Roy Ahn

Human trafficking: review of educational resources for health professionals

CONTEXT Human trafficking is an increasingly well-recognized human rights violation that is estimated to involve more than 2 million victims worldwide each year. The health consequences of this issue bring victims into contact with health systems and healthcare providers, thus providing the potential for identification and intervention. A robust healthcare response, however, requires a healthcare workforce that is aware of the health impact of this issue; educated about how to identify and treat affected individuals in a compassionate, culturally aware, and trauma-informed manner; and trained about how to collaborate efficiently with law enforcement, case management, and advocacy partners. This article describes existing educational offerings about human trafficking designed for a healthcare audience and makes recommendations for further curriculum development. EVIDENCE ACQUISITION A keyword search and structured analysis of peer-reviewed and gray literature, conducted in 2011 and 2012, yielded 27 items that provide basic guidance to health professionals on human trafficking. EVIDENCE SYNTHESIS The 27 resources differed substantially in format, length, scope, and intended audience. Topic areas covered by these resources included trafficking definitions and scope, health consequences, victim identification, appropriate treatment, referral to services, legal issues, and security. None of the educational resources has been rigorously evaluated. CONCLUSIONS There is a clear need to develop, implement, and evaluate high-quality education and training programs that focus on human trafficking for healthcare providers.

Uterine balloon tamponade for the treatment of postpartum haemorrhage in resource-poor settings: a systematic review

Background  Effective interventions addressing postpartum haemorrhage (PPH) are critically needed to reduce maternal mortality worldwide. Uterine balloon tamponade (UBT) has been shown to be an effective technique to treat PPH in developed countries, but has not been examined in resource‐poor settings.

Focused Maternal Ultrasound by Midwives in Rural Zambia

Point-of-care ultrasound is being increasingly implemented in resource-poor settings in an ad hoc fashion. We developed a focused maternal ultrasound-training program for midwives in a rural health district in Zambia. Four hundred forty-one scans were recorded by 21 midwives during the 6-month study period. In 74 scans (17%), the ultrasound findings prompted a change in clinical decision-making. Eight of the midwives were evaluated with a 14-question observed structured clinical examination (OSCE) and demonstrated a slight overall improvement with mean scores at 2 and 6 months of 10.0/14 (71%) and 11.6/14 (83%), respectively. Our pilot project demonstrates that midwives in rural Zambia can be trained to perform basic obstetric ultrasound and that it impacts clinical decision-making. Ultrasound skills were retained over the study period. More data is necessary to determine whether the introduction of ultrasound ultimately improves outcomes of pregnant women in rural Zambia.

Methodological approaches of health technology assessment

In this era of evolving health care systems throughout the world, technology remains the substance of health care. Medical informatics comprises a growing contribution to the technologies used in the delivery and management of health care. Diverse, evolving technologies include artificial neural networks, computer-assisted surgery, computer-based patient records, hospital information systems, and more. Decision-makers increasingly demand well-founded information to determine whether or how to develop these technologies, allow them on the market, acquire them, use them, pay for their use, and more. The development and wider use of health technology assessment (HTA) reflects this demand. While HTA offers systematic, well-founded approaches for determining the value of medical informatics technologies, HTA must continue to adapt and refine its methods in response to these evolving technologies. This paper provides a basic overview of HTA principles and methods.

Alternative Rehydration Methods: A Systematic Review and Lessons for Resource-Limited Care

OBJECTIVE: Dehydration is a significant threat to the health of children worldwide and a major cause of death in resource-scarce settings. Although multiple studies have revealed that oral and intravenous (IV) methods for rehydration in nonsevere dehydration are nearly equally effective, little is known about effectiveness beyond these 2 techniques. With this systematic review we analyzed the effectiveness of nonoral and nonintravenous methods of rehydration. METHODS: The Medline, Cochrane, Global Health, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for articles on intraosseous (IO), nasogastric (NG), intraperitoneal (IP), subcutaneous (hypodermoclysis), and rectal (proctoclysis) rehydration through December 2009. Only human pediatric studies that included data on the effectiveness or complications of these methods were included. RESULTS: The search identified 38 articles that met the inclusion criteria: 12 articles on NG, 16 on IO, 7 on IP, 3 on subcutaneous, and none on rectal rehydration. NG rehydration was as effective as IV rehydration for moderate-to-severe dehydration. IO rehydration was effective and easy to obtain, although only 1 randomized trial was identified. IP rehydration had some benefit for moderate dehydration, although none of the trials had control groups. Limited data were available on subcutaneous rehydration, and only 1 case series showed benefit. CONCLUSIONS: NG rehydration should be considered second-line therapy, after oral rehydration, particularly in resource-limited environments. IO rehydration seems to be an effective alternative when IV access is not readily obtainable. Additional evidence is needed before IP and subcutaneous rehydration can be endorsed.

Integrating Curricula on Human Trafficking Into Medical Education and Residency Training

Today in the United States , human trafficking occurs in cities, suburbs, and rural areas across all 50 US states.1 “Severe forms” of human trafficking are defined under the US Trafficking Victims Protection Act of 2000 as the following: (1) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age or (2) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. According to data collected by the US Human Trafficking Reporting System between January 2008 and July 2010, 83% of confirmed sex trafficking victims were US citizens, and 95% of confirmed labor trafficking victims were foreignborn nationals. Moreover, 87% of sex trafficking victims were younger than 25 years, compared with 38% of labor trafficking victims.2 Health outcomes associated with human trafficking include infectious diseases such as tuberculosis and human immunodeficiency virus (HIV)/AIDS, noninfectious diseases such as dental disease and malnutrition, reproductive health problems, substance abuse, mental health problems including posttraumatic stress disorder, depression, and suicidal ideation, and physical injuries from violence experienced during enslavement.3,4 From a public health perspective, trafficking may be an important means of HIV transmission, as suggested by one study that found a 38% HIV prevalence among repatriated sex-trafficked Nepalese women and girls, with a 60% infection rate among girls trafficked prior to 15 years of age.5 The health care profession may be one of the few professions likely to interact with trafficking victims while enslaved. A 2011 study found that 50% of trafficking survivors interviewed reported having visited a physician while trafficked.6 Key informants working closely with trafficking survivors were also interviewed and 100% described additional clients who had received medical care while under their trafficker’s control.6 Low awareness and a lack of guidance or protocols for responding to human trafficking in the health care setting are particularly salient barriers to a more effective health sector response in the United States.3 A recent study demonstrated that a brief educational intervention for health professionals increased their knowledge about human trafficking, as well as selfreported recognition of human trafficking victims.7 In the same study, an overwhelming majority of respondents— 79% preintervention and 92% postintervention— agreed or strongly agreed that it was important for them to know about human trafficking for their professions.7 Calls for Educational Training About Human Trafficking Multiple health professional organizations have issued calls for their member physicians to receive educational training about human trafficking. These organizations—including the American College of Obstetricians and Gynecologists (2011), the American Medical Association–Medical Student Section (2012), the Christian Medical & Dental Associations (2013), and the American Academy of Pediatrics (2014)—have been joined by similar calls from allied health professions, including nursing and social work. Following the January 2014 release of the US government’s Federal Strategic Action Plan on Services for Victims of Human Trafficking in the United States: 2013-2017, the US Department of Health and Human Services launched the SOAR to Health and Wellness Network, a pilot initiative to educate health care professionals on how to identify and serve victims of trafficking. For more information, please refer to the US Administration for Children & Families website at http: //www.acf.hhs.gov/press(press release dated January 14, 2014).

A postpartum haemorrhage package with condom uterine balloon tamponade: a prospective multi‐centre case series in Kenya, Sierra Leone, Senegal, and Nepal

To evaluate the effectiveness and safety of an ultra‐low‐cost uterine balloon tamponade package (ESM‐UBT™) for facility‐based management of uncontrolled postpartum haemorrhage (PPH) in Kenya, Sierra Leone, Senegal, and Nepal.

Emergency and urgent care capacity in a resource-limited setting: an assessment of health facilities in western Kenya

Objective Injuries, trauma and non-communicable diseases are responsible for a rising proportion of death and disability in low-income and middle-income countries. Delivering effective emergency and urgent healthcare for these and other conditions in resource-limited settings is challenging. In this study, we sought to examine and characterise emergency and urgent care capacity in a resource-limited setting. Methods We conducted an assessment within all 30 primary and secondary hospitals and within a stratified random sampling of 30 dispensaries and health centres in western Kenya. The key informants were the most senior facility healthcare provider and manager available. Emergency physician researchers utilised a semistructured assessment tool, and data were analysed using descriptive statistics and thematic coding. Results No lower level facilities and 30% of higher level facilities reported having a defined, organised approach to trauma. 43% of higher level facilities had access to an anaesthetist. The majority of lower level facilities had suture and wound care supplies and gloves but typically lacked other basic trauma supplies. For cardiac care, 50% of higher level facilities had morphine, but a minority had functioning ECG, sublingual nitroglycerine or a defibrillator. Only 20% of lower level facilities had glucometers, and only 33% of higher level facilities could care for diabetic emergencies. No facilities had sepsis clinical guidelines. Conclusions Large gaps in essential emergency care capabilities were identified at all facility levels in western Kenya. There are great opportunities for a universally deployed basic emergency care package, an advanced emergency care package and facility designation scheme, and a reliable prehospital care transportation and communications system in resource-limited settings.

Evaluation of a novel training package among frontline maternal, newborn, and child health workers in South Sudan

To develop, implement, and evaluate an evidence‐based Maternal, Newborn, and Child Survival (MNCS) package for frontline health workers (FHWs) in South Sudan.

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.