Hanni Stoklosa

Medical education on human trafficking.

Training for health care professionals on human trafficking should be informed by a human rights perspective and include prevention and identification of trafficking and treatment of trafficking-related health conditions.

Use of uterine balloon tamponade for control of postpartum hemorrhage by community-based health providers in South Sudan

To determine whether use of uterine balloon tamponade (UBT) for management of uncontrolled postpartum hemorrhage (PPH) by community‐based providers in a resource‐limited setting could be feasible, effective, and safe.

Training US health care professionals on human trafficking: where do we go from here?

ABSTRACT Some 21 million adults and children are labor-trafficked or sex-trafficked through force, fraud, or coercion. In recognition of the interface between trafficking victims and the healthcare setting, over the last 10 years there has been a notable increase in training of health care professionals (HCPs) on human trafficking (HT) and its health implications. Many organizations have developed curricula and offered training in various clinical settings. However, methods and content of this education on trafficking vary widely, and there is little evaluation of the impact of the training. The goal of this study was to assess the gaps and strengths in HT education of HCPs in the US. This mixed-method study had two components. The first component consisted of structured interviews with experts in human trafficking HCP education. The second portion of the study involved an analysis of data from HCP calls to the National Human Trafficking Resource Center (NHTRC). The interviews captured trainer-specific data on types of HT training, duration and frequency, key content areas, presence of evaluation approaches and indicators, as well as an assessment of barriers and strengths in HT training for HCP. NHTRC call database analysis demonstrated increasing trends since 2008 in calls by HCPs. Overall findings revealed the need for standardization of HT training content to assure correct information, trauma-informed and patient-centered care, and consistent messaging for HCPs. Evaluation metrics for HT training need to be developed to demonstrate behavior change and impact on service delivery and patient-centered outcomes for HT victims, according to our proposed adapted Kirkpatrick’s Pyramid model. HT training and evaluation would benefit from an agency or institution at the national level to provide consistency and standardization of HT training content as well as to guide a process that would develop metrics for evaluation and the building of an evidence base. Abbreviations: AAP: American Academy of Pediatrics; ACF: Administration for Children and Families; CME: Continuing medical education; ED: Emergency department; HCP: Health care professional; HEAL: Health, Education, Advocacy, and Linkage; HHS: United States Department of Health and Human Services; HT: Human trafficking; IOM: United States Institute of Medicine; MH: Mental health; NHTRC: National Human Trafficking Resource Center; SOAR: Stop, Observe, Ask, and Respond to Health and Wellness Training

A Review of U.S. Health Care Institution Protocols for the Identification and Treatment of Victims of Human Trafficking

ABSTRACT The purpose of this study was to characterize and assess human-trafficking (HT) identification, treatment, and referral protocols of U.S. health care service provider institutions. A total of 30 protocols from 19 states and 2 national organizations were analyzed. Across the protocols, the most commonly listed indicator of HT victimization was patient history of physical- or sexual-abuse victimization, which was included in 73% of the protocols. In addition, the majority (70%) of the protocols listed ≥ 1 medical-symptom indicator of HT victimization (e.g., bruises, scars, frequent injuries), ≥ 1 indicator based on a patient’s apparent dependence on another person (e.g., patient not in control of personal identification), and ≥ 1 indicator related to how the patient communicates (e.g., inconsistencies in the patient’s story about his or her medical condition). A smaller proportion of protocols included indicators of HT that pertained to housing (60%), the patient’s appearance (47%), the patient’s mental health (63%), sexual history (63%), or technology-related indicators such as the patient possessing explicit digital photos of himself or herself with another person (20%). We conclude that additional research is needed to establish ideal protocol content but propose that in the interim protocol developers consider using practice-informed and evidence-based information that pertain to six areas of victim identification and assistance.

Public Health Research Priorities to Address US Human Trafficking

The article discusses the authors call for U.S. public health research to prioritize the issue of human trafficking prevention, and it mentions Americas Trafficking Victims Protection Act of 2000 and the various investigations into suspected human trafficking that were opened by the U.S. Department of Homeland Security and the nations Department of Justice in fiscal year 2015. The health consequences of human trafficking are examined, along with reproductive health and mental health.

Health Care Providers’ Experience with a Protocol for the Identification, Treatment, and Referral of Human-Trafficking Victims

ABSTRACT The health care setting is thought to be one of the most promising places to identify victims of human trafficking. The present study was designed to relay the experiences of a sample of 10 health care providers and hospital administrators who developed and have used a protocol to identify victims of human trafficking since February 2014. To our knowledge, the protocol was one of the first to be adopted by any health care system in the United States. Three primary themes emerged from the participant interviews. First, developing the protocol was challenging because, at the time, there were no predecessor examples. Second, providers reported that the protocol is simple to use and victim identification is easier because of it. Third, identifying and serving victims of human trafficking remains challenging, because there is still a deficit of trained providers and a lack of community resources for survivors. The field needs evidence that this and similar protocols improve users’ knowledge and skills, result in the better identification and treatment of trafficking victims and ultimately improve public safety and public health.

Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing

This article reviews an emergency department-based clinical vignette of a trafficked patient with co-occurring pregnancy-related, mental health, and substance use disorder issues. The authors, including a survivor of human trafficking, draw on their backgrounds in addiction care, human trafficking, emergency medicine, and psychiatry to review the literature on relevant general health and mental health consequences of trafficking and propose an approach to the clinical complexities this case presents. In their discussion, the authors explicate the deleterious role of implicit bias and diagnostic overshadowing in trafficked patients with co-occurring addiction and mental illness. Finally, the authors propose a trauma-informed, multidisciplinary response to potentially trafficked patients.

Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey

Objectives Our aim was to determine whether emergency physicians (EPs) felt their standard patient evaluation practice was modified by two non-private clinical encounters: hallway encounters and encounters during which a companion was present. Methods We administered an iteratively developed cross-sectional survey at an annual national professional meeting. We used logistic regression to compare relationships among non-private clinical encounters and predictors of interest. Results 409 EPs completed the survey. EPs deviated from standard history-taking when practising in a hallway location (78%) and when patients had a companion (84%). EPs altered their standard physical exam when practising in a hallway location (90%) and when patients had a companion (77%). EPs with at least a decade of experience were less likely to alter history-taking in the hallway (OR 0.55, 95% CI 0.31 to 0.99). Clinicians who frequently evaluated patients in the hallway reported delays or diagnostic error-related to altered history-taking (OR 2.34, 95% CI 1.33 to 4.11). The genitourinary system was the most common organ system linked to a delay or diagnostic error. Modifications in history-taking were linked to delays or failure to diagnose suicidal ideation or self-harm (25%), intimate partner violence (40%), child abuse (12%), human trafficking (8%), substance abuse (47%) and elder abuse (17%). Conclusions Our study suggests that alterations in EP usual practice occurs when the doctor–patient dyad is disrupted by evaluation in a hallway or presence of a companion. Furthermore, these disruptions are associated with delays in care and failure to diagnosis medical, social and psychiatric conditions.

Identifying Gaps in Human Trafficking Mental Health Service Provision

ABSTRACT Human trafficking is a global concern resulting in complex, long-lasting mental health consequences for survivors. The U.S. nongovernmental sector has emerged as a key service provider in facilitating and directly providing comprehensive services for survivors, including crucial mental health services. This study aimed to better understand barriers to and potential improvements for human trafficking survivor mental health service delivery by applying a deductive framework analysis to semi-structured interviews with 15 U.S.-based nongovernmental organizations. Analysis of interview data underscored key challenges, including extensive and complex human trafficking survivor mental health needs, limited service provider capacity, and a fragmented multisector response. Themes for strategies to improve mental health service delivery included improved multisector collaboration as well as increasing mental health professional capacity through human trafficking–specific training. Implications and recommendations to improve comprehensive, trauma-informed, and client-centered human trafficking survivor care, including future research directions, are discussed.

The high cost of diarrhoeal illness for urban slum households–a cost-recovery approach: a cohort study

Objectives Rapid urbanisation has often meant that public infrastructure has not kept pace with growth leading to urban slums with poor access to water and sanitation and high rates of diarrhoea with greater household costs due to illness. This study sought to determine the monetary cost of diarrhoea to urban slum households in Kaula Bandar slum in Mumbai, India. The study also tested the hypotheses that the cost of water and sanitation infrastructure may be surpassed by the cumulative costs of diarrhoea for households in an urban slum community. Design A cohort study using a baseline survey of a random sample followed by a systematic longitudinal household survey. The baseline survey was administered to a random sample of households. The systematic longitudinal survey was administered to every available household in the community with a case of diarrhoea for a period of 5 weeks. Participants Every household in Kaula Bandar was approached for the longitudinal survey and all available and consenting adults were included. Results The direct cost of medical care for having at least one person in the household with diarrhoea was 205 rupees. Other direct costs brought total expenses to 291 rupees. Adding an average loss of 55 rupees per household from lost wages and monetising lost productivity from homemakers gave a total loss of 409 rupees per household. During the 5-week study period, this community lost an estimated 163 600 rupees or 3635 US dollars due to diarrhoeal illness. Conclusions The lack of basic water and sanitation infrastructure is expensive for urban slum households in this community. Financing approaches that transfer that cost to infrastructure development to prevent illness may be feasible. These findings along with the myriad of unmeasured benefits of preventing diarrhoeal illness add to pressing arguments for investment in basic water and sanitation infrastructure.