Human Trafficking Education for Emergency Department Providers

Many trafficked persons receive medical care in the Emergency Department (ED); however, ED staff have historically not been educated about human trafficking. In this article, we describe interventions aimed to train ED providers on the issue of trafficking. We performed a scoping review of the existing literature and found 17 studies that describe such interventions: 14 trainings implemented in the ED, two taught at conferences for ED providers, and one assessing a statemandated training. These studies demonstrate that even brief education can improve provider confidence in screening and treating patients that experienced trafficking. We advocate for interventions to promote a team-based approach specific to the ED setting, acknowledge the importance of survivors’ input on curriculum development, and assess outcomes using preand post-surveys.


Introduction
Human trafficking is a problem both worldwide and in the United States (US) 1 and it can cause a variety of health issues for survivors. Trafficking survivors are at high risk of mental health issues like complex post-traumatic stress disorder (PTSD), substance use disorders, and self-harm due to repeated exposure to unpredictable physical and psychological violence. Trafficking survivors also suffer higher rates of injury, untreated chronic conditions, undesired pregnancies, and sexually 1 'Forced Labour, Modern Slavery and Human Trafficking', International Labour Organization, 2014, retrieved 18 October 2020, https://www.ilo.org/global/topics/ forced-labour/lang--en/index.htm. transmitted infections (STIs). 2 Since trafficking relies on secrecy and isolation, it is common for trafficked persons to come into contact with professional services only when they visit a healthcare provider. 3 Therefore, medical visits offer an opportunity for trafficked persons to receive much-needed medical assistance, as well as other resources for their complex psychosocial needs. 4 ED personnel have historically not received adequate education and training about trafficking. 9 Doctors, nurses, and other healthcare workers in the ED are often ill-equipped to recognise trafficked persons, screen them, or refer them to appropriate services. This lack of education and training contributes significantly to negative health outcomes for this population. 10 A recent systematic review of human trafficking educational interventions demonstrated that educating healthcare providers can improve their confidence and the care they deliver to trafficked patients. 11 Despite this evidence and the disproportionately high use of the ED by trafficked persons, there has been no thorough review of educational interventions on trafficking for ED providers. A review is necessary to determine how ED providers are currently educated about trafficking and where the gaps lie in training.
This article provides a scoping review of the literature on trafficking educational interventions for ED providers. We describe the interventions, summarise common themes among them, and discuss our recommendations for future educational tools, as well as describe opportunities for future research.

Methodology
We utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) 12 to conduct a scoping review. We chose a scoping review because our objective was to explore the existing literature on a topic that has not been reviewed in either a scoping or systematic protocol, rather than to systematically evaluate and compare current 9 P Arulrajah and S Steele, 'UK Medical Education on Human Trafficking: Assessing uptake of the opportunity to shape awareness, safeguarding and referral in the curriculum ', BMC Med Educ, vol. 18, issue 1, 2018, article no. 137, https://doi. org/10.1186/s12909-018-1226-y.

Research Question
The objective of this study was to investigate evidence addressing the research question: 'What studies exist in the current literature that aim to educate ED providers on the issue of human trafficking?'

Study Identification
We searched the following databases from their inception until 2 November 2020: MEDLINE/PubMed, Ovid EMBASE, CINAHL, ERIC, MedEdPortal, Sociological Abstracts, and Academic Search Complete. The search strategies were drafted by first author Shadowen and further refined through discussion with an experienced academic librarian. We piloted the search in MEDLINE and included the following terms: ('Human Trafficking'[MeSH] OR human trafficking OR sex trafficking) AND ('Emergency Service, Hospital'[MeSH] OR 'Emergency Medical Services'[MeSH] OR 'ED' OR 'emergency department' OR 'emergency room'). Terms were subsequently adapted to and searched in each of the included databases. A total of 757 records were identified. These references were exported into EndNote. After first author Shadowen removed duplicates, 493 unique publications remained.
As a secondary source, we searched Google Scholar from the inception of the database through 5 April 2021. First, the search included the following terms [allintitle: (education OR training) AND ("human trafficking") AND ("emergency department" OR "ED")]. Two results were identified. Next, we searched (allintitle: [education OR training] AND ["human trafficking"]). As a result of this search, 107 results were identified.

Study Selection
We used the following inclusion criteria to determine if the articles were eligible for final selection: (1) performed on human subjects; (2) related to human trafficking; (3) included an educational intervention specific to US-based ED healthcare professionals; and (4) published in English. We screened article titles 13 A systematic review is a method of research synthesis that utilises a structured protocol of retrieving and evaluating current literature to answer a research question, thereby minimising bias. A scoping review, while still considered rigorous, aims more so to evaluate gaps in knowledge in the current literature regarding a specific topic, often with the goal of acting as a precursor for a future systematic review. See Z Munn, et al., 'Systematic Review or Scoping Review? Guidance for authors when choosing between a systematic or scoping review approach ', BMC Med Res Methodol, vol. 18, 2018, article 143, https://doi.org/10.1186 and abstracts of the 602 publications that remained after our database search and excluded 557 articles because they did not meet the above criteria.
Some systematic review papers include snowballing of citations, which is when authors use a paper's citation or reference list to find additional relevant papers for the current review. 14 This approach can be considered when results from a primary literature search are especially limited. Since we determined our primary and secondary searches to be adequately exhaustive, and our research team had limited resources, we chose not to perform snowballing of citations for this paper.
Authors Shadowen and Beaverson completed a full-text review for the remaining 45 articles based on the same criteria listed above. After the full-text review, 28 additional articles were excluded, and 17 articles remained.

Data Extraction
During the full-text review, the research team extracted the following information from each of the 17 included articles: citation information; article objective(s); clinical setting (e.g., urban versus rural hospital or annual patient census); description of educational intervention (e.g., time requirement or in-person versus virtual); outcomes (if measured); and unique features of each. We used a spreadsheet to track the information abstracted for each study. We decided not to assess the quality of each study using any standardised quality measure because our study was exploratory in nature and aimed to describe the existing literature on this topic and gaps therein, rather than to describe or compare the academic rigor of each study.

Findings
Overall, our scoping review yielded 17 articles describing the results of an educational intervention on human trafficking for ED providers. We summarise these studies in chronological order. 14 C Wohlin, 'Guidelines for Snowballing in Systematic Literature Studies and a Replication in Software Engineering', Proceedings of the 18th International Conference on Evaluation and Assessment in Software Engineering, Blekinge Institute of Technology, https://www.wohlin.eu/ease14.pdf. Interventions were shown to be quite effective overall in improving providerreported knowledge and confidence. All studies but one ( Pre-tests demonstrated a general lack of previous training on trafficking, with up to 98 per cent (Chisolm-Straker et al., 2012) and 100 per cent (Cosgrove) of participants reporting they had never received formal training on the topic. Pretest confidence was quite low amongst most participants: 15 per cent of Ford's nursing cohort indicated confidence identifying trafficked persons, and Cosgrove's participants rated their confidence a mean of 1.65 on a 5-point Likert scale, with 5 being highest confidence.
All but one of the studies (Cummings) that assessed post-survey knowledge or confidence found significant improvement post-intervention. For example, Donahue's pre-test indicated that less than 50 per cent of participants had a comprehensive understanding of trafficking, while post-test results increased to 93 per cent. In that same study, overall confidence in treating trafficked persons was 4/10 pre-test and increased to 8/10 post-test. By contrast, Cummings postulated that the lack of significant improvement post-intervention among its participants could have been due to high levels of knowledge prior to the intervention.
In addition to assessing outcomes of an intervention on providers, several studies evaluated the Electronic Medical Record (EMR) to investigate impacts on patients. Derr evaluated the EMR for 12 months after the intervention, finding nearly 100 cases of possible physical abuse, sexual abuse, or exploitation. Cosgrove evaluated the EMR for six months post-intervention and did not identify any suspected trafficked persons. Egyud evaluated the EMR for five months post-intervention and identified 38 potential victims. Sakamoto assessed the EMR for four months and found two suspected trafficked persons.
Several studies included an extra component to aid staff in making necessary changes to their clinical care for suspected trafficked patients. Lamb provided participants with a card to attach to their ID badge with key local resources to share with patients. Sakamoto's and Greiner-Weinstein's clinical participants were given a smartphrase (an abbreviation that inserts a pre-programmed paragraph of written content into the note) or recording protocol to help with patient documentation in the EMR. The SANE participants in Noyes' study were provided with a validated victim identification tool to use when screening patients after their training. The hospital where Derr's study took place was provided with posters to hang in the ED that included local resources written on pull tabs for patients to take as needed.

Discussion
Our literature review demonstrated that all but one study assessed outcomes of a human trafficking educational intervention, demonstrating that training increased provider comfort with recognising and treating trafficked persons. Furthermore, several studies investigated patient outcomes, illuminating increased identification of and resource provision for patients post-intervention. Though there is a dearth of studies describing and evaluating human trafficking trainings for ED providers, even brief educational initiatives-especially those tailored to the unique physical and logistical constraints of an ED and informed by survivors-can improve awareness of and clinical competence in this critical area. Trafficking education has historically not been integrated into training for ED personnel and, consequently, staff have had limited confidence in their ability to address the issue. There is no evidence to our knowledge of any of the reviewed approaches being superior to the others, and comparative studies have not yet been conducted. Further research is needed to compare and validate these ED-specific educational interventions to close gaps in the current literature.
Though we found an overall lack of peer-reviewed studies on the topic of human trafficking education for ED providers, there has been increased awareness in recent years, with studies emerging in the 'grey literature' in the form of poster presentations and theses. These data support the ED as a critical place of opportunity to engage with trafficked persons in care, as well as the notion that when ED providers feel knowledgeable about how to triage and treat trafficked persons, these patients' medical care improves. where providers should receive training to give comprehensive, non-judgmental care. 28 When patients feel that they are in a safe and non-biased environment, they may be more comfortable to speak about their situation and ask for resources. 29 While the goal of treatment of trafficked patients is not to force disclosure, it is imperative for ED providers to create an atmosphere of support and expertise to optimise patient interactions. Comprehensive training can increase confidence and the ability to produce a safer setting.

Mandated Training on Human Trafficking
All of the studies we reviewed that assessed provider-reported measures found deficiencies prior to the educational intervention. Lack of knowledge and confidence are major barriers to optimal care provision for trafficked persons. As attention is drawn to the issue, more resources are being allocated to develop triage protocols and care partnerships. 30 For example, many US states now require training on human trafficking when providers recertify their licenses. 31 One of the studies we reviewed (Adelung) found that mandated training was efficacious for participants because it increased baseline awareness of trafficking across different training levels. Because literature on other healthcare issues reveals that increased provider confidence can improve patient outcomes, 32 our hope is that increased provider confidence in interacting with trafficked patients may improve those outcomes as well. ED administrators and providers need to be educated on trafficking as an important issue so that resources and protocols can be in place for the proper screening and treatment of patients. For example, an ED can have universal screening questions in place that ED providers ask all patients. ED providers may also be given an algorithm to follow if a patient screens positive, such as alerting a social worker and using a template to document their findings in the EMR. Furthermore, EDs can consider incorporating training materials at department meetings or educational conferences.

Focusing Interventions on the ED
In addition to evaluating the impact of an educational intervention, one of the studies we reviewed aimed to develop a human trafficking screening tool specific to the needs of an ED (Chisolm-Straker et al., 2012). Despite the high prevalence of trafficking and its interface in the ED, there are few standardised screening protocols for how ED providers should treat potentially trafficked patients. When surveyed, survivors of trafficking noted that they repeatedly visited the ED and wondered why the frequency and nature of their visits did not 'raise a red flag '. 33 This finding indicates the potential missed opportunities that occur for providers to connect with patients and screen them for trafficking.
For EDs that do have screening protocols, the most common assessment method are universal questions on feelings of safety (e.g., asking every patient, 'Do you feel safe at home'?). 34 Many healthcare institutions-EDs in particular-have attempted to develop screening protocols to identify and treat trafficked patients. 35 Methods for quick, universal screenings in the ED are currently in process of validation, 36 which is greatly needed for effective care. We know from the ED literature that screening tools in the ED are most effective when they are short, computer-based, and given to patients while waiting to see a provider. 37 These same characteristics should be applied to screening measures focused on potentially trafficked persons.
Several of the studies we reviewed gave nurses and physicians specific 'red flag' medical complaints to be aware of when attempting to identify trafficked persons.
In the ED, trafficked persons often present themselves with acute physical manifestations of physical and sexual violence (e.g., pelvic pain, STIs, or injuries).

33
'A Roadmap for Systems and Industries to Prevent and Disrupt Human Trafficking Health Care', Polaris, retrieved 6 October 2020, https://polarisproject.org/ wp-content/uploads/2018/08/A-Roadmap-for-Systems-and-Industries-to-Prevent-and-Disrupt-Human-Trafficking-Health-Care. Their acute physical complaints may also manifest as traumas from hazardous work or living conditions (e.g., weight loss or dehydration). 38 Even when trafficked persons do not arrive at the ED with a life-threatening physical symptom, they need to be thoroughly examined and screened. Trafficked persons have been shown to have higher rates of chronic diseases, which may present themselves in more insidious and nuanced ways than acute conditions. 39 Additional research is needed to evaluate the incorporation of trafficking-informed care into primary care, where these chronic diseases can be more thoroughly addressed and treated.

Strengths of Survivor Input on Training
The content of trafficking training is critical to its usefulness in the clinical setting. Historically, there have been multiple misrepresentations and misguided principles perpetuated in trafficking education; for example, trainings have at times overemphasised trafficking in the sex trade and under-emphasised trafficking in other sectors, 40 both of which may narrow the scope of 'who' is anticipated to be a potential victim. Similarly, instructing health care providers to only focus on 'red flags', though helpful in some cases, may rely on the experience (and biases) of the providers 41 and therefore impact who is screened or treated. Training, therefore, must involve a nuanced conversation about different forms of trafficking in the context of the respective local areas, including a frank dialogue about the appropriate involvement of law enforcement.
Human trafficking training for healthcare providers must be informed by survivors. One of the studies discussed in this review included what the authors referred to as a 'rescue plan' in the resources given to providers (Egyud et al.).
Though treatment plans have historically stated goals like patient 'rescue' and 'disclosure', trafficking advocates called for a move away from such terminology and aims, toward a trauma-informed approach focused not on 'rescue' but rather on universal education and violence prevention that acknowledges that all patients may benefit from some form of safety contingency planning. 42 We know from the literature that survivors benefit when given the opportunity to lead training development and that training is more effective with their input. 43 When survivors take part in developing curricula, results are consistently culturally aware, victim and survivor-centred, and trauma-informed, which creates a more robust training for providers. 44 Trafficking survivors, advocates, and community stakeholders should participate in developing educational measures to ensure appropriate and consistent goals, protocol, and language.
Several of the studies highlighted that many providers may be uncomfortable with the topic of trafficking, and trafficked persons often experience forms of trauma that providers are unfamiliar with. We advocate for providers to be reassured that their discomfort is understandable, yet it need not interfere with the care they provide. Administrators should have the resources in place to support practitioners. For example, providers who interact with a suspected trafficked patient may need to see a counsellor to discuss their experience, and they should be excused from work duties in order to do so. Further, administrators should encourage partnerships between providers and forensic nurses, social workers, and other specialists to provide trauma-informed, patient-centred care. A way to encourage such collaboration is to host trainings and discussions (traffickingspecific and otherwise) with providers from different disciplines.

Importance of a Team-Based Approach
Most studies we reviewed emphasised the team approach to emergency care in the ED, highlighting the distribution of educational interventions comprised of a variety of staff including physicians, technicians, and even non-clinical employees. We value this 'team-based' model and extend it to providers beyond the ED, because ED nurses, physicians, and social workers cannot be responsible for addressing all aspects of trafficked persons' health and social circumstances. Rather, this kind of comprehensive treatment requires a longterm multidisciplinary team. ED providers should focus on addressing urgent or emergent needs, and ED-specific training measures must equip them to do so. Providers can then refer patients for primary care, mental health treatment, and other support, hopefully through established connections with service providers in their communities. Care for trafficked persons is most effective when it is comprehensive (addresses more than one body system) and integrated (addresses social, emotional, and legal needs). 45 Therefore, the ED healthcare provider is a significant part of a team that can begin to delegate the often-complex needs of trafficked patients to appropriate experts.

Incorporating Training into Healthcare Education
Three studies reviewed here included learners, such as medical and nursing students, in their participant pool. Consistently in the literature, medical and nursing trainees report a lack of formal education on human trafficking in their curricula, with one survey of medical schools in the United Kingdom showing that 72 per cent did not provide trafficking education of any kind and 70 per cent had no plans for doing so. 46 The few trainings that focused on students showed promising outcomes, including increased student confidence in interacting with trafficked patients and increased trainee interest in pursuing trafficking as a research topic. 47 Diverse educational formats like simulation and case-based learning can be impactful on students' interactions with trafficked patients when they encounter them in the hospital setting. 48 More research is required in the medical and nursing school education domain to determine how interventions for students and institutions can be effective on a long-term basis.

Prioritising Marginalised Groups
One study highlighted the importance of recognising patients at higher risk of being trafficked, including youth and racially or ethnically minoritised groups, and individuals who do not have work or residency permits (Cole et al.). In addition to survivor participation in education, we agree with the recommendations given by The Survivor Council from the Presidential Task  needs or disabilities. These marginalised groups face structural discrimination that increases the risk of being trafficked. Furthermore, because they are often excluded from awareness efforts, their health outcomes may be more negatively impacted. 49 We therefore advocate for future educational interventions to include informed awareness of and focus on these gaps.

Limitations
The limitations of our study include the decreased rigor of a scoping compared with a systematic review. We chose a scoping review due to our study objective, which was exploratory rather than to rigorously assess the quality of each study through a validated measure. One strength of our study is the inclusion of poster presentations, abstracts, and thesis papers from the 'grey literature', which highlight how the topic of human trafficking education for ED providers is rapidly emerging.
Overall, our review found a lack of studies, but also promising outcomes for providers and patients when training is implemented. We advocate for the development of educational interventions that are team-based (e.g., involve all ED team members and relevant community partners); include self-reported outcomes measures (e.g., pre-and post-surveys); and are patient-centred and informed by survivors. Additionally, we endorse the development of interventions that fit with the unique timing and physical constraints of the ED workflow. More research is needed to develop a validated educational tool for ED providers and compare interventions for participant and patient outcomes. Future studies might also consider investigating patient outcomes pre-and post-intervention in addition to provider perceptions.

Conclusion
Human trafficking education is a critical opportunity to increase ED staff preparedness and positively impact outcomes for trafficked patients. Though the ED may be considered a challenging place to care for trafficked patients due to the nature of this busy, fast-paced environment, our review demonstrates that, if staff are adequately trained and protocols are in place, the ED can be an ideal setting to engage these patients in care. Educational interventions need to fit into the busy environment of an ED, ideally to be completed through flexible modalities (either online or in-person) during work hours, and include as many members of clinical and non-clinical staff as possible. Education must allow
space for providers' discomfort with the topic of trafficking while recognising the ED encounter as a window of opportunity in a trafficked patient's journey. We strongly recommend that states and countries mandate trafficking trainingwith pre-and post-test results-in recertification programs for ED staff. Such trainings should be developed in conjunction with survivors because they are the experts on content, and their expertise should be valued and compensated.