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Needs Assessment of Human Trafficking Awareness of Health Professionals

Info: 2866 words (11 pages) Nursing Essay
Published: 11th Feb 2020

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Human Trafficking Awareness: A Needs Assessment of Current Experience, Knowledge, and Views of Healthcare Professionals in the Denver Metro Area.


Background and Rationale:

Human trafficking, which encompasses both sex and labor trafficking, remains a prevalent problem both nationally and locally.  Labor Trafficking is defined as 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, debt bondage, or slavery.  Sex Trafficking is defined as the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act, in which the 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.

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Trafficking can affect anyone, however certain populations are more vulnerable, including undocumented individuals, sex workers, minors not residing with a parent, and individuals experiencing homeless.1  It is difficult to surveil trafficking, as many trafficked individuals do not realize they are being trafficked, or are afraid to seek help.  An estimated 24.9 million victims are trafficked worldwide. Of these, 64% were exploited for labor, 19% were sexually exploited, and 17% were exploited in state-imposed forced labor.2  In 2017, the National Human Trafficking Hotline received 405 calls from Colorado and 110 human trafficking cases were reported.3

Victims of human trafficking experience high levels of abuse including physical violence (being hit, kicked and assaulted with weapons), sexual violence (rape and forced participation in sexual acts), psychological violence (including threats to self and to family, surveillance, humiliation, intimidation), economic restrictions (including confiscation of earnings, restriction of access to funds), and other controlling behaviors, including confiscation of passport and other identity documents, and threats to report the victim to immigration, or police and child welfare authorities. High levels of physical and mental health problems have been reported among victims of human trafficking, including non-specific symptoms such as headache, back pain, stomach pain and dizziness, and mental disorders such as depression, anxiety and post-traumatic stress disorder.1 

Trafficked individuals often do not immediately seek help or self-identify as victims of a crime due to a variety of factors, including lack of trust, self-blame, or specific instructions by the traffickers regarding how to behave when talking to law enforcement or social services.  One study estimates that at least half of trafficked individuals will come into contact with a healthcare provider while being trafficked.4,5  However, little is known about the knowledge and readiness of healthcare providers to identify victims, to make appropriate referrals, and to provide clinical care.

The Denver Anti-Trafficking Alliance (DATA) works to facilitate a victim-centered, multidisciplinary response to human trafficking in Denver through enhancing collaborative efforts; supporting trauma-informed services; promoting collaborative investigations and prosecution; improving education and awareness; and advancing public policy and advocacy.  The Healthcare Subcommittee is in the process of creating a victim-centered/trauma-informed template protocol to support healthcare professionals in their response to human trafficking. The subcommittee hoped to learn more about the experiences, knowledge, and views of local healthcare professionals regarding human trafficking to better inform this project.

The purpose of this key-informant survey is to assess the current knowledge and training gaps of healthcare professionals in the Denver Metro Area regarding human trafficking.


This mixed-methods key-informant survey was adapted from PROTECT survey (Provider Responses, Treatment, and Care for Trafficked People).  The PROTECT survey (figure 1) was designed for use in the UK, and modifications were made to target our audience in the Denver metro area.  Several open-ended questions were also added for qualitative analysis.  Members of the subcommittee made several edits to the survey to ensure it aligned with the purpose of the project.  The survey (figure 2) consisted of 31 questions which contained a mix of dichotomous, multiple choice, open-ended questions, as well as a section of questions on the likert-scale.  The survey was broken into 4 sections, background, training and experience, perceived knowledge, and responding to human trafficking.  The survey was self-administered, took approximately 10 minutes to complete, and was designed to be relevant across a range of clinical disciplines and settings.

Figure 1

The healthcare subcommittee chose 15 key informants who are healthcare professionals working in the Denver Metro Area.  The 5 key informants who responded have titles including ‘nursing director,’ ‘director of clinical quality and risk’ and ‘risk manager,’ and most supervise other clinical providers.  The surveys were collected electronically, and analyzed using tenants of grounded theory.  Codes were developed using open coding to label concepts and define and develop categories based on their properties and dimensions.  After the initial round of coding, axial coding was used to relate codes to each other and develop themes.  The themes were used to guide recommendations and to write a final report for subcommittee use.

Figure 2


The main themes identified include ‘minors’, ‘confidence’, ‘knowledge’, ‘experience’, and ‘training’.  These themes guided the recommendations as follows.  The professionals surveyed had little experience with trafficked individuals.  Only 2 responses indicated their patient interactions included suspected trafficked individuals.  All responses indicated they believed it is likely they will encounter a trafficked individual in their current role.  Also, the responses indicated a high level of confidence in providing care for health issues associated with trafficking.

The amount of human trafficking training received varied from ‘none’ to ‘biannually’.  The findings suggest that healthcare professionals would welcome information and training on human trafficking. The trainings received seem to be less comprehensive than DATA’s current training program and do not include information on federal or local legislation regarding trafficking.  Responses indicated a high level of training and confidence when providing care in situations involving child abuse or neglect, and all responses confirmed their organizations have existing child abuse protocols.  This may be a direct result of Colorado’s mandatory reporting laws.  According to Colorado State law, a report is required when a mandatory reporter has reasonable cause to know or suspect that a child has been subjected to abuse or neglect or has observed the child being subjected to circumstances or conditions that would reasonably result in abuse or neglect.  All healthcare providers, social workers, therapists, first responders, clergy, and healthcare support staff are mandatory reporters.6

Perceived barriers to care include identifying trafficked individuals, what questions to ask if trafficking is suspected, assessing the danger level a trafficked individual is in, and knowledge of or access to national and local resources.  Similarly, respondents reported very little knowledge regarding their role in identifying and responding to human trafficking, what questions to ask to identify potential cases, what to say or not to say to a patient who has experienced human trafficking, documenting human trafficking in a medical record, assessing danger for a patient who may have been trafficked, local and national support services for trafficked people, and policies on responding to human trafficking.  Perceived knowledge was slightly higher with respect to indicators of human trafficking and health problems commonly experienced by trafficked people.



Recommendations: (Figure 3)

The following list of recommendations was compiled after analyzing the main results.  While mostly qualitative in nature, quantitative results were also used to create a more complete picture.  The six recommendations are as follows:

  1. As the results indicated all institutions represented have an existing child abuse protocol and that the providers are highly familiar with this protocol, the subcommittee should model their human trafficking protocol after existing child abuse protocols.  This can include modeling the protocol format, including familiar content, or both.
  2. The template should include trafficking-specific information clearly outlined, and should avoid the use of vague language such as “contact the proper authorities” as it makes unsafe assumptions.  Mandatory reporters are required to report suspected child abuse, however contacting the authorities in situations of suspected trafficking may actually put the individual in more danger.  Patient consent needs to play a large role in the reporting process for adults.
  3. Assembling a ‘master list’ of resources and referrals will be essential to connecting providers to a network of other professionals which will serve to continue the care of trafficked individuals.  Providers seem unaware of existing resources, and are receptive to utilizing outside resources for the purpose of continuity of care.
  4. The current DATA training program is sufficiently comprehensive.  The results indicate the training program should focus on how to identify and respond to human trafficking, including what questions to ask, how to assess risk, and how to make appropriate referrals to support providers. 
  5. The subcommittee should perform an evaluation on the current training module to determine the effectiveness of the program in improving the identification, response to, and referral of potential victims of human trafficking.  This could include the use of a pre and post training knowledge check.
  6. The training instructors should incorporate the finished protocol template and provide the master list of resources during the training session to demonstrate how to flesh out the template for use and/or modification at their current organization.

Figure 3



The survey was conducted from professionals at multiple sites with variable job descriptions, which is ideal when performing qualitative analysis.  Although the responses to open-ended questions were brief, the mixed-methods design of the survey allowed the coder to form a complete picture of the responses.  The PROTECT Questionnaire has good internal consistency, correlation among theoretical constructs, and discriminative characteristics in relation to previous human trafficking training.7

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We had a low response rate and sample size, meaning any quantitative analysis performed would be unreliable.  As the responses were brief in nature, it was difficult and time consuming to interpret the results.  The responses were received anonymously in an attempt to elicit more candid responses to this difficult subject matter.  As a result, I was not able to member check the responses.  This project did not have multiple coders, and thus the results may contain biases held by the lone coder.  The coder has a background as a health center assistant and clinical research coordinator at a reproductive health center in the Denver metro area.

 Although the results provided valuable information, the subcommittee may benefit from distributing the survey to a larger sample size, and could consider focusing on providers who have more contact with patients.  This could include bedside nurses, PA’s, medical assistants, and doctors.  Results from our current sample indicate that providers who have more patient contact have greater perceived knowledge and confidence providing care for trafficked individuals.  Having a larger sample size with this new target population may elucidate further insights regarding provider experiences with trafficked individuals.  Furthermore, although the survey format was convenient for our target audience, the brief responses were difficult to interpret.  It may be worthwhile to explore other options for delivering the survey, such as via focus groups, phone interviews, or in-person interviews.

Public Health Significance:

Healthcare providers can play a critical role in efforts to tackle human trafficking, including by identifying and referring potential victims of human trafficking and by providing clinical care. Healthcare professionals in Denver are in contact with potential victims of human trafficking, but lack confidence in how to respond appropriately. Targeted training for professionals may improve preparedness to identify and respond to potential victims of human trafficking and improve the well-being and safety of this vulnerable group.

Creation of a standardized protocol will assist the training module in providing clear and specific structure to follow when encountering a potential trafficking victim.  The protocol can serve as a reminder for providers between training sessions and can guide providers who haven’t received training specific to responding to human trafficking.  Assembling a master list of referrals will allow providers to further the care of trafficked individuals when patients need additional support outside of the scope of their provider and will give trafficked individuals a wider range of care options that are specific to their situation.

Works Cited



Cathy Zimmerman LK. Human trafficking and exploitation: A global health concern. PLoS Med. November 2017;11.


International Labour Organization. Global Estimates of Modern Slavery: Forced Labour and Forced Marriage: ILO; 2017. 978-92-2-130131-8.


National Human Trafficking Hotline. Colorado. National Human Trafficking Hotline. 2018. Available at: https://humantraffickinghotline.org/state/colorado. Accessed May 9, 2019.


Dovydaitis T. Human Trafficking: The Role of the Health Care Provider. Journal of Midwifery, Women’s Health. September 2010;55(5462-467).


CS et al. Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors. Health and Human Rights. June 2017;1.


CDHS. Mandatory Reporting. Colorado Adult Protective Services. Available at: https://www.coloradoaps.com/about-mandatory-reporting.html. Accessed May 9, 2019.


Ross et al. Human Trafficking and Health: a Cross-Sectional Survey of NHS Professionals’ Contact with Victims of Human Trafficking. BMJ Open. 2015;5(e008682).





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