history, patients’ lack of engagement, availability of services and interagency working. Decision for Use LOE: V Strengths: Study used an innovative methodology and date resource to access anonymous information in comprehensive medical health records for an otherwise hard to reach group. Demonstrated the potential of electronic health records as a resource for qualitative research. Weaknesses: Professionals varied in the type and detail recorded. Due to the Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Bias: None identified Country: South London and the challenges that mental health professionals experience in responding to trafficked people’s needs. criteria: Patients who identified as being trafficked and were in contact with secondary mental health services, social services or volunteer sector support. Patients who were disclosing their experiences of exploitation and abuse. Exclusion criteria: All others that did not meet the abovementioned criteria were excluded if eligibility was not met. used. Extracted sections relevant to the aim of the study were extracted and transferred to an excel spreadsheet for analysis. 45 read, with relevant text extracted as above, and initial coding framework developed. Third, collated into potential themes. search strategy used, it is feasible that individuals were missed if histories were not documented properly and some data and information may have been missed, there were also potential limitations on the generalizability of the findings. Conclusion: Training to increase awareness of trafficking, encourage safe/helpful responses, and inform staff about the available support for trafficked people that would help mental health professionals in responding to the needs of trafficked people or potential victims of trafficking. Applicability/ Feasibility pt population: Survey and qualitative research suggests that mental health professionals lack the confidence in responding appropriately Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 46 to trafficked people including how to ask about experiences in trafficking, and how to make referrals to support service. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Long, E. & Dowdell, E. (2018). Nurses’ perceptions of victims of human trafficking in an urban emergency department: A qualitative study. Journal of Emergency Nursing. 44(4). 375383. https://doi.org/1 0.1016/j.jen.201 7.11.004 Funding: No funding specified Bias: None identified. Country: U.S.A Theoretical framework through evidence informed practice. Design: Qualitative study using a semistructured interview approach. Purpose: To understand the perception of ER nurses about HT, victims of violence and prostitution. N= 10 DS: Emergency room nurses were recruited for this study through flyers and at shift change meetings over a span of 3 months. Inclusion criteria: Being a RN with a BSN degree who have worked in the ER for at least 2 years. Exclusion criteria: Not working in the ER as a registered nurse with a BSN at the hospital in northeastern US IV: Victims of HT DV: HT exists in the patient population, but no screening is performed. HT victims are young, female and foreign born, identifying victims of violence, victims of violence viewed as “sad and grieving,” prostitutes are seen as “hard and tough,” no HT education for emergency nurses. Victims of HT can suffer from physical, sexual, and psychological Data collected from the interviews were analyzed systematically which is recommended for qualitative data. 47 Content analysis was used to analyze the data. Thematic analysis was performed after interviews were recorded, transcribed and thematic analysis was performed. Findings: The findings of this study emphasize that emergency nurses are in a key position to identify as well as provide care to victims of HT and violence. Because nurses are often the first HCP’s to see the patients, it is important that they are given tools to better identify and care for the victims. LOE: V Strengths: Most of the study participants did have education or inservice programs on how to care for victims of violence in the emergency department. ER nurses can use their education to develop hospital-wide policies on screening and encourage their colleagues in other specialties to be aware and screen for this highrisk population. Weaknesses: Small sample of nurses interviewed, range of ages and nursing, specific ER and gender. Having 4 male and 6 females could have affected how victims of violence and prostitutes are perceived. Conclusion: ER nurses are in key positions to identify and provide care Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING health problems such as sexually transmitted infections, genital mutilation urinary difficulties, pregnancy, etc. 48 to victims of HT, violence and prostitution. The study showed how each of these patient populations are perceived differently by emergency nurses. The study stressed that emergency nurse’s want to become more aware and have additional education on resources specific to victims of HT. Applicability/ Feasibility pt population: Media has influenced nurses’ perceptions of HT population. Victims of violence are looked at as different from prostitutes, but there is a need for education about violence and information about specific resources open to victims. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Westwood, J., Howard, L., Stanley, N., Zimmerman, C., Gerada, C., Oram, S. (2016). Access to, and experiences of, healthcare services by trafficked people: findings from a mixedmethods study in England. British Journal of General Practice, 66, 794-801. https://doi: 10.3399/bjgp16 X687073 Funding: Department of Health Policy Research Programme and National Institute for Health Research Theoretical framework Design: A mixed methods study, a crosssectional survey compromising a structured interview schedule and open- ended questions. Purpose: To explore trafficked people’s access to and use of, health care during and after trafficking N= 136 DS: A twostage recruitment strategy was employed. 19 voluntary sector organizations, 10 healthcare organizations and 15 social services department were approached. Organization taking part approached a convenience sample of potential participants, provided basic study information and worked with the study team to schedule research interviews. IV: Trafficked people DV: Sociodemogra phic characteristics, trafficking experiences, medical history and current health problems. Key barriers faced include restrictions from traffickers, poor access to interpreters and requirements to provide identity documentation to register for care. A structured survey was used, a topic guide was used, and interviews were performed. The interviews lasted 60-90 minutes. Participants were asked open-ended questions about their experiences in health services. Responses were digitally recorded and transcribed verbatim. Those who did not consent to the recording made handwritten notes. Interviews 49 NVivo (version 10) using thematic analysis, in line with guidance from Braun and Clarke. Analysis involved coding keywords and phrases, then grouping them into sub-themes and synthesizing them into meaningful thematic clusters. Findings: A minority of trafficked people can access health services while being trafficked. There is a reliance of healthcare workers to access and use healthcare services after escape from exploitation. LOE: V Strengths: This is the largest study of trafficked people’s access to and experiences of healthcare services conducted to date in a high-income country. Weaknesses: Findings are limited to the experiences of trafficked people who were in contact with support services and its not possible to comment on the experiences of those trafficked who were not in contact with support services. Participants could not include people in the process of being trafficked, information regarding healthcare experiences is retrospective and recall bias cannot be ruled out. Conclusion: Trafficked people access health Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING professorship and NIHR SLaM NSH Foundation Trust Biomedical Research Centre Mental Health. Bias: None recognized Country: England Inclusion criteria: Age 14 or older, in contact with voluntary sector services providing specialist support to formerly trafficked people, healthcare services or local authority social in England between June 2013 and December 2014 Exclusion criteria: Still in the exploitation setting, too unwell or distressed to participate or unable to provide informed consent. were conducted with professionally qualified and independent interpreters. 50 services during and after the time they are exploited but encounter significant barriers. Practitioners would benefit from guidance on how these people can be supported to access care, mostly if they lack official documentation. Applicability/ Feasibility pt population: Improving the access and experiences of care requires mechanisms for them to be able to access medical treatment even when they are unable to provide proof of identity and legal status. Trafficked people must be provided with the opportunity to be seen privately, have access to professional interpreting services and be given clear information in their own language about the medical tests and treatments they receive No restrictions Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 51 were placed on language, country of origin, type of exploitation or time since exploitation. Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 52 Appendix B Synthesis Table Author Fraley et al. Year Design/Level of Evidence: Bias Demographics Age (Range) Female (%) Male (%) Children/Mino rs (%) Population Graham et al. Dell et al. 2020 SR peer reviews/V Hemming s et al. 2016 SR & QA of peer reviews/ V 2019 SR of peer review publications/ V 2019 SR of databases/ V Selection None None 2020 SR of literature, Qualitative semistructured interviews/ V None None Study Characteristics 96% 4% HCP, social workers, psychologists , chiropractor Victims of human traffickin g (adults & Survivors of trafficking for sex or labor Garg et al. Survivors of human trafficking Muraya et al. 2016 SR of databases, lib, articles & grey literature/ V Ottisova et al. 2016 SR & MA/V Domoney et al. 2015 Qualitativ e study of EHR/V Long et al. None None None None None ER nurses’ Trafficked people >14 in contact w/ sector 2018 Qualitativ e studysemi structured /V Westwoo d et al. 2016 MM, Cross sectional study/V 1-17 63% Child victims of human trafficking Child sex trafficking Victims Victims of human trafficking Trafficked people in contact with mental Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Setting: Sample Size/ # of Studies Included Measurement Tools USA, Middle East, Caribbean, Central Africa children) USA USA USA, Asia and Africa USA 53 Switzerlan d, Ireland, Nepal, USA, Serbia, Cambodia & Germany. South, southeast Asia, Europe, Latin America, North America health South London ER Northeast ern USA services England N=7 N=44 N=53 N=161 N=18 N=15 N=31 N=131 N=10 N=136 Leung & Waters (2012) PGF Checklists from the Joanna Briggs Institute Electronic spreadsheet Full text screened by 2-3 reviewers MMAT version 2018 Flow diagram of the document CASP Free text notes Structure d survey, topic guide and interview s. Date Ranges for the study 1/1/20009/1/2018 1/1/1990 -2/2015 1/20007/2017 2005-2015 1/20005/2013 1/1/20114/17/2015 20062012 Content systematic analysis from semistruct ured interviews None stated Systematic search databases Interviews Surveys Quality appraisal Flow Diagram X X X 1/1/19991/30/2019 IV – Interventions X X X X X 2015 X X Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Cochrane collaboration Joanna Briggs MMAT checklist Electronic spreadsheet X X Findings * QoL Stress X X Mental health Depression Life Satisfaction Mood Psychological Distress 54 * * ~ ~ ≠ * ~ ≠ *  (* for overall, social, & emotional CB) * + ~ (* in CB d/t late symptom s, aggressio n& resistance of PwD) + + ~ ≠ ≠ Compared to EG w/o booster ≠, Compared to CG * * ~ Key: BSN- Bachelors of Science in Nursing; CASP- Critical Appraisal Skills Programme; CBT – cognitive behavioral therapy; CG- control group; CM- case management; DS – databases searched; DV-dependent variable; ER- emergency room; HCP- health care providers; HT- human trafficking; IV- independent variable; MA- meta-analyses; MMAT- Mixed Methods Appraisal Tool; N-number of studies (if SR) or participants in study; n- number of participants (if SR) or number of participants in subset; NGO – Non-governmental organization; NIHR- National Institute for health research; NRNCT – nonrandomized noncontrolled trial; PGF- Psychometric Grading Framework PRISMA – Preferred Reporting Items for Systematic Reviews and Meta-Analyses; randomized control trial; pt- patient; PTSD- post traumatic stress disorder; QA- qualitative analysis RN- registered nurse; SD – standard deviation; SG – support groups; SLaM- South London and Maudsley NHS Foundation Trust; SR- systematic review; SSA- Social Services Abstracts; ST- sex trafficking; TF- Trauma focused; U.S.A- United States of America EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Appendix C Kolb’s Learning Cycle 55 EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Appendix D Rosswurm & Larrabee Model 56 EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 57 Appendix E Pre-test and Post-Test 1. Where do healthcare providers encounter MOST often encounter patients who are at risk for human trafficking or who have experienced trafficking? Primary Care Office Pediatrician's Office OB/GYN office Emergency Department 2. True or False. The questions on the Human Trafficking Screening form are designed to be asked directly to the patient. True False 3. When a healthcare provider suspects a child is being trafficked, what should be done? Nothing, it's too dangerous Nothing, it's not your business Report trafficking immediately Take the victim aside to gather more information 4. What are risk factors for being lured into human trafficking? Select all that apply Homelessness Being a runaway Having low self esteem History of prior abuse 5. What is the three-pronged approach associated with the Trafficking Victims Protection Act (TVPA) of 2000? Recognition, rehabilitation, and restoration Knowledge, awareness and resources Honor, hope and healing Prevention, protection and prosecution 6. What types of ser EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 58 vices does an individual need who is at risk of trafficking, currently experiencing trafficking or who has experienced trafficking need? Select all that apply. Behavioral health services Law enforcement or legal services Social services (i.e. public assistance, housing or domestic violence programs Community based services Behavioral Health Sciences 7. True or False: Reporting a suspected case of human trafficking always violates HIPAA (Health Insurance Portability and Accountability Act). True False 8. Physical signs or "red flags" of human trafficking include which of the following? Select all that apply. Bruising, burns, tattoos Injuries at various stages of healing Dental carries Working late hours 9. Who completes the Human Trafficking screening form? Registration Triage Nurse Physician and/or PA Triage Technician 10. True or false. If a patient chooses to decline resources or referrals for human trafficking, you must call the police. True False EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING Appendix F List of Human Trafficking Screening Questions 59 EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 60 Appendix G Human Trafficking Education Pre-test Consent to Participate Your participation in the educational session, intervention, and post-intervention survey is voluntary. You can skip questions on the survey if you wish. If you choose not to participate or to withdraw from the project at any time, there will be no penalty. Participation in this project will not affect your position at Honor Health prior to, during, or after your participation. Your responses on the pre and post-intervention test will be used to assess the project effectiveness and will remain anonymous. We will not collect your name or other personal identifying information. The results of this project may be used in reports, presentations, or publications as aggregate data only. Attending the education session and completing the surveys will be considered your consent to participate. If you have any questions concerning this project, please contact the following team members: Lisa Rosch at 602-579-0395 or by email at lalanis@asu.edu or you can contact my PI, Dr. Rochelle Chiffelle, 602-300-0862 or rchiffe@asu.edu. Thank you for the time and consideration of participating in my Doctoral pilot program. By taking this pre-test, you are agreeing to be part of this educational program. EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 61 Appendix H Post Trafficking Education Survey 1. On a scale of 1 to 5, with 1 being "a great deal" and 5 being "none at all," how well do you know the indicators "common signs" of human trafficking? 2. Please respond to the following statement according to scale of 1 to 5, with one being “strongly disagree” and 5 being "strongly agree." I am confident I can make the appropriate referrals for victims who have been trafficked. 3. Please respond to the following statement according to scale of 1 to 5, with 1 being “extremely comfortable” and 5 being “extremely uncomfortable.” I am comfortable asking a person if they are in danger. 4. Please respond to the following statement according to a scale of 1 to 5, with 1 “a great deal” and 5 being “not all all” I am confident I can identify potential victims of trafficking. 5. On a scale of 1 to 5, with 1 being "a great deal" and 5 being "none at all," how well do you know the indicators "common signs" of human trafficking? 6. On a scale of 1 to 5, with 1 being “a great deal” and 5 being “none at all,” how much do you know about reporting a suspected instance of human trafficking? 7. Please share your thoughts about this training EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 62 Appendix I Flyer Learn the basics about human trafficking, including local statistics/information  Learn how to recognize signs and indicators of human trafficking  Review the Human Trafficking Screening form in EPIC  Learn what to do if you suspect someone is a victim of Human Trafficking Training is intended for healthcare providers (Physicians and Nurses) at John C. Lincoln.  Presented by: Lisa Rosch, BSN, RN, DNP Student at Arizona State University Questions? Contact Lisa Rosch at lalanis@asu.edu 602-579-0395 or PI, Rochelle Chiffelle at rchiffe@asu.edu or 602-300-0862 Further details to follow via Email regarding this virtual training EDUCATING HEALTHCARE PROVIDERS HUMAN TRAFFICKING 63