Nurses ’ Awareness Regarding Human Trafficking

Problem: A review of the literature indicated that human trafficking is a worldwide problem and not all nurses in the healthcare setting were adequately trained to identify and care for human trafficking victims. Purpose: The purpose of this study was to further explore nurses’ awareness regarding human trafficking. Method: This quantitative, cross-sectional, non-experimental study with a descriptive design, studied the issue by administering a survey to nurses actively working in the field. The theoretical framework of forced labor and Orem’s self-care deficit nursing theory were used to guide the study. The data were collected using SurveyMonkey®, an Internet-based confidential data-collection tool. The survey contained eight demographic questions and sixteen Likert-type statements. The researchers obtained personal email addresses and used Facebook contacts to send out the survey initially. In this study, a Snowball sampling was used to obtain nurse participants. Results: A total of 166 responses were received from nurses across the United States. The results confirmed that there is a lack of awareness among nurses about human trafficking. An increase in both training and education amongst nurses could increase the number of victims, which go unnoticed, being saved or provided with assistance. Nurses also must be more self-aware about the patients they are encountering and be more observant of signs that look suspicious. The most agreed upon statement by participants was that counseling should be available to people who are affected by human trafficking (M = 3.75, SD = 0.48).


Introduction
Many may think that slavery no longer exists in the world, but human trafficking is a form of modern slavery that has become a global problem.A report by the Centers for Disease Control and Prevention (CDC, 2017) indicated, "Human trafficking is a serious public health problem, placing a toll on the well-being of individuals, families, and communities" (para.2).A report from the World Health Organization (WHO, 2012) indicated, "health care providers and organizations with trafficked persons should increase their capacity to identify and refer people in trafficking situations and provide sensitive and safe services to people post-trafficking" (p.5).These reports indicated that it is essential for nurses to identify victims and provide them with the help they need.This quantitative, cross-sectional, non-experimental study with a descriptive design investigated nurses' awareness regarding human trafficking.The guiding theoretical framework of forced labor and Orem's self-care deficit nursing theory were used to guide the study.

Background
Human trafficking is a worldwide problem.A report from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2016) highlighted, "Human trafficking is a global problem present in all countries, including the United States.Within the United States, sex trafficking is more common than labor trafficking" (p.458).There are numerous forms of human trafficking, and each one brings a great deal of pain and suffering to the victims.It is a current problem and a modern form of slavery; it is seen in the form of sexual exploitation, forced labor, and domestic servitude (AWHONN, 2016).The three forms of human trafficking are typically not recognized by the average person and are increasing throughout society.Sexual exploitation takes the form of prostitution in which victims are forced to have sex for a certain price.Forced labor occurs when victims work in factories or on farms for long hours without food or sleep, leading to health issues.Domestic servitude occurs when maids or nannies are underpaid, are not allowed to keep their wages, or have unfair living conditions (see Figure 1).

Figure 1. Three major forms of human trafficking
There is a noticeable knowledge gap in the literature regarding human trafficking and the lack of awareness nurses possess to provide appropriate care.This crime affects all ages and genders, so nurses in all fields need to be aware of potential victims (McNulty, 2014).Victims of human trafficking may seek healthcare in a variety of areas where nurses work.Proper training and education of nurses are essential.It is crucial to identify victims, even if there is slight suspicion, because it may be the only chance for the victims to escape.The victims have little control over their personal lives (Byrne, Parsh, & Ghilain, 2017).The moment they enter a hospital, it gives them an opportunity to ask for help when not closely monitored by their abuser.A nurse must be able to identify signs of human trafficking and know how to separate the victim from their abuser to complete a proper assessment.Nurses need to be leaders during this time and help identify and treat victims (AWHONN, 2016).Now more than ever, nurses should be proactive and receive proper training or education required to identify and help trafficked individuals.
Human trafficking is a fast-growing business with more than 1.2 million children exploited every year (Byrne et al., 2017).Child victims are often illegal aliens, or citizens who are kidnapped, or runaways taken in by abusers.The children are sold into sexual exploitation or forced labor.Children who run away are even more vulnerable, and one out of three runaways are captured by sex traffickers (McNulty, 2014).Nurses can still play a role in prevention through assessment.Reporting cases in which families may be abusing or neglecting their child is a way of prevention.When a child arrives in the emergency department or health care professional's office and appears afraid or displays a behavior of feeling unsafe, this should raise a red flag to the nurses, and further questioning should occur.These situations emphasize why nurses' awareness regarding human trafficking is vital.

Problem Statement
An increase in human trafficking victims indicated that nurses are able to identify human trafficking victims.Roe-Sepowicz et al. (2016) confirmed that nurses are one of the few who interact with victims while they are still under the control of their abuser.Nurses can use their knowledge and experience with violence or trauma to identify and help trapped victims, regardless of age, race, or gender.Human trafficking is a billion-dollar business, the second most profitable criminal enterprise in the world (Perkins, 2015).This indicated the likelihood of a victim seeking care from a nurse is more significant than most would think.

Purpose Statement
The purpose of this quantitative study was to examine nurses' awareness regarding human trafficking.

Research Questions
The focus of this study was generated by the research question: What is the awareness of nurses regarding human trafficking?

Databases
The literature reviewed for this study was obtained using the Google Scholar search engine and the college library EBSCOhost database, specifically the Cumulative Index of Nursing and Allied Health Literature (CINAHL).The

Sexual Exploitation
Forced Labor Domestic Servitude articles selected for review were peer reviewed and published from 2014 to 2017.Keywords used in the search were human trafficking, sex trafficking, health care professionals, nurses, victim, preparation, identification, and awareness.

Definition of Terms
Forced labor is defined as, "all work or service which is exacted from any person under the menace of any penalty and for which the said person has not offered himself voluntarily" (The International Labor Office [ILO], 2005, p. 5).Human trafficking is defined as, "the recruitment and movement-most often by means of coercion, deception or abuses of vulnerability-for the purposes of exploitation" (Ross et al., 2015, p. 1).Sex trafficking is defined as, "the recruiting, transporting, receiving, harboring, or obtaining of an adult for that purpose commercial sexual exploitation through means of force, fraud, deception, or coercion through the use of physical or psychological threats" (Hachey & Phillippi, 2017, p. 32).Victims are defined as, "minors under the age of 18 who have been coerced into commercial sex acts, those age 18 or older who are forced, deceived, or coerced into commercial sex acts, or anyone forced to perform labor or services involuntarily through force, fraud, or coercion" (McNulty, 2014, p. 244.)In this study, nurses include licensed practical nurses (LPNs) and registered nurses (RNs).Awareness is defined as the understanding and concern for human trafficking victims and situations.

Types of Human Trafficking
Sexual exploitation, forced labor and domestic servitude are the three major reasons for human trafficking.Human trafficking is a $150 billion per year industry (Hachey & Phillippi, 2017).Human trafficking is a moneymaking affair; no individual is left out who can be used and controlled as a means to making a profit.While there is no commonly accepted profile for victims of minor sex trafficking, specific populations are more vulnerable than others.Adolescent boys and lesbians, transgendered and queer/questioning (LGBTQ) individuals are often victims.According to a recently released study, boys make up almost half of the victim population (Roe-Sepowitz et al., 2016).Women and children make up more than half of the population of victims trafficked (Macias-Konstantopoulos, 2016).Lederer and Wetzel (2017) warned that victims often feel as though they deserve this lifestyle and many do not think of themselves as a victim."Survivors were overwhelmingly traumatized not only physically, but also mentally" (Lederer & Wetzel, 2017, p. 70).The brutal treatment endured created ongoing psychological and mental conditions in many of these victims and exploited existing mental instability in others.Prolonged physical, emotional, and mental abuse takes a toll on the victims to the point where they are too afraid to try to leave and alert a nurse.Victims are coached to lie to nurses and other health professionals to protect their cover (Roe-Sepowitz et al., 2016).Nurses' ability to aid these victims can decrease the human trafficking pandemic and treat these people the way they deserve to be addressed.

Forced Labor
Labor trafficking can be defined as "either forced hard labor, usually in agriculture or textile sweatshops; or domestic labor, such as working as a nanny or house servant" (Green, 2016, p. 9).Society does not usually view individuals with a job as persons in need of help.The way these individuals get involved in human trafficking include entering the country illegally, obtaining seasonal jobs, and being forced to give their earnings to the person in charge (Alpert et al., 2014).People often ask why trafficked individuals do not come forward and ask for help, but most of the time, the trafficked victims are not aware they are in trouble.They are given a job, sometimes food, and told what to do.Some may not speak English, creating a language barrier, which causes hesitation in seeking help.
Working conditions include days that are long, averaging 12 to 20 hours, the pay is little to none, sometimes sleep is scarce, and often they are abused as well (Perkins, 2015).When this happens, it is only a matter of time until a health concern occurs.Health issues may increase the possibility of becoming injured or ill, and because their sole purpose is to make money, the ones in charge may bring them to the hospital for care.Ross et al. (2015) discovered that 95% of health care professionals had no formal training in responding to victims and could not identify a victim seen in the emergency department.This is an indication that a majority of health care professionals may have had contact with potential victims, yet little to no action occurred due to lack of awareness.The moment a victim is admitted to a hospital, there is an opportunity to be rescued.

Sexual Exploitation
Sexual exploitation occurs when "individuals are coerced, recruited, sold, or abducted and forced into having sex or are sexually exploited" (McNulty, 2014, p. 244).Women and children are usually victims of this abuse.The people in control are usually called "pimps" and control who the victims are "sold" to, including the cost for service.They are assigned a quota and must meet it if they do not want to be harmed (Perkins, 2015).Female prostitutes are stigmatized and ignored by society.People believe that these women have chosen this lifestyle.Few recognize that prostitution is a means of survival for some, despite the pain they experience or the pressure of being in the profession against their will.
The average age of victims forced into sexual exploitation is 12 to 14 years (Byrne et al., 2017).Research has established that it is difficult for health care professionals to identify victims, but there are "red flags" which can alert a nurse to a patient who may need help (Chisolm-Straker et al., 2016).If the person with the victim does not leave them alone or if they insist the nurse not remove clothing, this is a red flag and assistance is needed immediately.A nurse has an opportunity to build trust with the victim, so despite the fear, they can hopefully ask for help.

Domestic Servitude
Domestic servitude occurs when maids or nannies are underpaid, are not allowed to keep their wages, or have unfair living conditions.Beck et al. (2015) reported that preparing nurses to identify human trafficking victims has occurred in some areas around the country.Nurses who received professional training recognized situations, such as human trafficking, were more likely in an urban setting than a rural setting.Beck et al. highlighted the importance of training and its ability to increase health care workers' understanding of sex trafficking, their awareness of the issue locally, and skills in identifying and caring for victims.Stoklosa, Showalter, Melnick, and Rothman (2017) found that participants in a Midwestern hospital who received education and training on identifying trafficked victims revealed more confidence and realized possible missed identification opportunities.An issue identified with training is that it is not mandatory and identifying victims requires a multidisciplinary approach.Including a multidisciplinary approach is important because there is a need for local services available to help victims after being identified (Stoklosa et al., 2017).Standardization of training is vital to maintaining consistency for all health care professionals to identify victims (Powell, Dickins, & Stoklosa, 2017).

Education and Training for Nurses to Identify and Report
Hachey and Phillippi (2017) stated that lack of training among nurses to identify human trafficking victims are missed opportunities to intervene and end the human trafficking journey for that individual.Human trafficking victims often seek treatment while in captivity.Health facilities that come into contact with human trafficking victims are the "emergency department, family planning clinics, urgent care, primary care clinics, community health clinics, health departments, pediatrics, obstetrics and gynecology, and private offices" (Hachey & Phillippi, 2017).In these situations, it was evident that patients suffered a significant amount of abuse and or neglect, and the nurses failed to identify them.Nurses are mandatory reporters and must report any signs of abuse or neglect that an individual presents.Egyud and Whiteman (2016) highlighted that the best way for the nurse to get a human trafficking victim to talk to them honestly is for them to separate the victim from the victimizer.Separating them creates a vital time when nurses should provide the victims with support and safety."Restoration occurs after the rescue and involves the interdisciplinary services of helping the victim return to an independent lifestyle" (as cited in Egyud & Whiteman, 2016, p. 16).Grace et al. (2015) claimed that 28% to 50% of trafficking victims have encountered health care but were not identified as victims.Nurses are trained to identify victims of abuse but are not educated on the health problems of human trafficking victims (Grace et al., 2015).Stoklosa et al. (2017) found that only 20% out of 782 health care professionals received training.The United States Federal Strategic Action Plan on Services for Victims of Human Trafficking has established the need for training in identifying human trafficking victims (Stoklosa et al., 2017).
In summary, the literature indicated the need to improve the awareness of human trafficking in the health care setting.Victims of human trafficking are present, and it is the duty of nurses to identify warnings and question the reason for the visits.A prepared nurse can improve the livelihood of an individual by stopping the crime of human trafficking.No matter which form an individual is trafficked, once the individual is in a health care setting, that individual should be given the opportunity to open up and feel safe enough to speak openly.The nurse can be the bridge to obtaining the help needed to remain safe and discontinue the trafficking lifestyle.

Theoretical Framework
The Global Alliance of the ILO composed a report on forced labor to bring attention to the current issues of human trafficking."Forced labor is present in some form on all continents, in almost all countries, and in every kind of economy" (ILO, 2005, p. 1).The report continues to bring updated information on the new ways forced labor, or human trafficking, is creeping into the community.The issue is the lack of political investigation and resources spent on the problem.This may be a reason victims do not come forward or are found too late.Forced labor is also not listed as a crime and makes charges hard to hold.Looking into the future, there is hope of laws being established and actions being taken against forced labor (ILO, 2005).As shown in Figure 2, the typology of forced labor acknowledges three main types of forced labor situations: forced labor imposed by the state, forced labor imposed by the private agents for commercial sexual exploitation, and forced labor imposed by private agents for economic exploitation (ILO, 2005).Taylor and Renpenning (2011) suggested that the Orem self-care deficit nursing theory shows an imbalance in the self-care an individual requires and their ability to perform that care (p.4).When the individual does not provide this care, help is required from a healthcare professional.Hoblet, Butler, Kuhn, Perne, and Phillips (2017) mentioned that self-care is learned through relationships and communications with those in our environment.The environment, in which human trafficking victims are found, does not provide them the opportunity for self-care due to poor living conditions.Victims can be unaware of the severity of their situation and not realize they are incapable of caring for themselves (Orem, 1991).Healthcare professionals must be aware of what signs to look out for, such as delayed development of care, and be able to deliver it to the victims.

Design
Approval of the study from the college Institutional Review Board (IRB) was obtained.The researchers completed web-based training through the National Institutes of Health on protecting human research participants.Quantitative, non-experimental, with cross-sectional sampling, describes the research method.A Likert-type scale comprised of survey statements was used to evaluate the nurses' awareness regarding human trafficking.

Sample and Setting
The populations for this study were nurses in the United States who were defined as registered nurses (RNs) and licensed practical nurse (LPNs).The nurses were invited through Facebook and email to participate in the study.They were provided with the link to access the survey at www.surveymonkey.com.They were encouraged to forward the survey to fellow nurses.The participants were given the opportunity to complete the survey at their leisure and were notified of the closing date of the survey.

Survey Instrument
The survey was developed after a thorough review of the literature.Two professors and two peer reviewers provided feedback, which was used to update the instrument for face validity.The survey contained eight demographic questions and sixteen Likert-type statements.The statements assessed the nurses' awareness regarding human trafficking.The Likert-type scale contained four response choices that range from strongly Forced labor imposed by State Forced labor imposed by private agents for criminal sexual exploitation Forced labor imposed by private agents for economic exploitation disagree to strongly agree with each statement.The response choices were scored from one to four, one equaled strongly disagree and four equaled strongly agree.The survey was opened for two weeks.

Informed Consent and Confidentiality
Informed consent was a prerequisite for completing the survey.The survey was accessible by the Internet, and access to the server was only granted by first providing an electronic signature on the informed consent.Participants were provided the faculty supervisor's contact information and the researchers' names and email addresses for contact regarding any questions or problems.All data were kept confidential by an encrypted password protection only accessible by the researchers.

Data Collection
The data collection process allowed participants to complete the survey anonymously and conveniently.The final sample originally consisted of 181 responses, which was reduced to 166 valid responses after eliminating incomplete surveys.

Participants' Demographic Characteristics
This included nurses from 15 states and 25 different specialties.One hundred and sixty-six participants finished the surveys completely.Nurses Reported a Suspected Victim of Human Trafficking

Data Analysis and Discussion
Data were analyzed using descriptive statistics.The researchers used the cumulative data to calculate the mean and standard deviation using Excel.The most agreed upon statement by participants was that counseling should be available to people who are affected by human trafficking (M = 3.75, SD = 0.48).Lederer and Wetzel (2017) warned that victims often feel as though they deserve this lifestyle and many do not think of themselves as a victim."Survivors were overwhelmingly traumatized not only physically, but also mentally" (Lederer & Wetzel, 2017, p. 70).Research has showed a need for aftercare services for human trafficking victims."Restoration occurs after the rescue and involves the interdisciplinary services of helping the victim return to an independent lifestyle" (as cited in Egyud & Whiteman, 2016, p. 16).
The United States Federal Strategic Action Plan on Services for Victims of Human Trafficking has established the need for training in identifying human trafficking victims (Stoklosa et al., 2017).Data analysis revealed that only 16.2% out of the 166 nurse participants had received training in human trafficking.The finding corresponds to a previous study in the literature review, in which Stoklosa et al. (2017) found that only 20% out of 782 health care professionals received training.Only a small percentage of health care professionals are receiving training in this worldwide crisis.Participants showed agreement that there should be more screening tools available for nurses to identify victims of human trafficking (M = 3.43, SD = 0.52).Research has established that it is difficult for health care professionals to identify victims, but there are "red flags" which can alert a nurse to a patient who may need help (Chisolm-Straker et al., 2016).
Health facilities that come into contact with human trafficking victims are the "emergency department, family planning clinics, urgent care, primary care clinics, community health clinics, health departments, pediatrics, obstetrics and gynecology, and private offices" (Hachey & Phillippi, 2017).The categories of specialty areas showed that 12% of participants worked in the emergency room, 11.4% worked in pediatrics, 4.2% worked in family practice, and 1.8% worked in the psychiatric and school settings.Out of all of the areas listed, 11.4% suspected a patient may have been a victim of human trafficking, but only 7.8% reported to the authorities a suspected victim of human trafficking.The reporting difference is evidence of missed opportunities and a lack of training in identifying victims.Hachey and Phillippi (2017) stated that lack of training in nurses to identify human trafficking victims is missed opportunities to intervene and end the human trafficking journey for that individual.This could also indicate that the nurses did not feel empowered to report what they suspected.Findings from data analysis showed that participants agreed human trafficking victims are not adequately identified by nurses (M = 3.15, SD = 0.15).
Analysis demonstrated a lack of awareness by the participants of the populations affected by human trafficking.A lower mean, shows less agreement out of participants with the statements women are the majority of victims trafficked (M = 3.17, SD = 0.58), children are the majority of victims trafficked (M =2.92, SD = 0.67), and males are rarely trafficked (M = 2.09, SD = 0.61).Women and children make up more than half of the population of victims trafficked (Macias-Konstantopoulos, 2016).The average age of victims forced into sexual exploitation is 12 to 14 years (Byrne et al., 2017).Children who run away are even more vulnerable, and one out of three runaways are captured by sex traffickers (McNulty, 2014).According to a recently released study, boys make up almost half of the victim population (Roe-Sepowitz et al., 2016).Literature review revealed that anyone is capable of being a victim of human trafficking.This crime affects all ages and genders, so nurses in all fields need to be aware of potential victims (McNulty, 2014).
Human trafficking victims often seek medical care.Analysis of the statement surveyed from participants regarding human trafficking victims often do not seek medical care (M =3.25, SD = 0.62), demonstrated a lack of awareness in identifying victims.Grace et al. (2015) claimed that 28% to 50% of trafficking victims have encountered health care but were not identified as victims.The findings also show the lack of awareness of the different forms of human trafficking.The two forms analyzed were sexual exploitation (M = 3.01, SD = 0.65) and forced labor (M = 2.99, SD = 0.58), both received low mean scores.Labor trafficking can be defined as "either forced hard labor, usually in agriculture or textile sweatshops; or domestic labor, such as working as a nanny or house servant" (Green, 2016, p. 9).Health care providers are not adequately educated regarding the different forms of human trafficking and the lack of education and training corresponds with not being aware of possible encounters with victims.
In analyzing the data, the participants had a higher mean on the following statements: human trafficking is a worldwide crisis (M = 3.70, SD = 0.54), human trafficking is a growing industry that is cause for concern (M = 3.62.SD = 0.59), human trafficking is currently a problem in the United States (M = 3.50, SD = 0.69), and that human trafficking is a billion-dollar industry (M = 3.47, SD = 0.70).The higher mean demonstrated a higher agreement, which showed that nurses are aware that human trafficking is an issue.Other evidence from the data collected showed a lack of awareness in identifying victims and a lack of training.Nurses are trained to identify victims of abuse but are not educated on the health problems of human trafficking victims (Grace et al., 2015).The participants, who were nurses, are aware that services are needed and tools in identifying victims are needed as well.The issue presented from the research is how are services and tools going to be used if only 16.2% out of 166 participants have been trained in human trafficking.
The lack of awareness of the populations affected by human trafficking is evident in the data collected.The participants had a low mean for children are the majority of victims trafficked (M =2.92) and women are the majority of victims trafficked (M = 3.17).Interestingly, the mean was the lowest for human trafficking primarily involves individuals from the United States (M = 2.04).Human trafficking is a current issue within the United States and the victims include citizens of the country.AWHONN (2016) highlighted, "Human trafficking is a global problem present in all countries, including the United States.Within the United States, sex trafficking of U. S. citizens is more common than labor trafficking" (p.458).
A majority of the participants surveyed were from Indiana (78.9%).The participants indicated that more policies and legislation should be enacted to assist the needs of victims in human trafficking (M = 3.15, SD = 0.15).Beck et al. (2015) highlighted the importance of training and its ability to increase health care workers' understanding of sex trafficking, their awareness of the issue locally, and skills in identifying and caring for victims.

Limitations
Limitations included the small sample size, and possible lack of computer access.The two-week window for data collection may have also contributed the low number of returned surveys.The sample may not represent the majority of nurses, which led to decreased generalizability.Surveys that were incomplete were discarded.The male to female ratio was also not equal in the sample.There were a larger percentage of female nurses (94%) than male nurses (6%).The broad range of specialties could prevent those who are normally in an area such as administrative/management to not be exposed to victims, as they do not provide as much bedside care.Despite these limitations, valuable data was obtained.

Clinical Implications
The study of the nurses' awareness of human trafficking could save enslaved victims.Previous studies indicated that victims do seek health care, but nurses were not aware of their situation or they failed to report.Therefore, increased awareness would better equip nurses at assessing individuals' needs throughout health care.Better assessments would lead to better outcomes for the patients to seek medical attention.
Surveying the nurses indicated that there is a lack of awareness regarding human trafficking.Understanding more about human trafficking and the forms it takes, would allow nurses to help suspected victims.Nurses should receive training at their job so they are better prepared in reporting and saving the victims.If there were an increase in awareness among nurses, there would be more chances for victims to receive the help they need during an active capitation.

Conclusion
The conclusion from this study was nurses lack an awareness regarding human trafficking.Human trafficking is an increasing issue within the United States and worldwide.Constant surveillance and continuing education on human trafficking allows for better assessments when caring for individuals.Forced labor creates a variety of health issues, ranging from physical to mental health.Millions of individuals, no matter the age, race, or gender, are affected by the billion-dollar industry.The analysis of the research question indicated that assessing the awareness of nurses regarding human trafficking demonstrated a need for education and training in identifying victims.

Recommendations for Practice
Based on these findings, nurses need to be made more aware of the likelihood that they will care for a human trafficking victim and the importance in identifying them.Training in identifying victims should be implemented throughout hospitals as well as a protocol set in place on what to do next.An increase in both training and education amongst nurses could increase the number of victims, which go unnoticed, from being saved or provided with assistance.Nurses also must be more self-aware about the patients they are encountering and be more observant of signs that look suspicious.Options such as counseling are also an important factor to offer to victims and those affected.

Figure 2 .
Figure 2. Human trafficking based on the International Labor Office global report

Figure 3 .
Figure 3. Percentage of nurses who received training in human trafficking

Table 1 .
Table 1 contains the descriptive statistics for the participants' demographics.The most common age range was 26-35 (34.9%) years.More females (94%) than males (6%) participated.With a total sample size of 166 participants, individuals with a BSN (54.8%) accounted for over half of the responses.Descriptive statistics for participant demographics and background