Title: Identifying Human Trafficking Victims in the Emergency Room: - - PDF document

Title: Identifying Human Trafficking Victims in the Emergency Room: An Evaluation of an Identification Protocol Pilot Project for Front-Line Healthcare Providers Authors: Arduizur Carli Richie-Zavaleta, DrPH, MASP, MAIPS1; Teresita Hinnegan, MMS2; Nora Kramer, MSN, RN3; Anh Hua, MPA4; Anand Petigara, MSW4, Jeffrey Turner, MPH5; Stephan McDonald, MSN, RN6, & Joseph Anton6 Institutions:

• 1. Drexel University Dornsife School of Public Health & the University of New England

Online College of Graduate and Professional Studies

• 2. Center for the Empowerment of Women
• 3. Thomas Jefferson University Hospital Department of Nursing
• 4. Nationalities Service Center
• 5. Public Health Management Corporation Research
• 6. Thomas Jefferson University Hospital Emergency Department

Contacts: (Protocol) Anh Hua email: ahua@nscphila.org (Other inquiries) A. Carli Richie-Zavaleta arichiezavaleta@une.edu Abstract: Human Trafficking (HT) is defined as Modern Day Slavery. In the United States (US), HT is manifested mainly through sex and labor trafficking. Most sex trafficking victims are primarily US-natives and females. Although HT is a hidden crime, its victims at times seek medical care. However, many are unidentified due to a lack of training and identification protocols within healthcare settings. Literature on training of and identification-protocols for use by healthcare providers (HCP) are scant. Therefore, this pilot project evaluation aimed to assess providers’ confidence levels after attaining training on different areas of HT, and usefulness of an identification-protocol designed to facilitate victim detection and referral. This pilot-project was implemented at Thomas Jefferson University Hospital in Philadelphia, PA, among Emergency Department front-line personnel between January-August, 2016. Its evaluation used a single-group semi-time series design (0 X 0 0) as well as mixed-methods. Pre and post-tests were imparted at the initial time of training (N=12), followed by a post-test at 3- months (N=9). Analysis for quantitative data used a Paired Sample T-Test with a P < .05. Semi- structured interviews followed post-test assessment (N=3) and were analyzed using a thematic

• approach. Triangulation of data was accomplished by comparing QUAN and QUAL data sets

and member checking during preliminary data findings.

Richie-Zavlaeta, et al., 2 This pilot project’s findings suggest: 1) Increased confidence levels among healthcare providers trained in different areas related to HT; 2) Reliance on tools designed to screen, assess, and refer potential HT victims; and 3) Improved HCP efficacy when using the noted protocol. Training and screening protocols are essential in order to identify HT victims in healthcare settings. More multi-site time-series evaluation designs on trainings and identification-protocols are therefore needed. Terms and Definitions:

• 1. Front-Line Personnel: These are the healthcare providers who are ultimately responsible to

guide the potential victim through the established human trafficking protocols. They can be a frontline staff or any other health care provider. They are the most critical staff for the recommended protocol to be successful.

• 2. Front-Line Healthcare Personnel Trafficking In Person Protocol (FLHP-TIP): It is an

identification protocol intended to assist healthcare providers and front-line personnel to identify, assist and refer victims of HT at any given healthcare setting.

• 3. Human Trafficking (HT): It is defined by the recruitment, harboring, transportation,

provision or obtaining of a person for the purposes of commercial sex act, labor or services, through the use of force, fraud, or coercion.

• 4. Philadelphia Anti-Trafficking Coalition (PATC): An affiliation of social service,

government, and law enforcement agencies dedicated to combating the issue of human trafficking in the Philadelphia area.

• 5. Point of Entry: It is any healthcare setting where injured or sick persons go to receive health

and/or urgent care. They are the following: Hospital Emergency Room, Freestanding Clinic/Center, Urgent Care Centers and Municipal, State or Federal Health Clinics, Mental Clinics or Hospitals or Pharmacies.

• 6. Point-Person: The key trained personnel within the healthcare setting who posses a more in-

depth understanding, confidence and skills of how to identify, assist and refer a victim of Human

• Trafficking. He or she is the “to-go” person during any given shift when any other staff or

healthcare provider identifies potential red flags or human trafficking victimization in a patient.

Richie-Zavlaeta, et al., 3 Aims: This pilot project’s evaluation aimed to understand:

• 1. Confident levels of participants after undergoing its training on different areas of HT
• 2. Identify usefulness of the identification-protocol to identify and refer HT victims.
• 3. Gathered recommendations to improve the training and identification protocol.

Purposes of the Evaluation: PATC members developed the FLHP-TIP Protocol steps based on personal experiences working with trafficked victims and research and reports that have been published by other experts in the

• field. The team requested an evaluation of the pilot project to assess the impact of the protocol

steps in helping healthcare staff in identifying potential victims of trafficking and to assess the effectiveness of the training for healthcare staff. The evaluation was carried out at Thomas Jefferson University Hospital’s Emergency Department, where the pilot project took place. The results of the evaluation would be used to provide recommendations for healthcare settings in developing human trafficking protocol and training for their staff. An MSW student at UPenn, an Evaluation Program Manager at PHMC, and a PhD in Public Health Candidate at Drexel University in consultation with the PATC members developed the

• evaluation. Due to constraint in funding, an independent evaluation was not obtained; the

evaluation was implemented by those we were involved in the implementation of the pilot project. Evaluation Design & Methods: This evaluation design was based on mixed-methods approach. This type of design allows for greater comprehension of participants perspectives and context (Turner, Cardinal, & Burton, 2015). In this evaluation design, the evaluation team collected both types of data—qualitative and quantitative (Creswell, et al., 2004). This design also allows for triangulation of data as the two types of data increase understanding and confirmation of themes likely to emerge. This mixed-method design also allows for the potential emergence of different dimensions stemming from the evaluation objectives being pursued. The mixed-method design of this evaluation followed a Sequential QUANTITATIVE-qualitative (QUAN-qual) methodology with greater weight on the Quantitative data. Quantitative data informed qualitative instruments. The quantitative methodology included pre and post-training assessments at the initial time of in-depth 2 hour training implementation, followed by post-test at 3-months after implementation of

• training. It also included the creation of a protocol to identify and assess potential victims
• f HT at the ED. The training included the presentation and explanation of the protocol to

participants of the ED. Some of the limitations of this evaluation design were the following:

Richie-Zavlaeta, et al., 4

• 1. It did not cover enough timeframe to observe if there were any changes of

the knowledge and efficacy of the participants within a longer period of time; for example, 12-months after training.

• 2. The qualitative data was limited by the lack of participation on the Non-

Point Person staff that participated at the initial time of the training.

• 3. During the 3-month follow-up post-test there was attrition. Some initial

participants were not longer employed by the hospital. There are definitely some possible confounding issues. One of them is the exposure to mass media and other sources of communication and information that could have influenced the participants’ knowledge and awareness about the issue of human

• trafficking. A way to address this type of confounding issues is by implementing a multi-

series evaluation design over a longer timeframe period. However, this was not possible for this pilot-project given the limited time available and the limited resources to accomplish such evaluation design. Therefore, a sequential QUAN-qual evaluation design was the best approach for this small pilot-project. This design provides both the initial time of training implementation followed by a 3-month measure and interviews that allow for a richer context and provide a greater comprehension and triangulation of data. Outcome Measures: Instruments

• 1. A 2-hour in-depth training was used to raise awareness and

knowledge of the ED healthcare personnel who wanted to become Point-Person—nurses, administrators, counselors, interns and security guards—on the concepts, laws, definitions, processes of how victims become trapped, and illustrations different cases of human trafficking in the US.

• 2. The presentation also included the protocol as well as resources for

the participants to use when they would encounter a potential victim (See Figure 1).

• 3. A shorter presentation was also used to share with the rest ED staff

who participated 3-months after the initial training.

• 4. More electronic materials were provided to all participants—Point

Person and General ED staff. These included: articles, video clips, and power point presentations with the goal of accessibility and reaffirming the knowledge gain through the trainings.

• 5. In order to measure the outcomes of the pilot-project, two

assessment surveys were developed by the group of volunteers who represent the work of the Philadelphia Anti-Trafficking Coalition’s Health Task. This group included graduate research students, evaluators, healthcare and social service providers, and interns

Richie-Zavlaeta, et al., 5

• 6. Lastly, two semi-structure interview questionnaires were

formulated; one for Point-Person participants and non-Point- Person participants.

Figure 1—Front-Line Personnel Protocol for the Identification of Trafficking in Persons Victim at any Healthcare Setting or Point or Entry.

Data collection procedures

• 7. At the initial time of the implementation of the training, a short-

survey was distributed to all initial participants for the Point- Person group—pre-assessment survey (N=12).

• 8. After training, a post-assessment survey also distributed to

measure their knowledge, awareness and self-perception of their ability to identify a potential victim.

• 9. An only 3-month follow-up assessment was also distributed via
• nline (N=9).
• 10. During the month of June—August of same year, three semi-

structured interviews were conducted. The interviews were recorded and then transcribed verbatim. Participants gave a fictitious name of their choice and were also assigned a randomized number to keep their identity confidential e.g. Rosie #221.

• 11. There was also a report given to the PATC team of those who were

identified as potential victims after the training was implemented.

• 12. Last, but not least, there was also communication between the

PATC team and the national hot line personnel to see if pilot-

Richie-Zavlaeta, et al., 6 project participants at the ED used the national 800 number as a resource to assist potential victims who came to their setting. Implementation Measures: Instruments and data collection approaches used

• A. The instruments for the evaluation of the pilot project were surveys.

They were a total of surveys (pre and post-assessments for the initial training and the post-assessment for the 3-month follow-up). These evaluation instruments were put together by the evaluation team who included an evaluator and graduate students in the field of public

• health. social work and policy. The questions and constructs were also

based and developed on previous research findings (Chisolm-Straker, 2007; Dovydaitis, 2010; Turner, Cardinal, & Burton, 2015; Vera Institute of Justice, 2014). The surveys were then assessed and gained face-validity by the rest of the team who included—healthcare, and social service providers who have an extensive decades of training in their fields and are aware of the both the need for healthcare training in identification of HT victims and the complexities of HT. The surveys were created in both online format and hard-copies. Both forms were tested through the team members. Recommendations and edits were made after the testing of the assessment instruments.

• B. For the qualitative data, the guiding questions were designed for those

who actively became PPs and those who decided not to become PPs after the training. The guiding questions were designed by the evalution team. These questions covered three main areas of analysis: 1) Experience on the using the protocol; 2) their opinions on the protocol, process of application of the protocol, and recommendations

• n how to improve the training, protocol, or any other aspect of the

pilot project, and 3) knowledge on their decision process to become PPs Data collection procedures—

• A. The evaluation data collection for the PP group was collected in the

month of January, 2016. The 3-month assessment link was sent to the participants via email in the month of April 2016. Several reminders were sent to the participants. Some of the initial participants were no longer employees of Jefferson hospital; therefore there was attrition of some of the initial participants during the follow-up face.

• B. For the qualitative interviews, the evaluation team invited all

participants who were in the initial PP training starting in the months

• f April-August, 2016. Only three interviewees were able to
• participate. The interviews were digitally recorded and then

transcribed verbatim. Consent forms were provided to participants before the interview. In order to keep participants confidential, they

Richie-Zavlaeta, et al., 7 choose pseudo names and randomized numbers were also assigned; for example, Rossie #222. Recommendations: Evaluation

• 1. A larger sample and multiple sites are needed to evaluate the

Front-Line identification protocol’s ability to train and provide enough tools for the identification and the assistance of victims of HT who attend their medical needs in an Emergency Department. Training

• 2. Expand the HT and the Front-Line Identification Protocol training

to all ED staff and healthcare providers and other departments within the hospital that are may encounter potential victims.

• 3. Have the training in an online format and as a required course.
• 4. Provide refreshers to Point-Persons
• 5. Training to include survivors’ stories at the healthcare setting

Point- Person at Hospital

• 6. Have a Point-Person at all shifts.