Strategies for healthcare professionals to identify and assist migrant children at risk of labour exploitation or trafficking

Increasingly large numbers of children and youth are migrating across international borders with many seeking employment in both formal and informal work sectors. These young people are at high risk of exploitation. Healthcare professionals need to be able to recognise vulnerable patients and advocate for their protection and safety, yet there is a paucity of literature that provides guidance on how to accomplish this. The goal of this paper is to provide guidance to clinicians on identifying and assisting migrant paediatric patients at risk of being exploited in the work sector, including conducting a risk assessment and making decisions about mandatory reporting. First, the best interest of the youth within their cultural context should be examined respecting their desires and goals, as well as immediate and longer-term physical health, mental health and safety issues. Second, clinicians should consider the best interest of the family, with attention to varying socioeconomic and psychosocial conditions including acculturation, immigration challenges, as well as cultural norms and values. Third, the situation must be evaluated within the legal framework of the host country regarding child labour, exploitation and trafficking. Cultural humility, open-mindedness, the active engagement of patients and families and an understanding of child labour within cultural contexts and legal statutes will empower healthcare professionals to identify and support patients at risk of exploitation in work settings. These recommendations serve to prioritise the best interests of vulnerable working migrant children and youth. The healthcare and migration systems of the USA will be used as a case for exploration.

Creating a Collaborative Trauma-Informed Interdisciplinary Citywide Victim Services Model Focused on Health Care for Survivors of Human Trafficking

Although human trafficking is recognized as a public health issue, research on the health effects of human trafficking and best intervention practices is limited. We describe 2 citywide collaborative victim services models, the THRIVE (Trafficking, Healthcare, Resources, and Interdisciplinary Victim Services and Education) Clinic at the University of Miami and Jackson Health System in Miami, Florida, and the Greater Houston Area Pathways for Advocacy-based, Trauma-Informed Healthcare (PATH) Collaborative at Baylor College of Medicine, CommonSpirit Health, and San Jose Clinic in Houston, Texas, funded in part by the Office for Victims of Crime, which focus on trauma-informed health care delivery for victims of human trafficking. From June 2015 through September 2021, the THRIVE Clinic served 214 patients with an average age of 28.7 years at the time of their first visit. From October 2017 through September 2021, the PATH Collaborative received 560 suspected trafficking referrals, 400 of which screened positive for labor or sex trafficking. These models serve as a framework for replication of interdisciplinary practices to provide health care for this unique population and preliminary information about the strategies put in place to assist victims during their recovery. Key lessons include the importance of a citywide needs assessment, patient navigators, interdisciplinary care, and building community partnerships to ensure safe housing, transportation, identification, health insurance, vocation services, input from survivors, peer-to-peer mentorship, and medical-legal services. Further research is needed to understand the detrimental health effects of trafficking and the health care needs of victims. In addition, a need exists to develop optimal models of care for recovery and reintegration for this patient population and to address public health, legal, and medical policies to ensure access to and sustainability of comprehensive, trauma-informed, interdisciplinary victim services.

Professional integrity in maternal - fetal innovation and research: an essential component of perinatal medicine

OBJECTIVES

Clinical innovation and research on maternal-fetal interventions have become an essential for the development of perinatal medicine. In this paper, we present an ethical argument that the professional virtue of integrity should guide perinatal investigators.

METHODS

We present an historical account of the professional virtue of integrity and the key distinction that this account requires between intellectual integrity and moral integrity.

RESULTS

We identify implications of both intellectual and moral integrity for innovation, research, prospective oversight, the role of equipoise in randomized clinical trials, and organizational leadership to ensure that perinatal innovation and research are conducted with professional integrity.

CONCLUSIONS

Perinatal investigators and those charged with prospective oversight should be guided by the professional virtue of integrity. Leaders in perinatal medicine should create and sustain an organizational culture of professional integrity in fetal centers, where perinatal innovation and research should be conducted.

Motivational Interviewing as a Therapeutic Strategy for Trafficked Persons

It is estimated that 40 million people worldwide have experienced human trafficking (UN, International Labour Organization & Walk-Free Foundation, 2019), with 313,000 trafficked persons in the state of Texas alone (Busch-Armendariz et al., 2016). These staggering numbers are indicative of human trafficking as a growing public health concern. To date researchers have neither studied nor proposed a specific psychotherapeutic modality in the treatment of trafficked persons. Given the unique concerns of this populations, including mistrust of authority, emotional coercion, and abuse by traffickers, often co-occurring substance use concerns, and difficulty with standard treatment adherence, we propose a therapeutic strategy that might assist providers in addressing a broad range of concerns, particularly assisting trafficked persons in the effort to leave their situation. This strategy is motivational interviewing (MI; Miller et al., 2009) and has shown substantial efficacy to enhance motivation to change as applied within in a broad range of healthcare settings. We briefly review the broad tenants of MI and illustrate its application within two hypothetical cases of trafficking. Future research that examines the potential benefits of MI within trafficking populations is warranted.

Potential Impact of Climate Change on Human Trafficking: A Narrative Review

ABSTRACT

Climate change is a threat to the public health with wide-reaching impacts that are becoming more studied and recognized. An aspect of climate change that has not yet gained adequate scholarly attention is its potential impact on human trafficking. We review the potential impact of climate change on risk factors to human trafficking including poverty, gender inequality, political instability, migration or forced displacement, and weather disasters. We conclude that climate change is a crucially important consideration in understanding the complex and multifactorial risks for human trafficking. These findings add to the priority for health professionals to embrace efforts to prevent and to mitigate the effects of climate change and to take account of these risk factors in screening and identifying trafficked persons.

Trustworthiness and Professionalism in Academic Medicine

Trustworthiness is the cornerstone professional virtue in the practice of medicine. The authors' goals for this Invited Commentary were to provide an account of the professional virtue of trustworthiness and its historical origins as well as to suggest how trustworthiness in a professional curriculum can be taught and assessed. They identified 2 components of trustworthiness that originate in the work of John Gregory (1724-1773) and Thomas Percival (1740-1804), who invented the ethical concept of medicine as a profession. The first is intellectual trust, the commitment to scientific and clinical excellence. The second is moral trust, the primary commitment of physicians and health care organizations to promote and protect the interest of patients while keeping individual and group interests secondary. Teaching should focus first on the mastery and understanding of the conceptual vocabulary of intellectual and moral trust through a range of formats, including modeling by faculty on how they respect and treat patients and learners. Assessment should be behaviorally based and articulated in increasing, observable, and integrated levels of mastery through training. Medical educators and academic leaders also share the responsibility to inculcate and sustain an organizational culture of professionalism that is respectful, critically self-appraising, accountable, and committed to its learners and to the promotion of physician well-being. These proposals can be used by medical educators and academic leaders to assist learners to become and remain trustworthy physicians.

Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs

OBJECTIVE

This study sought to evaluate the status of psychiatric education in Ob/Gyn residencies.

METHODS

A 17-item anonymous questionnaire was sent to program directors of 239 Ob/Gyn US residencies. Data analysis was performed using STATA 14.2.

RESULTS

Ninety-five programs participated (40%), including partial responses. The majority of Ob/Gyn programs offered didactics in psychiatric topics (84%), with most of the sessions provided by Ob/Gyn faculty. Programs that reported didactics led by psychiatric faculty (57.9%) were more likely to have a higher number of mental health didactics in total. Fewer than half of programs covered intimate partner violence (47%), non-obstetric depression (44%), anxiety (43%), medication management (30%), eating disorders (26%), human trafficking (20%), or PTSD (11%). Elective rotations involving mental health were offered by 20% of programs. Barriers to psychiatric training were lack of integration between Ob/Gyn and psychiatry (46%), ACGME surgical requirements (42%), and lack of knowledgeable instructors (38%). Most program directors (81%) disagreed that residents are fully equipped to identify psychiatric needs in patients.

CONCLUSION

Lack of integration between Ob/Gyn and psychiatry was the most cited barrier to effective psychiatric education of Ob/Gyn residents, highlighting the importance of increased partnership between the two fields. Didactic instruction decreased compared to 2001, and considerable gaps still remain. Most program directors perceive that residents are not equipped to identify patients' psychiatric needs.

Towards a Definition of "Self-Neglect" in Psychiatric Patients: Descriptions of a Case Series

Self-neglect, although frequently studied in geriatric populations, has received only limited attention in psychiatric populations. To address this gap, we utilize a behavioral framework to present a set of case examples in order to illustrate the complex relationship between self-neglect behaviors and conditions and various psychiatric illness. Cases are discussed with respect to ascending severity of presentations of self-neglect in adult non-geriatric inpatient psychiatric populations. Self-neglect is conceptualized as a range of behaviors, as well as an overall condition that affects an individual's functioning in several major domains. The concept of self-neglect in non-geriatric psychiatric patients warrants additional study, including development of a formal definition, as well as evaluation of its associated manifestations and implications for treatment and prognosis.

"Just one bad high:" considering synthetic cannabinoid outcome expectancies in adolescents

BACKGROUND/OBJECTIVES

Certain medical consequences seem unique to synthetic cannabinoid (SC) and not cannabis use. We report the case of an adolescent, whose drug expectancies appear to minimize the severity of SC-related adverse events.

METHODS/RESULTS

An 18-year-old male presented with altered mental status and seizure, complicated by respiratory failure. He was stabilized and on discharge, despite counseling on the harms of SC usage, the patient planned to resume use, insisting that the hospitalization was "just one bad high".

DISCUSSION/CONCLUSIONS/SCIENTIFIC SIGNIFICANCE

Diminished negative expectancies related to SC use among adolescents may reflect generalizations from cannabis. Effective interventions should counter cannabis-related expectancies of minimal harm. (Am J Addict 2016;XX:1-3).

A Randomized Controlled Trial of Team-Based Learning Versus Lectures with Break-Out Groups on Knowledge Retention

OBJECTIVE

This goal of this study was to evaluate the efficacy of team-based learning (TBL) on knowledge retention compared to traditional lectures with small break-out group discussion (teaching as usual (TAU)) using a randomized controlled trial.

METHODS

This randomized controlled trial was conducted during a daylong conference for psychiatric educators on attention-deficit hyperactivity disorder and the research literacy topic of efficacy versus effectiveness trials. Learners (n = 115) were randomized with concealed allocation to either TBL or TAU. Knowledge was measured prior to the intervention, immediately afterward, and 2 months later via multiple-choice tests. Participants were necessarily unblinded. Data enterers, data analysts, and investigators were blinded to group assignment in data analysis. Per-protocol analyses of test scores were performed using change in knowledge from baseline. The primary endpoint was test scores at 2 months.

RESULTS

At baseline, there were no statistically significant differences between groups in pre-test knowledge. At immediate post-test, both TBL and TAU groups showed improved knowledge scores compared with their baseline scores. The TBL group performed better statistically on the immediate post-test than the TAU group (Cohen's d = 0.73; p < 0.001), although the differences in knowledge scores were not educationally meaningful, averaging just one additional test question correct (out of 15). On the 2-month remote post-test, there were no group differences in knowledge retention among the 42 % of participants who returned the 2-month test.

CONCLUSIONS

Both TBL and TAU learners acquired new knowledge at the end of the intervention and retained knowledge over 2 months. At the end of the intervention day and after 2 months, knowledge test scores were not meaningfully different between TBL and TAU completers. In conclusion, this study failed to demonstrate the superiority of TBL over TAU on the primary outcome of knowledge retention at 2 months post-intervention.

Is pharmacologic research on pregnant women with psychoses ethically permissible?

There is a consistent view in the literature that research on pregnant woman with psychoses is ethically questionable or impermissible. This paper provides a critical appraisal of these views by asking whether pharmacologic research on pregnant women with psychosis for maternal, fetal, and newborn benefit is ethically permissible. We examine separately the documented clinical benefits and risks to the pregnant patient, the fetal patient, and the neonatal and pediatric patient. The outcomes reported in the pertinent literature do not support the conclusion that pharmacologic management of psychosis during pregnancy results in documented, unacceptable risk to the pregnant, fetal, or neonatal patient and is therefore ethically ruled out. Claims that research on the pharmacologic management of psychosis during pregnancy is ethically impermissible because of unacceptable risk of harm to pregnant, fetal, neonatal, or pediatric patients cannot therefore be supported. Having shown that such research is permissible, we then ask what ethical considerations should guide study design. We show that Phase I studies are appropriate and can meet the requirements of the Common Rule, which are more specific than international guidance. As a matter of professionally responsible obstetric practice, pregnant women with psychoses should be included, and not be neglected, in research for both maternal and fetal benefit.

The Prevalence of Physicians Who Have Been Stalked: A Systematic Review

It has been suggested that physicians are particularly vulnerable to being stalked. Our goal was to examine the prevalence of physicians who have been stalked and the associated consequences for the victims. We conducted multiple searches of PubMed and PsycINFO for articles in English from 1950 to 2013, using the terms stalker, stalking, aggression, assaults, patient, physician, resident, registrar, intern, and trainee. Reference lists of relevant articles were also searched. We developed and used a five-point evaluation tool for critical appraisal of the articles. We found 12 prevalence studies on the stalking of physicians, of which 8 were national surveys and 4 were focused exclusively on stalking. The studies varied in their methodological quality with common limitations including the lack of a national sample, the lack of construct validity of the survey tool and of the provision of a formal definition of stalking, and low response rates. Prevalence rates ranged from 2 to 25 percent, although one study found a prevalence rate of 68.5 percent. Information on the physical and psychological consequences of having been stalked was also limited. Although a substantial minority of physicians reported having been stalked, there remains a dearth of high-quality studies on the topic.