Providing medical care for suspected human trafficking victims: Perceptions among a cohort of health care providers in Myanmar

Background: Myanmar is a source country for men, women, and children who are subject to human trafficking and forced labor. Given that human trafficking and forced labor victims frequently experience physical and mental health concerns, healthcare practitioners have a unique opportunity to identify and assist victims. This study aims to understand the attitudes, perspectives, and levels of comfort for healthcare providers in caring for victims of human trafficking. It also seeks to understand the types of additional educational resources that could better equip medical personnel to improve care for survivors of human trafficking. Methods: A 20-question survey collected data anonymously from a convenience sample of healthcare providers that attended a one-day emergency care conference in Yangon, Myanmar. Results: While a significant number (70%) of medical professionals surveyed reported that they feel the problem of abuses for labor or sex in the community was "serious" or "very serious", a majority of them felt neutral or uncomfortable about identifying patients that are currently being abused in some way. Only 2% of respondents felt comfortable identifying victims of abuse. Over half of the healthcare workers surveyed indicated they would be interested in attending conferences, symposia, or lectures specific to human trafficking and receiving training in identifying victims and assisting victims of exploitation. Conclusions: Health care providers in Myanmar consider labor and sex trafficking as a significant problem in their community, but do not feel adequately trained to identify and help victims of exploitation. Given that even brief educational interventions can increase providers knowledge and self-reported recognition of human trafficking victims, there is a window of opportunity in Myanmar to provide training to currently practicing health providers.


Abstract
Background: Myanmar is a source country for men, women, and children who are subject to human trafficking and forced labor. Given that human trafficking and forced labor victims frequently experience physical and mental health concerns, healthcare practitioners have a unique opportunity to identify and assist victims. This study aims to understand the attitudes, perspectives, and levels of comfort for healthcare providers in caring for victims of human trafficking. It also seeks to understand the types of additional educational resources that could better equip medical personnel to improve care for survivors of human trafficking.
Methods: A 20-question survey collected data anonymously from a convenience sample of healthcare providers that attended a one-day emergency care conference in Yangon, Myanmar.
Results: While a significant number (70%) of medical professionals surveyed reported that they feel the problem of abuses for labor or sex in the community was "serious" or "very serious", a majority of them felt neutral or uncomfortable about identifying patients that are currently being abused in some way. Only 2% of respondents felt comfortable identifying victims of abuse. Over half of the healthcare workers surveyed indicated they would be interested in attending conferences, symposia, or lectures specific to human trafficking and receiving training in identifying victims and assisting victims of exploitation.
Conclusions: Health care providers in Myanmar consider labor and sex trafficking as a significant problem in their community, but do not feel adequately trained to identify and help victims of exploitation. Given that even brief educational interventions can increase providers knowledge and self-reported recognition of human trafficking victims, there is a window of opportunity in Myanmar to provide training to currently practicing health providers.

Background
Human trafficking broadly involves situations of exploitation that a person cannot refuse or leave due to threats, coercion, deception, or abuse of power. It includes acts of forced labor, that includes modern slavery, debt bondage, and sex trafficking. In 2016, it is estimated that 25 million people were victims of forced labor, including 4.3 million children. (1) Human trafficking continues to be a significant problem in Myanmar (formerly Burma). It is a source country for forced labor and sex trafficking in Burma and abroad, most commonly Thailand and China, supplying victims that include men, women, and children. In 2019, Myanmar was given the lowest designation of a Tier 3 country in the US State Department's Trafficking in Persons Report (2) Health care services can be an inroad to assisting victims of human trafficking. A considerable percentage of human trafficking victims are known to interface with medical providers during their time being trafficked, and these interactions are considered an opportunity to identify and aid these victims. (3,4,5). Further, victims have specific health needs while being trafficked, and require ongoing specialized care after surviving and escaping. (3,6,7). The ability to identify, approach, and treat current victims and post-trafficking survivors, requires an indepth understanding of these specific needs, including specialized training and access to resources. (4,7,8,9) This study sought to better understand the current state of opinion on providing health care to victims of human trafficking amongst emergency health care practitioners in Myanmar. The findings sought to understand providers' level of comfort in caring for victims of trafficking, in order to aid in the development of educational resources that may augment their care for these individuals.

Methods
A 20-question survey was delivered to a convenience sample of health care providers attending a one-day emergency medicine conference in Yangon, Myanmar.
The educational conference was held in May of 2017, and was open to all healthcare providers including trainees. The content of the conference covered key topics in emergency care and was primarily directed to providers who manage acute care patient populations. There was no training or practice criteria required to attend, and the conference was open to public and private providers. Upon arrival to the symposium, all attendees over the age of 18 were asked to fill out a short survey. Participation in the survey was entirely voluntary and anonymous, which was explained in writing on the survey and verbally to participants. Their participation in the survey did not interfere with their participation in the course and no incentives, financial or otherwise, were offered to attendees in exchange for participation. All information was presented in English.
Data was collected by paper form. Survey questions covered broad categories, including provider demographics, provider experience with and understanding of delivering health care to victims of human trafficking, and perceptions on future need. Survey questions were informed by previous research that characterized the prevalence of victim's encounters with healthcare workers, and the types of medical visits that may be common for those encounters (10,11). Questions in our survey included self-reported ability to identify patients as victims of abuse, awareness of services available for victims of trafficking, and the current state of acute care medical services and training.
Questions were a combination of Likert scale and multiple choice with 2 spaces for free text comments regarding 'next steps' after identifying a concern within a patient encounter. Additional survey edits were made by Dr. Htoo Ohn given his fluency in English and Burmese to ensure the intent of the questions were clear.
The data was compiled electronically, extracted, and analyzed via Stata (Version 13, College Station, TX). Comparisons at the univariate level stratified on comfort in identifying patients that are victims of abuse, as well as comfort in identifying next steps in care were completed with Chi-square and Fisher's exact tests where appropriate. We considered statistically significant results with p-values of 0.05 or less.
No identifying data regarding the respondent's name, program, geographic location, or patient name was gathered.
This study was approved by the hospital institutional review board and deemed to be exempt from the formal informed consent. Permission was granted by the Symposia leadership to distribute the survey to participants.

Results
A total of 212 participants completed the survey. Of these, 92% (n = 194) were doctors, and 8% (n = 18) were nurses. They worked in government hospitals (50%, n = 106), private practice (42%, n = 90) or both (8%, N = 16). Overall, very few healthcare providers feel comfortable both identifying and caring for suspected victims of abuse, regardless of their training background. A majority of respondents noted they would be "uncomfortable" or "very uncomfortable" identifying patients who are being abused for labor or sex (60%, n = 126). Only five felt comfortable with identifying victims of abuse (2%), with the rest (36%, n = 73) feeling neutral on this skill. Those who felt comfortable identifying victims of abuse were also significantly more likely to report feeling comfortable caring for these victims (p < .001). There was a slight trend toward those with specific training in treatment of injuries such as broken bones, bleeding, and trauma in feeling more comfortable identifying victims of abuse (p = 0.09).
If respondents were to identify a patient who was a suspected victim of abuse, only 8% (n = 18) felt that they would be comfortable identifying the next step in their care, with the majority being uncomfortable (45%, n = 96) or neutral (38%, n = 81). When asked specifically what their next steps would be in open response, several remarked that they would offer counseling and reassurance, and a few mentioned referrals to the authorities, social services, or other aid organizations. 55% (n = 116) report being aware of counseling services available for patients psychologically affected by exploitation or abuse. There was a significant relationship between providers who considered traumatic injuries such as broken bones to be a serious problem in their community and those individual's comfort in caring for patients with suspected abuse (p = 0.031).
Only 21% (n = 45) reported having encountered patients who were victims of abuse by their employer, and of these the majority report seeing this infrequently, e.g. less than 5 times in their career (15%, n = 31). 30% (n = 63) of respondents report having treated patients with severe anxiety or post-traumatic stress disorder (PTSD) in relation to exploitation or abuse for labor or sex.
More broadly, 70% identify the problem of abuses for labor or sex in the community they serve as "serious" or "very serious." When asked about future educational opportunities, 64% (n = 136) were interested in receiving training in identifying and assisting victims of exploitation and 46% (n = 97) expressed interest in becoming part of a service provider network assisting victims of exploitation.

Discussion
Human trafficking victims interface with medical professionals during and after their time of abuse, a time that is seen as a window of opportunity for identifying and aiding these victims. This study shows that some medical professionals in Myanmar are self-described as largely inexperienced and untrained in working with victims of human trafficking. This education gap appears to be irrespective of the providers' training or specialty.
However, the survey does demonstrate an opportunity for intervention through education, as a large proportion (64%) of these respondents demonstrated interest in training in this area. Further, many (46%) also demonstrated interest in being a part of a service provider network assisting victims of exploitation in Myanmar.
Health care providers with previous training in human trafficking are more likely to acknowledge human trafficking as a local problem, are more able to identify victims, and have greater confidence in providing care to these victims. (12) Education for healthcare workers can be built into medical school curricula, or can be offered as a stand-alone short course or presentation. Health care providers have demonstrated benefit from short presentations and training in caring for victims of human trafficking, improving their ability to identify and aid victims of human trafficking. (13,14) Such training programs and specialized curricula can ensure providers are identifying victims and are providing trauma-informed and culturally sensitive care. (15,16) These survey results indicate that healthcare providers in Myanmar are interested in further education and involvement in providing direct services to human trafficking victims.
There are inherent biases in our sampling process, as we employed a convenience sample rather than a random sample. Individuals attending this symposium may not accurately represent the broader population of health care workers in their knowledge of and experience in treating victims of human trafficking. Further, delivery of the survey in English may have limited the number of our participants.

Conclusions:
In Myanmar, where human trafficking continues to be a significant problem, the interaction between medical professionals and their patients is a key opportunity for identifying and addressing trafficking and other human rights abuses. There is an opportunity for education surrounding this topic for healthcare providers in Myanmar, who may be in the position to aid victims of trafficking.

Not Applicable
Ethics approval and consent to participate: This study was approved by the Stanford University institutional review board and deemed to be exempt from formal informed consent given their determination that this research does not involve human subjects as defined in 45 CFR 46.102(f) or 21 CFR 50.c(g). HSR Determination # 43086. Permission was granted by the Symposia leadership, Dr. Htoo Ohn, to distribute the survey to participants. In Yangon, the study protocol was also reviewed by the Golden Zaneka Public Limited Ethics Committee and was approved. Letter of approval available upon request.

Consent for publication:
Not Applicable Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request Competing interests: The authors declare that they have no competing interests Funding: There was no funding for this study Authors' contributions: RW created the survey, designed the study and led the research team. AS created and distributed the survey in Myanmar. CB analyzed and interpreted the data. SZ initiated manuscript and performed background literature search. HO organized survey participants and edited survey. All authors read and approved the final manuscript.