Journal Article Summary on a topic related to Health and Culture

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?2018 Insight Medical Publishing Group
Diversity and Equality in Health and Care (2018) 15(2): 77-86
Research Article
Access to Healthcare for Victims of Human
Trafficking: A focus group with Third Sector
Agencies
Emily Brace1, Julia Sanders2 and Hanna Oommen3
Cardiff & Vale University Health Board / School of Care Sciences, University of South Wales, UK
School of Healthcare Sciences, Cardiff University, UK
3
Care Sciences, University of South Wales, UK / Häme University of Applied Sciences HAMK, Finland
1
2
ABSTRACT
Human Trafficking is becoming increasingly recognised as
a global public health epidemic with an estimated 45.8 million
individuals affected by some type of exploitation. The effects of
trauma and exploitation have profound health implications and
often leave victims isolated from society. Victims of Human
Trafficking are commonly associated with vulnerability, comorbidities, poor access to, and engagement with, healthcare
services. Given this situation, an exploration of trafficking and
access to healthcare was indicated. A focus group explored the
experiences of six third sector workers in supporting victims
of Human Trafficking. Thematic analysis was used and four
overarching themes emanated: a call for improved access to
treatment for victims affected by mental illness; improved
knowledge and training of health professionals in identifying
victims; the challenges for victims navigating two complex
systems (National Referral Mechanism/Asylum Process)
and victim’s self-identification. The findings highlighted the
associated complexities that victims commonly face when
accessing healthcare and emphasised the fundamental need
for ensuring that equitable services are available. To enable
safeguarding and individualised care to become embedded, a
shift in culture and a move away from judging healthcare need
on immigration status was recognised as a key requirement.
Improved access to psychological therapy for victims was
also suggested, alongside better education for all health
professionals and frontline staff. To improve healthcare for
victims of Human Trafficking in the ways recommended
would require Government and National Health Service (NHS)
support including increased financial and staff resources.
Keywords: Human Trafficking; Mental illness; Victims;
Health access; Self-identification
What is known about this topic?
•
An increasing number of victims are falling into the hands of Human Traffickers
•
Victims of Human Trafficking are predisposed to poor health exacerbated by limited access to healthcare services
What this paper adds? This paper:
•
Describes the complexities that victims face in accessing healthcare services
•
Suggests interventions that are required to promote equality in service provision
•
Describes a need for more collaborative working across organisational boundaries and a shift away from working in silos
Suggests a shift towards proactive rather than reactive care management
Introduction
Human Trafficking, also known as modern day slavery is
distinctively different to people smuggling and recognised as
a global public health epidemic, carrying with it significant
debilitating effects for exploited individuals [1,2]. It reflects
a profound violation of human rights, with frequent bouts of
violence, the stripping of identities and the denial of freedom of
movement [3].
Human Trafficking and the notion of slavery is often
presumed as a problem of the past, although such views are
not reflective of the current situation (UN Office for Drugs
& Crime [4]. In 2016, the Gallup surveys estimated that 45.8
million people across 167 countries, were forced into some type
of exploitation, although, Human Trafficking is often a hidden
crime and as such statistics should be interpreted with caution
[5]. In the UK, the implementation of the National Referral
Mechanism (NRM) has helped identify and quantify the
prevalence of Human Trafficking [6]. However, this data only
captures victims who are referred into the NRM and individuals
who decline referral remain significantly underrepresented [7]. In
2016, 3805 potential victims were identified through the NRM;
a 17% increase in comparison to 2015 [6]. The uncertainty of
the true prevalence of Human Trafficking, remains a significant
challenge in the identification and care of victims [7].
The NRM’s mandate is to support the identification of
Global Health Care Concerns
78
Emily Brace
victims and ensure appropriate management and subsistence is
provided [8]. First responders such as the police, social services
and authorised third sector agencies are trained to undertake the
initial NRM assessments. These are then passed to the competent
authorities for a decision to be made on whether there are
reasonable grounds to believe the individual is a victim of Human
Trafficking. The asylum process is separate and independent
from the NRM, although, the conflation of the NRM/Asylum
and frequent ‘abuse of processes’ has been previously noted
(Anti-Trafficking Monitoring Group; unsurprising given that
the Home Office is one of the competent authorities [8-10]. The
acknowledged that the NRM is not currently fit for purpose and
at its worst, flagrantly disregards professionals’ views.
several barriers, including traffickers interpreting for victims
and victims being denied access to healthcare services without
official papers. Recommendations included, an emphasis on
the need for better guidance and training to improve health
professionals’ awareness, but also acknowledged the need to
reach out to frontline staff. Therefore, supporting equitable
healthcare regardless of residency status. Advocacy support
to enable access was also considered as a critical component
to breaking down barriers. The need for better awareness and
specialist educational training packages for health professionals
[21-24]. In addition, supported the implementation of designated
referral pathways and protocols aimed at providing a better
overall service for victims.
The most widely cited definition of Human Trafficking is
from the ‘UN Protocol to Prevent, Supress and Punish Trafficking
in Persons’ [11]:
Some studies have explored health professionals’ views
around barriers associated to accessing healthcare, although,
this has primarily focused on a generalised concept, such as
ethnicity, asylum seekers and refugees [18]. The literature
looking at the connections to Human Trafficking and health is
sparse or dated, particularly from a third sector’s perspective
[25]. Since BAWSO’s [25] report, new community and
Government initiatives have been implemented in Wales to
tackle some of the gaps within service provision. Further
exploratory work was therefore indicated to ascertain whether
the previously identified challenges remain for victims when
accessing healthcare.
‘The recruitment, transportation, transfer, harbouring or
receipt of persons, by means of the threat or use of force or other
means of coercion, of abduction, of fraud, of deception, of the
abuse of power or of a position of vulnerability or of the giving
or receiving of payments or benefits to achieve the consent of a
person having control over another person, for the purpose of
exploitation’.
The notion of vulnerability is closely associated with
trafficked victims. The UNODC (2008) identified that it
is common for traffickers to prey on individuals who find
themselves disempowered, vulnerable, impoverished, disabled
and socially excluded [12,13]. Furthermore, Human Trafficking,
with substandard living conditions and barriers to healthcare
result in poorer health including increased rates of mortality and
morbidity [14]. The National Institute for Health and Clinical
Excellence identified the importance of ensuring that seldomheard groups have seamless access to healthcare services [15].
It is acknowledged that factors including homelessness, asylum
seeking, language barriers and a lack of individual knowledge
regarding the benefits of accessing healthcare can all act as
barriers. However, it is recognised that if clear provisions are
tailored towards the characteristics of the most commonly
identified vulnerable groups then barriers will be significantly
reduced [15-18].
The effectiveness of delivering psychological therapy
to victims, remains poorly evaluated, systematic review by
Hemmings et al. [19] identified that victims of Human Trafficking
frequently suffer post-traumatic stress disorder (PTSD) and
complex medical, physical, psychological healthcare needs.
Furthermore, recognised that Mental Health professionals are in
a pivotal position to support victims of Human Trafficking and
acknowledged a professional duty to ensure victims are referred
to the necessary care and treatment [20].
Westwood et al. [21] identified that despite profound
physical and psychological health comorbidities associated with
Human Trafficking, there remained a lack of knowledge around
victim’s personal experience in accessing healthcare. The crosssectional survey of 136 victims explored the utilisation of health
care services during and post exploitation. The survey identified
Research Aims and Questions
The aim of this study was to identify and explore with
leading third sector support workers, any barriers to accessing
healthcare experienced by victims of Human Trafficking.
The main objectives were:
1. To explore with third sector workers their knowledge
and personal experience in relation to supporting victims
of Human Trafficking accessing healthcare
2. Assess whether community/health service projects have
helped support victims
3. Identify any specific health sectors that present barriers
in accessing care
Methods
A qualitative research approach was conducted through a
focus group discussion. Agency representatives were used as
a proxy for the experiences of trafficked individuals accessing
care. This method was chosen as professional support workers
have a deep understanding of the potential challenges that
victims of Human Trafficking experience. Qualitative research
exploring Human Trafficking, has been noted to be an invaluable
resource, providing a deeper understanding of the true extent of
the posed challenges that victims are presented with Hennink,
Hutter and Bailey [26].
Recruitment
The third sector agency representatives invited to take part in the
focus group were primary leads involved with victims of Human
Global Health Care Concerns
Access to Healthcare for Victims of Human Trafficking: A focus group with Third Sector Agencies 79
Trafficking in Cardiff & Vale (C&V) University Health Board.
Some agencies had cross national representation with the asylum
process and Human Trafficking agenda; others represented smaller
local bespoke projects. All agencies represented had experience of
the challenges faced by victims of Human Trafficking. Electronic
invitation letters, along with a Participant Information Sheet (PIS)
were sent to Directors of all third sector agencies, requesting their
support workers’ involvement in the research. After receipt of
the nominated names of participants by email, this was followed
up with a phone call. This provided an opportunity to clarify the
study’s aims and objectives. After receiving acknowledgement
and nominated names, an email was sent to the recommended
potential participants along with the PIS. The only inclusion criteria
for recruitment was previous or current experience in supporting
victims of Human Trafficking.
Ethical approval
Ethical approval was obtained from the University of
South Wales. An electronic PIS was developed and provided to
potential participants by email. To support confidentiality and
anonymity, ground rules were discussed, and each participant
chose a pseudo name prior to the focus group commencing.
Any identifiable information that was disclosed during the focus
group, was anonymised on transcribing. The audio recording
was destroyed following transcription.
Data collection and analysis
One 80-minute focus group of six participants with
representation from third sector agencies was conducted in
November 2017 in one of the third sector agency offices,
at a central city location. The discussion was facilitated by
moderators EB and JS. Although, the moderators were flexible
in their approach, a topic guide was used to facilitate and guide
discussion (Figure 1). Participants included support workers
with experience of working with male victims, female victims
and as acting advocates for children.
The focus group was audio recorded and professionally
transcribed verbatim. The transcript was independently read and
re-read by the first author (EB) and then thematically analysed
using a coding framework. Themes and sub-themes were
identified. The transcription was kept securely on a passwordprotected computer and within a password-protected word
document. Only the first and second authors (EB, JS) had access
to the transcription.
Purposeful sampling was utilised to reflect a cross section
of the lead third sector organisations across C&V with a view
to recruit between 6-8 participants. The identified sample size
and sampling method was deemed by the authors as the most
applicable for the purpose of this study, as acknowledged by
Robson and McCarten (2016) [27]. Of the 14 participants
initially invited, 8 agreed informally via email to take part;
representing 9 leading third sector agencies. Of the 8 who
expressed interest, 6 were recruited and actively participated;
representing 4 leading third sector agencies (Figure 2).
Results
Four overarching themes emerged from the analysis, a call
for improved access to treatment for mental illness, improved
knowledge and training of health professionals, the complexities
of navigating two systems (NRM/Asylum Process) and victim’s
self-identification (Figure 3).
Further mental health provision required to support
victims of human trafficking
The need for improved access to mental health services was
recognised by all participants. Current services were described
as inconsistent and disjointed:
Aisha Access to mental health is honestly very, very difficult.
We have people telling us that they’re feeling suicidal and they
will discuss thoughts of self-harm. But taking them to the GP
What is your experience in supporting victims of human trafficking?
What are the challenges or support needs for victims of human trafficking?
An aspect I am particularly interested in, is health access and registration of patients?
What is the impact of the asylum process and the National Referral Mechanism (NRM) having on
victims affected by human trafficking?
Are victims who are destitute and have no recourse to public funds prevented to registering with primary
care services?
Are translation services and provision of information a concern?
Is training a concern?
Is continuity of carer a concern?
Are there specific health disciplines considered to be more of a concern regarding access than others?
(e.g. Accident & Emergency, Mental Health, Primary Care, Dental, Maternity)
Should Health be a first responder with regards the NRM process?
With the increased commitment across the UK in tackling the human trafficking agenda, have you
noticed an improvement in access to care? And what has influenced this? Or do gaps remain?
How do you perceive the knowledge and processes of healthcare staff and safeguarding personnel when
dealing with cases of human trafficking?
Figure 1: Focus group questions.
Global Health Care Concerns
80
Emily Brace
(General Practitioner) and getting them to be taken serious as
a victim of Human Trafficking is not always straightforward.
Getting a mental health referral is also a massive uphill struggle.
Catrin We’re finding that people are often confused
and overwhelmed with their mental health and immediate
counselling or talking therapy is not usually available.
Jameela It takes a long, long time to get someone to be
referred into mental health services and even get them assessed.
They just think ‘witchcraft’ or ‘juju magic’ because they’re from
that part of the continent.
Some participants considered time and financial pressures were
likely to be challenging factors on the current health service:
Third Sector Agencies Approached
9
Participants Invited
14
Expressed Interest
8 participants from 6 agencies
Agencies Actively Recruited
4
Participants Actively Recruited
6
Participant demographics
Support Area
Length of Experience Numbers (N)
Male Victim Refuge
4 years 6 months
1
Female Victim Refuge
4 years
1
Floating Community
3 years 6 months
2
Support
Community Advocacy
Support
1 year 6 months
10 years
1
Paralegal Support
6 years
1
Figure 2: Participant numbers.
Overemphasis on
immigration status
Sky I think ultimately it comes down to money. The NHS
seems to be working at a pace where they will try everything the
cheapest methods first. Then the problem either stays the same
or gets worse….
Most participants expressed concerns of the potential
overuse of medication in managing victims of Human
Trafficking psychological trauma. They voiced concerns around
the ‘blanket solution’ of prescribing and with no exploration of
the wider picture during health consultations. Participants did
mention that selective serotonin reuptake inhibitors (SSRI’s)
were an effective component of mental health management, but
urged for this to be in collaboration with psychological therapies
which was reported, to be currently limited for victims:
Sky I had a client that came to me the other day who had
been given medication. I think everyone who claims asylum
gets given anti-depressant medication. They don’t get explained
what it is, they don’t get offered other resources to health first,
they just get handed medication. It’s become the norm.
Blanket approach to
medication over
therapeutic support
Inconsistency with
NRMs
Not equitable
Reactive rather
than procative
Exacerbates
mental illness
Advocacy
support
Processes impact
health access
Language Barriers
Missed
opportunities for
early identi?cation
Fear of becoming
‘institutionalised’
Specialist
Services are
pivotal
Training to reach
frontline sta?
Improved training to
empower individuals
Juju Magic
Indoctrinated
Misconceptions of
exploitation & mental illness
Figure 3: Thematic Analysis Network.
Global Health Care Concerns
Access to Healthcare for Victims of Human Trafficking: A focus group with Third Sector Agencies 81
Aisha I think 90% of the people that we support are on antidepressants because that’s a blanket solution. I think it does
help if you have someone to advocate or accompany the person
to health appointments, as clients sometimes don’t have the
confidence to challenge or to say, ‘why do you keep giving me
anti-depressants? They’re not helping’.
Catrin I agree that’s a short-term solution Aisha, but it
shouldn’t even be happening; more awareness and other
solutions should be considered. Essentially why is it that we
must go and advocate for people not to be on anti-depressants
and get holistic mental health care?
One participant, described that the provision of psychological
therapy for members of the Black and Minority Ethnic (BME)
communities was inadequate. Prescription of SSRI’s over
therapeutic support, was often identified as being the common
course of action recommended for BME members:
Sue I went to a recent presentation around mental health
and regardless of language, the BME community in general get
medication as a first option far more. The figures they gave were
amazing.
Due to language barriers access to websites and leaflets was
also raised as an added challenge for victims:
Sky I knew someone who recently had some mental health
issues, a British person and they went to the GP and the first
point of call, was to give them some website information about
how to cope and to advise them of some g …
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