Human trafficking (HT) constitutes a horrendous violation of basic human rights and is a significant global and public health issue. It is reported that HT victims enter the health care setting for treatment at some point during their exploitation but are infrequently recognized (Chisolm-Straker et al., 2016; Chisolm-Straker, Richardson, & Cossio, 2012; Patel, Ahn, & Burke, 2010). Nurses, particularly those in the emergency department, are in a position to help identify patient-victims and intervene by offering treatment to at-risk individuals (Chisolm-Straker et al., 2016).
There are many states in the United States that mandate HT education as part of the continuing education requirements to be relicensed as an RN (Department of Licensing and Regulatory Affairs, n.d.). Further, the American Nurses Association (2016) and International Council of Nurses (2011) acknowledge that as professionals, nurses have an ethical obligation to protect and advocate for the health rights of patients. To best meet the complex health and legal needs of trafficked individuals and requirements of relicensure, it is paramount that nurses receive education in the evaluation and management of the HT patient-victim (Ahn et al., 2013; Chisolm-Straker et al., 2012; Department of Licensing and Regulatory Affairs, n.d.).
HT education for nurses should begin with identifying victims (Chisolm-Straker et al., 2012) using evidence-based screening tools and “red flag” checklists (National Human Trafficking Training and Technical Assistance Center [NHTTAC], 2018). They must learn how to recognize and address the unique, individual needs of trafficked individuals. Nurses must also become knowledgeable regarding available resources, including services to address immediate and long-term health, safety, and legal needs of HT patient-victims (Chisolm-Straker et al., 2012; NHTTAC, 2018). Formal evaluation of the HT educational intervention must be conducted to determine whether the offering results in a positive change in knowledge and practice (Macias-Konstantopoulos, 2016). The purpose of this pilot study was to determine the effects of an educational intervention on nurses' self-reported knowledge and beliefs regarding HT.
Human trafficking, or modern-day slavery, is a global public health issue beyond comprehension. It is defined as “the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of force, fraud, or coercion” (Department of State, 2015, p. 7). Acts of trafficking have been documented across the globe and may involve any individual regardless of age, gender, race, religious affiliation, or socioeconomic status (Department of State, 2015).
The International Labour Organization (ILO, 2017) reports that approximately 40.3 million people are trafficked globally, with almost 25 million involved in forced labor and the other 15 million in forced marriages. Approximately 71% (28.7 million) of trafficked individuals are female; and one in four victims are children (ILO, 2017). Believed to be the third largest criminal enterprise in the world (Federal Bureau of Investigation, n.d.), it is hard to pinpoint exact statistics as a result of underreporting and the clandestine nature of the crime. The ILO reports illegal profits from forced labor to be close to $150 billion annually (ILO, 2014).
Fifty percent to 68% of trafficked individuals report visiting a health care provider (HCP) at some point during their period of captivity (Baldwin, Eisenman, Sayles, Ryan, & Chuang, 2011; Chisolm-Straker et al., 2016), with victims most commonly presenting in the emergency department or urgent care (56%) or the primary care setting (44%) (Chisolm-Straker et al., 2016). These individuals experience many acute and chronic, physical, and psychological health consequences secondary to being trafficked (NHTTAC, 2018). Victims may seek medical treatment as a result of physical abuse and injury, as well as undiagnosed or untreated chronic health conditions, sexually transmitted infections, or substance abuse (Shandro et al., 2016).
When seen by an HCP, patients were identified as being trafficked less than half (43%) of the time (Chisolm-Straker et al., 2016). This low detection rate could be a result of lack of HCP education or could stem from the victim not being ready or able to disclose their entrapment at the time of screening. Victims may not disclose out of fear of retaliation from their trafficker or lack of self-identification as a victim. Because signs and symptoms of trafficking and the health consequences may be nonspecific and attributed to other illnesses or disease processes (NHTTAC, 2018), it is critical that HCP education on HT pertain to identification and treatment (Shandro et al., 2016).
Lack of formal education for HCPs on identification and treatment of HT patient-victims is an issue. In a study conducted to evaluate knowledge in nurse practitioner students, 94.5% of participants (n = 73) reported no previous education on HT (Lutz, 2018). Researchers developed an educational intervention that included a PowerPoint® lecture, discussion, and embedded video that was delivered over a 1-hour long presentation. Survey results postimplementation demonstrated significantly higher scores (p < .001) in terms of HT knowledge immediately following the intervention (Lutz, 2018).
Comparatively, nearly all of the HCP participants (n = 180) in a second study reported never receiving formal training on the clinical presentation or appropriate treatment of trafficking victims (Chisolm-Straker et al., 2012). Less than 27% of these participants reported that HT is a problem seen in the emergency department, and almost 60% were unsure whether HT is a problem seen in the emergency department. Researchers thus evaluated the effect of a 20-minute didactic training session on the perceived comfort of HCPs in the identification, recognition, and treatment of HT victims in the emergency department. After the educational intervention, confidence in participants' (n = 104) ability to identify HT victims increased from 4.8% to 53.8% and from 7.7% to 56.7% in treating victims (Chisolm-Straker et al., 2012).
Grace et al. (2014) also found that an intervention in the form of an educational presentation was effective in quickly increasing emergency department provider recognition and knowledge of resources for HT victims. Participants (n = 141) who self-reported that they were “knowledgeable or very knowledgeable” increased from 7.2% to 59% postintervention. Knowledge of who to call if encountering an HT victim increased from 24% to 100%, and participants also reported an increase in the ability to identify victims from 17% to 28% (Grace et al., 2014).
Study Purpose and Design
This pilot study was conducted to determine the effect of an educational intervention on nurses' self-reported knowledge and beliefs regarding HT. A quasi-experimental, pretest–posttest design was used to evaluate the effectiveness of the intervention. This study was conducted as part of an educational conference on HT held at a public university in the Midwest.
The educational intervention, “Human Trafficking 101: A Practical Conference on Understanding the Issues and Responding to the Epidemic,” was a 4-hour conference delivered by experts on HT with backgrounds in nursing, law, and criminal justice. The nurse's objectives were to describe the dynamics of HT, recognize signs and symptoms of HT, describe how to communicate with an HT victim, and describe how to offer appropriate interdisciplinary resources. The attorney focused on differentiating myths and misconceptions from facts regarding HT, identifying strategies to raise awareness about HT, and recognizing methods of force, fraud, or coercion used by traffickers. Finally, an officer from Homeland Security presented on the following objectives: discuss the roles of law enforcement related to HT, and state the goals of Home-land Security Investigations Blue Campaign (Department of Homeland Security, n.d.). Each speaker delivered their presentation via PowerPoint and allowed time for the audience to ask questions. Participants received continuing education contact hours for attending the conference.
Protection of Human Subjects, Sample, and Setting
The study was conducted on the campus of a public university in the Midwest. Institutional review board approval was obtained prior to data collection. The study used a convenience sample as all nurses who attended the conference were eligible to participate. The study was explained to attendees and it was discussed that participation was voluntary. Informed consent was implied by completing the pretest survey, which included demographic data.
The researchers developed a 19-item survey instrument based on conference objectives to measure the knowledge and beliefs of nurses regarding HT. The conference presenters reviewed the survey instrument to ensure it measured the presenters' objectives, which established content validity of the tool. The Likert-style tool used response options ranging from 1 = strongly disagree to 5 = strongly agree on each item:
- Understand the difference between labor trafficking and sex trafficking.
- Understand the difference between prostitution and sex trafficking.
- Understand that someone who is employed against their will is an HT victim.
- Understand that someone who is employed by the use of fraud is an HT victim.
- Understand that someone who is employed by the use of coercion is an HT victim.
- Understand that men can be victims of HT.
- Belief that the participant knows someone who is at risk for becoming an HT victim.
- Belief that HT can happen in any community.
- Awareness of state laws pertaining to HT.
- Awareness of federal laws pertaining to HT.
- Understand the role of homeland security in fighting HT.
- Confidence in one's ability to identify a victim of sex trafficking.
- Confidence in one's ability to identify a victim of labor trafficking.
- Confidence in knowing how to assist a victim of human trafficking.
- Understand mandatory reporting processes related to HT.
- Awareness of resources to assist HT victims.
- Awareness of agencies fighting HT.
- Belief that participants can make a difference in the fight against HT.
- Participant plans to be actively involved in the fight against HT.
Data were entered into SPSS® version 25. Approximately 10% of surveys had missing data; one to three questions were not answered on either the pretest or the posttest. This random pattern of missing data was addressed using estimation based on the average scores from the other participants. Descriptive statistics were used to analyze sample characteristics. Correlational analysis was used to determine whether there was a relationship between any of the demographic variables and the items on the pretest survey. Reliability analysis of the pretest and posttest survey was conducted. Finally, paired sample t tests were calculated to compare each item on the pretest and posttest survey.
A total of 93 nurses participated in the study and completed both the pretest and posttest surveys; 92 (98.9%) identified as female and one (1.1%) identified as male. The majority of participants were 25 to 54 years old (n = 68; 73.1%) and White/Caucasian (n = 88; 94.6%). One third of participants worked for 20 years or more as a nurse (n = 31; 33.3%), followed by 1 to 5 years (n = 23; 24.7%) and 6 to 10 years (n = 16; 17.2%). The majority of participants worked in a hospital (n = 74; 79.6%) and were employed full time (n = 65; 69.9%). Most had a bachelor's degree in nursing (n = 66; 71%) and did not have prior HT education (n = 65; 69.9%).
The survey tool consisted of 19 items and was found to be highly reliable on both the pretest (α = .90) and posttest (α = .81). No significant correlations were found between demographic variables and the pretest data. The paired sample t test results showed a significant change (p < .001) from pretest to posttest for 17 of 19 items on the survey, suggesting that the educational intervention was successful in improving the nurses' knowledge and beliefs regarding human trafficking. Table 1 provides the complete results.
Results of Pre- and Postsurveys and Paired Sample t Tests Comparing the Pretest and Posttest Scores on Each Item of the Survey
The results of this study indicate that the educational conference was an effective method to enhance the knowledge and beliefs of RNs regarding HT. Through this conference, nurses developed a better understanding of the definition of HT, the differences between labor trafficking and sex trafficking, and who is at risk of becoming an HT victim. In addition, nurses gained an increased awareness of state and federal laws pertaining to HT, as well as resources available to help HT victims. Furthermore, the nurses reported an increased confidence in their ability to identify trafficked individuals and how to assist HT patient-victims.
One survey item that did not show a significant change from pretest to posttest was the belief that HT can happen in any community. Upon analyzing this question further, the researchers agreed that this item was confusing as written and should be revised. The other item that did not have a significant change from pretest to posttest was that the participant plans to be actively involved in the fight against HT. The purpose of the educational intervention was to improve knowledge and beliefs of nurses regarding HT so nurses are better prepared to help HT patient-victims. This purpose was achieved; however, a change in knowledge and beliefs does not necessarily result in a plan to be more actively engaged in the fight against HT. The researchers may consider revising this item to better align with the conference purpose or revising future educational conferences to include more information about how to get involved and help in the fight against HT.
A study limitation was the small sample size and homogenous demographics; therefore, the results cannot be generalized to the larger population of nurses. Also, it is unknown whether the increased knowledge and beliefs translate into behavior changes in the practice of nurses and whether this will be a lasting change. Future research should include a larger, more diverse sample, as well as a longitudinal study to determine whether the results outlined in this study are lasting. Moreover, replication of the exact educational intervention may be difficult. Standardization of the educational intervention, curriculum, and evaluation method would be helpful in future studies. In addition, studies that determine whether the educational intervention results in a change in nursing practice are needed.
Nurses are in a unique position to address the public health crisis of HT. In order for nurses to meet this professional responsibility, health care institutions must have a standardized approach, or response protocol, that thoroughly outlines the actions of employees when encountering HT victims (NHTTAC, 2018). Macias-Konstantopoulos (2016) recommended agencies first develop a policy on the screening, identification, and management of trafficked individuals following national best practices. To support HCPs and patients, the health care institution must also have internal and external resources and partnerships to best meet the multifaceted needs of trafficking victims. A plan of action should be developed addressing steps toward meeting the needs of patient-victims. Nurses and other staff must receive education on identification, recognition of needs, and knowledge of resources. Finally, the health care institution must monitor and evaluate the effectiveness of their plan of action and staff education (Macias-Konstantopoulos, 2016).
Nursing is not alone in its professional mandate to help trafficked individuals; HCPs, social service workers, truck drivers, and countless others are part of the crusade to fight HT. This study found that an educational conference was instrumental in enhancing the knowledge and beliefs of nurses regarding HT. This same intervention could be repeated for other HCPs and those in other disciplines where HT education is part of their professional responsibility. Regardless of the format, evaluation of the impact of the educational intervention is necessary to ensure that the offering meets the needs of the participants and that of patient-victims. Further, the survey instrument developed and used in this current study would be a useful tool to measure this impact. Supporting continuing education and evaluation of outcome attainment is one way that nurses, researchers, and educators can take an active role in addressing the HT epidemic.
- Ahn, R., Alpert, E.J., Purcell, G., Konstantopoulos, W.M., McGahan, A., Cafferty, E. & Burke, T.F. (2013). Human trafficking: Review of educational resources for health professionals. American Journal of Preventative Medicine, 44, 283–289. doi:10.1016/j.amepre.2012.10.025 [CrossRef]
- American Nurses Association. (2016). The nurse's role in ethics and human rights: Protecting and promoting individual worth, dignity, and human rights in practice settings. Retrieved from https://www.nursingworld.org/~4af078/globalassets/docs/ana/ethics/ethics-and-human-rights-protecting-and-promoting-final-formatted-20161130.pdf
- Baldwin, S.B., Eisenman, D.P., Sayles, J.N., Ryan, G. & Chuang, K.S. (2011). Identification of human trafficking victims in health care settings. Health and Human Rights, 13, E36–E49.
- Chisolm-Straker, M., Baldwin, S., Gaïgbé-Togbé, B., Ndukwe, N., Johnson, P.N. & Richardson, L.D. (2016). Health care and human trafficking: We are seeing the unseen. Journal of Health Care for the Poor and Underserved, 27, 1220–1233. doi:10.1353/hpu.2016.0131 [CrossRef]
- Chisolm-Straker, M., Richardson, L.D. & Cossio, T. (2012). Combating slavery in the 21st century: The role of emergency medicine. Journal of Health Care for the Poor and Underserved, 23, 980–987. doi:10.1353/hpu.2012.0091 [CrossRef]
- Department of Homeland Security. (n.d.). Blue campaign. Retrieved from https://www.dhs.gov/blue-campaign
- Department of Licensing and Regulatory Affairs. (n.d.). Board of nursing: General rules. Retrieved from http://dmbinternet.state.mi.us/DMB/ORRDocs/AdminCode/1712_2017-037LR_AdminCode.pdf
- Department of State. (2015). Trafficking in persons report: July 2015. Retrieved from https://www.state.gov/documents/organization/245365.pdf
- Federal Bureau of Investigation. (n.d.). Human trafficking/involuntary servitude. Retrieved from https://www.fbi.gov/investigate/civil-rights/human-trafficking
- Grace, A.M., Lippert, S., Collins, K., Pineda, N., Tolani, A., Walker, R. & Horwitz, S.M. (2014). Educating health care professionals on human trafficking. Pediatric Emergency Care, 30, 856–861. doi:10.1097/PEC.0000000000000287 [CrossRef]
- International Council of Nurses. (2011). Nurses and human rights. Retrieved from https://www.icn.ch/sites/default/files/inline-files/E10_Nurses_Human_Rights%281%29.pdf
- International Labour Organization. (2014). Profits and poverty: The economics of forced labour. Geneva, Switzerland: ILO Publications.
- International Labour Organization. (2017). Global estimate of modern slavery: Forced labour and forced marriage. Geneva, Switzerland: ILO Publications.
- Lutz, R.M. (2018). Human trafficking education for nurse practitioners: Integration into standard curriculum. Nurse Education Today, 61, 66–69. doi:10.1016/j.nedt.2017.11.015 [CrossRef]
- Macias-Konstantopoulos, W. (2016). Human trafficking: The role of medicine in interrupting the cycle of abuse and violence. Annals of Internal Medicine, 165, 582–588. doi:10.7326/M16-0094 [CrossRef]
- National Human Trafficking Training and Technical Assistance Center. (2018). Adult human trafficking screening tool and guide. Retrieved from https://www.acf.hhs.gov/sites/default/files/otip/adult_human_trafficking_screening_tool_and_guide.pdf
- Patel, R.B., Ahn, R. & Burke, T.F. (2010). Human trafficking in the emergency department. Western Journal of Emergency Medicine, 11, 402–404.
- Shandro, J., Chisholm-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, 501–508. doi:10.1016/j.annemergmed.2016.03.049 [CrossRef]
Results of Pre- and Postsurveys and Paired Sample t Tests Comparing the Pretest and Posttest Scores on Each Item of the Survey
|1||Pre: difference between labor and sex trafficking||3.49||1.090||0.113||−12.120||92||.000|
|Post: difference between labor and sex trafficking||4.88||0.325||0.034|
|2||Pre: difference between prostitution and sex trafficking||3.81||0.900||0.093||−7.346||92||.000|
|Post: difference between prostitution and sex trafficking||4.62||0.641||0.066|
|3||Pre: employed against will||4.20||0.745||0.077||−5.504||92||.000|
|Post: employed against will||4.72||0.728||0.075|
|4||Pre: employed using fraud||4.14||0.802||0.083||−8.068||92||.000|
|Post: employed using fraud||4.87||0.337||0.035|
|5||Pre: employed using coercion||4.28||0.743||0.077||−5.046||92||.000|
|Post: employed using coercion||4.82||0.642||0.067|
|6||Pre: men as victims||4.60||0.809||0.084||3.552||92||.001|
|Post: men as victims||4.91||0.458||0.048|
|7||Pre: know someone at risk||4.03||1.047||0.109||−5.259||92||.000|
|Post: know someone at risk||4.58||0.742||0.077|
|8||Pre: labor trafficking in my community||4.29||0.815||0.085||−2.634||92||.010|
|Post: labor trafficking in my community||4.61||0.873||0.090|
|9||Pre: state laws||2.28||0.960||0.100||−16.707||92||.000|
|Post: state laws||4.00||0.643||0.067|
|10||Pre: federal laws||2.26||0.954||0.099||−17.898||92||.000|
|Post: federal laws||4.09||0.637||0.066|
|11||Pre: homeland security||2.42||1.067||0.111||−16.220||92||.000|
|Post: homeland security||4.34||0.542||0.056|
|12||Pre: identify sex trafficking victim||2.45||0.903||0.094||−14.352||92||.000|
|Post: identify sex trafficking victim||3.74||0.690||0.072|
|13||Pre: identify labor trafficking victim||2.37||0.870||0.090||−13.403||92||.000|
|Post: identify labor trafficking victim||3.70||0.734||0.076|
|14||Pre: assist victims||2.39||1.011||0.105||−14.134||92||.000|
|Post: assist victims||3.98||0.780||0.081|
|15||Pre: mandatory reporting processes||2.89||1.255||0.130||−10.469||92||.000|
|Post: mandatory reporting processes||4.26||0.736||0.076|
|16||Pre: resources to assist victims||2.44||1.047||0.109||−14.142||92||.000|
|Post: resources to assist victims||4.18||0.751||0.078|
|17||Pre: agencies fighting human trafficking||2.46||1.069||0.111||−16.780||92||.000|
|Post: agencies fighting human trafficking||4.38||0.569||0.059|
|18||Pre: make a difference in human trafficking||3.98||0.932||0.097||−3.848||92||.000|
|Post: make a difference in human trafficking||4.35||0.583||0.060|
|19||Pre: get involved in anti-human trafficking efforts||4.16||0.838||0.087||−2.417||92||.018|
|Post: get involved in anti-human trafficking efforts||4.37||0.688||0.071|