The health needs of trafficked and enslaved people – a social response
This study, part of a larger study undertaken within an Australian, Victorian hospital, examined the experiences of eighteen social workers situated within one of St Vincent’s Health Australia’s facilities, and reports the social workers’ knowledge of, experience with, and identification of trafficked (HT) or enslaved persons (EN). The results indicated that social workers were unable to confidently identify trafficked persons and did not have the skills and knowledge needed to identify and treat trafficked persons. The findings contribute to achieving systemic change in the Australian healthcare community and to social work practice, so that the needs of those affected by human trafficking can be more strategically addressed within the health sector.
The invisibility of trafficked and enslaved persons
Although no Australian data exists for how many HT or EN persons come into contact with the Australian health care system, Kovacic (2018), investigating the America context, estimates that approximately 13% to 88% of American trafficked victims have come into contact with a health care provider during their enslavement. Baldwin et al’s (2011) estimates as many as 30% to 50% of victims have come into contact with a health care provider during their time in captivity , however HT or EN persons remain largely unidentified when interacting with the health system (Davy, 2015; Lederer & Wetzel, 2014; Recknor, Gemeinhardt, & Selwyn, 2017).
HT or EN persons presenting at a health care facility may not report their experiences because of their distrust of authority (Dovydaitis, 2010), feelings of guilt or shame, a sense of complicity; fear of judgmental treatment; threats of physical harm by the trafficker; fear of retaliation against loved ones; fear of deportation; and, in the case of minors, fear of being reported and returned to an abusive home (Baldwin et al., 2011). Health workers may also contribute to the HT or EN person’s invisibility within the health system. International literature attributes the health providers’ limited understanding and education of the complexity of trafficking and enslavement and their unawareness of the patient characteristics that may indicate trafficking or enslavement (Gibbons & Stoklosa, 2016; Helton, 2016; Kovacic, 2018; Recknor et al., 2017; Titchen et al., 2015). Where identification was acknowledged, the media and the stereotypes propagated by the media, was attributed as the main source of information (Gregoriou & Ras, 2018; Larsen. & Renshaw., 2012)
Identification and treatment of trafficked persons - what works
Ahn et al (2013) concluded that a robust healthcare workforce that is aware of the health impact of this issue; educated about how to identify and treat affected individuals in a compassionate, culturally aware, and trauma-informed manner; and trained about how to collaborate efficiently with law enforcement, case management, and advocacy partners enables a healthcare workforce to become an active, vital partner in human traffıcking identifıcation, intervention, and prevention .
Kovacic (2018), researching the pivotal role played by health providers in the identification, treatment and support of trafficked persons, argues strongly that identifying victims of human trafficking should be integral to the practice of taking a patient’s health history. Her research, building on other’s research into health workers’ identification, treatment and support of trafficked persons, and subsequent development of the instrument measuring U.S. health care provider’s knowledge regarding human trafficking, confirmed that education and training were crucial in the capacity building of health worker skills and knowledge.
Similarly, several international researchers, to date none in Australia, have documented practices that support the identification and treatment of trafficked persons. For example, Schwarz et al (2016), exploring the American Emergency context-specific practices and protocols adopted in the University of Kansas Hospital, describes two stages when training health practitioners. Firstly, developing the practitioners’ sensitivity to the potentiality of past or ongoing trafficking and secondly, acting on this awareness, using “red-flags,” as prompts for further screening questions.
Alpert et al's (2014) development of an identification, assessment, and response guidebook for use in Massachusetts health care settings, similarly advise, as do Crane and Moreno (2011) and Schwarz et al (2016), alertness to “red-flags”. “Red flags” included a person not allowed to speak, an inability or reluctance to communicate living arrangement and circumstances, and any physical indicators of abuse, medical neglect or multiple sexually transmitted diseases. Schwartz et al (2016) argue the necessity for clearly defined stakeholder role definitions and clearly articulated and referencing of organisational policies that may be implicated (e.g. existing mandatory reporting that may be triggered by the abuse of the trafficked person) if treatment is to be successful and move beyond the first identification and treatment stage.
Social workers - contribution to identification and treatment of trafficked persons
Social workers have been singled out as having a critical role and expert skills and knowledge to contribute to the identification, treatment and referral of trafficked persons. Busch-Armendariz, Nsonwu and Heffron (2014) highlighted social workers and their utilization of social work perspectives as providing a strong and effective framework for service delivery and effective interdisciplinary collaboration. Similarly, Davy’s (2016) review of support programs of three U.S.-based human-trafficking victim support program evaluations, identified social work, when using its ecological theory perspective to support trafficked persons, to lead, coordinate and integrate support services, were at the forefront of effective service delivery for human-trafficking victims.
This small study, a collaboration between St Vincent’s Health Australia (SVHA) and Australian Religious Against Trafficking of Humans (ACRATH) situated within an Australian hospital, responds to the limited or lack of Australian research into social workers’ identification, treatment, and referral of trafficked persons. Reported is part of phase one of the projects: the scoping of social worker identification of trafficked persons. Phase two, for conclusion in 2019, the design and trail, based on the data gathered in phase one, an education package for health care workers that would inform health workers’ work with trafficked persons.
Methodology and method
A qualitative approach was used as the data gathering method. In response to general flyers advertising the focus groups, eighteen social workers representing 12% of the social workers employed at SVHA and 20% of social workers employed across SVHA Victorian sites, self-selected to attend a forty-five-minute focus group session. During the focus groups participants had an opportunity to explore and interpret their experiences, perceptions of trafficked persons, and their views of the professional skills, trafficking-enslavement-training programs needed to identify, treat, and refer them. Data was digitally recorded to ensure that specific quotes were retrievable at the data analysis stage. Additionally, an ACRATH note taker was present during each focus groups to document critical feedback. The researcher also added her field notes to the collected data. Focus group transcripts and recordings were analysed thematically using the NVivoTM computer program (QSR International). This involved becoming familiar with the transcripts through careful reading and rereading, coding and recoding units of data, establishing preliminary themes and settling on subthemes (Spencer, Ritchie, Ormston, O'Connell, & Barnard, 2014).
Findings and discussion
Confirming literature, trafficked and enslaved persons remained invisible to the participants within this project. Their understanding of the terms “trafficked” and “enslaved” were conflated with descriptions, said to be drawn from media representations, restricted to “young women forced to marry old men”, “provide someone to someone else in exchange for money”. Social workers acknowledged their unfamiliarity with the current human trafficking and modern slavery discourses and explained that the issue was beyond their immediate personal or professional experience (feels far away and something that happens overseas”, “wouldn’t consider it often”. “No concept of how many forced marriages, could even hazard a guess”) although were “aware of the issue through reading, news articles”. Discussing contact with HT or EN persons, seventeen social workers indicated that they “probably” or “quite likely” had come into contact with HT or EN persons but would not be aware of this encounter, however could not confidently claim to have knowingly treated a HT or EN person. On interrogating the “probability” of encountering a HT or EN person, a minority of social workers reflected international findings (Alpert et al., 2014; Crane & Moreno, 2011) that highlight the use of “red flags” as prompts to investigate the possibility of HT or EN (“A woman said she had debts overseas and was working in the field in the sun for long hours with few breaks – she said it was her family but her body language suggested otherwise”, “ I had a feeling, I couldn’t put a name to it”).
Similar to other research findings (Davy, 2015; Gibbons & Stoklosa, 2016) the absence of formal education underpinned the why HT or EN persons were not identified when presenting at the hospital. Data indicated that, although some were attuned to multiple or interrelated symptoms, none could “join the dots” and pursue suspicions of trafficking. As one social worker stated: “Woman aged 40, debilitated because of speech, she had poor mobility, poor personal care and was very scared and inconsistent with information – the closest I’ve come to thinking somethings not right”.
Social workers also indicated that the ability to identify, treat, and refer HT and EN persons also requires organisational capacity building with clear policy and procedures for health practitioners to follow. Their view was that identifying HT or EN persons was not without difficulty for the professional involved. Social worker’s limited opportunity to intervene in the cycle of exploitation and role in elevating the health of trafficked and enslaved person was negatively influenced by the lack of clarity around hospital policy and procedures (I’m reluctant to ask questions because I don’t know what to do afterwards”, “we don’t have a formal procedure, don’t know what I would do, I’m opening a can of worms”). The absence of clear policies and procedures was seen as further endangering the HT or EN person (don’t want to call the immigration department because it may put eh persons further at risk”). These views and concerns resonate with previous research that concludes the barriers to HT and EN successful negotiation of the health system and to health practitioners’ provision of health services (Dovydaitis, 2010; Yarborough, Jones, Cyr, Phillips, & Stelzner, 2000).
Reaffirming the efficacy of education and training supports, and strategies that build a knowledge and skill base within and across discipline groups (Ahn et al., 2013; Domoney, 2015) social workers emphasised the program services and education needs to be developed through the HT and EN person’s lens rather than the practitioner. This lens was regarded as consistent with the trauma informed lens currently used within the hospital to inform work with other vulnerable groups. The use of a trauma informed lens is noted in current HT and EN research literature (Alpert et al., 2014; Gibbons & Stoklosa, 2016). The ecological perspective, indicated as the social workers’ strong and effective practice framework (Busch- Armendariz et al., 2014; Davy, 2016) was also noted by the participants as the expert skills and knowledge that they could transfer to the identification, treatment and referral of HT and EN persons (we have benefited from family violence training. Existing structures are useful for this as for any other vulnerability”, “We are trained in things to look for in elder abuse, children at risk, family violence”).
This study confirmed the evidence elsewhere stressing the importance of well trained, educated and supported health care workers charged with the care of HT and EN persons. Barriers to the identification and treatment of HT and EN persons were situated in social workers’ skills and knowledge gaps as well as in the organisation’s lack of clear policy and procedures. These barriers can partly be addressed by educating health professionals in how to identify and treat trafficked persons. Previous studies have documented the positive improvement in treating HT and EN persons when health workers have been trained and policy and procedures are clear and unambiguous (Gibbons & Stoklosa, 2016; Macias-Konstantopoulos, 2016). The social work’s unique contribution to the identification, treatment and referral of HT and EN persons can be central to minimising barriers to HT and EN people’s engagement with the health system. Social work’s simultaneous focus on and attention to both the person and the person's environment. Social workers can respond to the challenges and needs presented by HT and EN survivors and responders. Using their skills and knowledge are able to work with groups, communities, organisations or programs, legal, health, and educational systems and navigate the micro level (the individual and family) and macro level structures to ensure that, as one social worker put it “Modern slavery and trafficking is in our back yard – we need to address it”.
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