Jeremy is a second year resident who is about to see a 25 year old female presenting with abdominal pain. During the history he notices the patient is remarkably quiet and that the patient’s male friend is answering all the questions for her. When Jeremy asks the male friend to leave the room for a moment, both the patient and the friend object. Jeremy starts wondering if this patient might be a victim of human trafficking. He wishes there was a resource he could consult to better learn about identifying patients of human trafficking.
This Feature Educational Innovation (FEI), titled, “Human Trafficking Awareness: A Learning Module for Improved Recognition of Victims in the Emergency Room” was originally posted by the CAEP EWG FEI Team in 2017 and answers the question: “How can we improve recognition and assistance to patients who are victims of human trafficking?” A PDF version is available.
Human trafficking is defined by the United Nations as the “recruitment, transportation, transfer, harboring, or receipt of persons by improper means […] for an improper purpose including forced labor or sexual exploitation”.1 In Canada, human trafficking takes place in the forms of sexual exploitation, labour trafficking, and organ trafficking.2 Although there has been increased awareness on the prevalence of trafficking in Canada, there continues to be a lack of recognition of victims when they present to the emergency room.2
Emergency physicians and staff are in a special position to help victims of human trafficking as the urgent care setting often offers the only opportunity for victims to seek help.2 In the United States, studies have found that over 80 percent of victims come into contact with health care professionals while under the control of the trafficker.3,4 Although physicians are trained to recognize child abuse and intimate partner violence, there is no routine education regarding identifying trafficking victims.5
A study in the United States interviewed trafficking victims in shelters where they learned that in addition to not being identified as needing help, the victims reported being hurt and humiliated by physicians during their encounter in the emergency room.3 Simple training modules, some as short as 20 minutes, have been shown to have a significant impact on physicians’ abilities to recognize and provide appropriate care to victims.3,6 Identifying this need for increased awareness in the urgent care setting, a module on human trafficking was implemented into the undergraduate medical education and departmental grand rounds at the University of Alberta.
The undergraduate medical curriculum at the University of Alberta was reviewed and identified no learning objectives pertaining to human trafficking as part of the curriculum mapping. A literature review assessing the need for awareness in emergency departments and the effectiveness of training modules on human trafficking was then completed. A one-hour lecture presented by ACT Alberta, a local organization that raises awareness and aids victims of human trafficking, was provided to medical students across all four years as a part of the Physicianship Longitudinal Themes course curriculum, a series of lectures and small group learning throughout all four years of the medical program covering topics pertaining to professionalism, cultural competency, ethics, clinical skills, and health systems.7 The lecture was also presented to residents and staff in the Department of Pediatrics grand rounds as a part of Faculty development. The session met the following learning objectives:
•Define human trafficking
•Understand the prevalence of human trafficking in Canada
• Recognize red flags
• Identify high risk demographics
• Discuss the protocol for aiding identified victims in an urgent care setting
• Become familiar with local organizations assisting victims
Additionally, an online module from Fraser Health was made available as an additional resource with case studies specific to the emergency room. Undergraduate medical students completed surveys prior to and following the learning module to evaluate improvement in acquired knowledge.
Medical students completed surveys consisting of 15 questions assessing knowledge on trafficking and opinions towards the need for this material to be introduced into the curriculum. The questions were a combination of a Likert scale, multiple choice, and short answer. There were 162 student respondents for the pre-lecture survey and 86 for the post-lecture survey. Although 69 percent of respondents agreed that human trafficking should be part of their medical education in the pre-lecture group, there was a significant increase in responses towards “strongly agree” in the post-lecture cohort and an overall 93 percent who agreed it should be part of the curriculum. Additionally, the post-lecture survey showed increased recognition in the prevalence of labour trafficking, in place of the former assumption that all trafficking victims were being sexually exploited. There was also greater identification that the majority of victims in Canada are Canadians as opposed to immigrants and refugees. When asked to list red flags for identifying a victim and to list health needs of a trafficked person, 64 percent of students responded as “unsure” compared to 18 percent in the post-lecture cohort. Out of those who responded with lists, there was improved recognition of the biological, psychological, and social health needs.
Implementation of a novel educational human trafficking lecture for healthcare professionals demonstrated improved knowledge on the topic of human trafficking, enhanced recognition of red flags in the urgent care setting, and increased awareness of subsequent steps in providing appropriate care. This program can similarly be implemented in other centres across Canada and could translate to higher rates of victim recognition and increased support for this vulnerable population.
When providing human trafficking screening education, one of the challenges is overcoming the lack of accurate statistics on prevalence in the emergency room. Exact numbers are difficult to assess as many victims are not being identified during visits to the ED. Additionally, statistics on human trafficking overall are inaccurate due to the number of unreported cases and furthermore when reported many traffickers are often charged with other crimes given the underdeveloped legal action against trafficking in Canada.8 Although there have been some studies to develop evidence based screening questions, further studies are being completed in Canada to provide additional evidence based screening tools and to explore the impact on patients.
Medical personnel may come into contact with victims of human trafficking and therefore, it is important that they are aware of how to screen and respond to trafficking cases.2 Although there is limited data on awareness amongst Canadian emergency physicians and other healthcare professionals, data from studies in the United States and the United Kingdom demonstrate that the majority of emergency physicians are not confident in identifying victims and are uncomfortable with the ways to provide adequate treatment.3,5–7 Additionally, after discussing the issue with local organizations assisting victims, it is clear that their clients’ health needs are not being met when they present to the emergency department.7 Implementation of brief training modules on human trafficking awareness can increase the rate of recognition and ultimately result in improved care.9 Future studies will continue to develop evidence based screening tools for human trafficking victims.
Does your institution have resources to help trainees learn about human trafficking in the Emergency Department?
How else can we ensure trainees have the awareness to recognize and manage patients that are victims of human trafficking?
More about CAEP FEI
This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.