Modern slavery, which includes human trafficking, is the recruitment, movement, harbouring or receiving of people through the use of force, coercion, abuse of vulnerability or deception for the purpose of exploitation (Such et al, 2017). The Global Slavery Index (2018) estimates that 136 000 people in the UK are living in modern slavery and one in eight clinicians comes into contact with a victim (a person still trapped in a modern slavery situation) at least once in their career (NHS England, 2016). Due to the higher prevalence in urban areas, however, this is likely to be a massive underestimation (Home Office, 2017).
Clinicians are in a unique but time-restricted position to help those who are being trafficked as barriers to healthcare means they may only seek help in emergency situations (Price et al, 2019). However, many health professionals are unaware of the issue itself or its magnitude. The limited contact practitioners have with this group means missing the indicators of modern slavery has a greater impact because it may force the victim to return to their exploiter (Ross et al, 2015).
Despite this, evidence-based guidance for clinicians to confidently identify and meet the complex care needs of these service users is inadequate (Hemmings et al, 2016). With training, paramedics would be in an optimal position to detect modern slavery; the nature of the ambulance paramedic role in particular means they can give more time to individual patients than other health professionals. Furthermore, paramedics see patients in their homes and workplaces, which increases the opportunities for identifying the signs of modern slavery (Box 1).
Aim
The aim of the current review is to synthesise the available literature relating to modern slavery and relate it to the paramedic context. Paramedics have a unique opportunity to tackle modern slavery and have the potential to alleviate suffering in a vulnerable group of people. An e-learning package may be enough to increase awareness of the indicators of modern slavery and the common contexts in which it occurs.
Method
A variety of databases (MEDLINE, AMED, PsychINFO, ERIC, CINAHL and Cochrane) were searched; this included those focusing on medicine, psychology and education because of the extensive impact of human trafficking and the multidisciplinary nature of the research and collaboration needed to combat the issue. A wide variety of studies were identified and considered for inclusion in the review. Abstracts were searched using keywords combined with Boolean operators (Appendix 1).
Modern slavery is an under-researched topic for a variety of reasons: many people do not believe that is an issue in their country; government response to the issue is still inadequate in most of the world; and research originates primarily from Europe, North America and Australasia (Global Slavery Index, 2018).
Following an assessment of the full text for eligibility, 11 articles were excluded because they focused on secondary care or clinic-based modern slavery recognition. The authors followed PRISMA guidelines (Moher et al, 2009) (Appendix 2). Five articles were included in the in-depth analysis and were summarised and themed by completing a critical summary table (Appendix 3), which identified the aims, types of data, main findings, strengths and limitations of the studies (Aveyard, 2014). A comparative analysis (Appendix 4) was carried out to identify relationships between the papers and to understand the topic more comprehensively (Paterson et al, 2001). Using this method, five themes were identified and inform the results and discussion in this review.
Results
The five themes identified were: barriers to healthcare access; causes of missing the indicators of trafficking; clinician knowledge; the need for training and education; and trauma-informed practices.
Barriers to healthcare access
One theme identified was the variety of reasons that victims may not access healthcare when they need it. Awareness of the barriers t ohealthcare may help to guide patient interaction in a potential modern slavery situation by using this knowledge to alleviate the barriers and encourage access to services.
Price et al (2019) created profiles for trafficking victims by grouping survivors (those who have been able to escape their exploiter) with shared experiences using by-person factor analysis (Q-methodology) and consulting with seven experts. This method of analysis allows practical application of the survivor profiles despite the relatively small sample size of 23 (McKeown and Thomas, 2013) and prevents researcher bias affecting results (Brown, 1996). Three victim profiles emerged: avoidant; constrained; and distrustful.
Avoidant respondents did not seek care unless it was essential because of a lack of time, limited options for transport and an opinion that health professionals would not know how to help. Of these respondents, 75% had been sexually exploited when they were younger than 16 years old.
Those in the constrained category had personal barriers such as poor mental health or substance misuse preventing them from accessing care but also identified lack of time and transport as factors.
The distrustful respondents were either still being exploited during the study or their exploitation had only recently ended. Consequently, they are the people paramedics may be most likely to come into contact with and have the greatest potential to help. This group avoids health services almost exclusively because of their poor experience with clinicians, stating that they do not listen, care or try to help.
Hathaway et al (2002) found that 8% of women victims did not disclose their abuse as they felt they were not being listened to by the clinician. It is therefore important to consider the ‘feeling of disenfranchisement’ (Price et al, 2019: 2) identified in the study by taking survivors' opinions and experiences into account and understanding the importance of making them feel heard. A positive experience with one paramedic could shape their opinion of the NHS and encourage them to seek help in the future (Macias-Konstantopoulos, 2016).
Causes of missing the indicators of trafficking
Poor listening and communication with victims was another key theme. Mason-Jones and Loggie (2019) conducted a thematic analysis of 11 child sexual exploitation serious case reviews in England. The breadth of reviews allowed themes to be identified, coded and compared to establish the deficits in practice that cause exploitation to be missed.
Although the nature of the review meant that only cases where serious harm or death occurred were included, the study does highlight where health professionals had the opportunity to prevent negative outcomes before this point. Given the unique perspective in healthcare that paramedics have because of the nature of their role and the opportunities for identifying cases of modern slavery that emerge as a result, their potential to play an important role in the identification of modern slavery cannot be overlooked. The main themes identified were: suboptimal communication and listening; a lack of knowledge, understanding and risk; and context and vulnerability.
The strongest theme across all cases was communication. In some of the cases, disclosures were made about rape and high numbers of sexual partners, which were subsequently reported as false allegations and not identified as indicators of abuse that should elicit safeguarding referrals. The findings emphasise the importance of effective communication and are supported by studies such as that by Price et al (2019), who found a lack of effective listening to be a barrier in the recognition of many types of exploitation.
It is important to note that health professionals who listened were perceived positively (Hathaway et al, 2002), which may encourage disclosure. Disclosure can be supported by recognising that purposefully omitted information and non-verbal communication such as avoiding eye contact or looking at the accompanying person for approval may be indicators that the patient is being coercively controlled (Macias-Konstantopoulos, 2016).
Clinician knowledge
Another key theme through all of the studies was clinicians' lack of knowledge regarding their role in identifying human trafficking.
In the UK, to address this knowledge deficit in 60.2% of NHS staff (Ross et al, 2015), Health Education England (2013) launched the ‘Identifying and supporting victims of modern slavery’ national e-learning project for health professionals. Helle and Steele (2019) found that only 0.12% of NHS staff completed the e-learning course, although more than 10 times that proportion of staff will encounter trafficking in their careers (Oram et al, 2015). It appears that providing a discretionary education package is not sufficient to address the apparent knowledge gap. Paramedics and other health professionals need to feel empowered to see that tackling modern slavery is part of their role.
Testa (2020: 97) found that health professionals had ‘a lack of clarity on policies’, experienced ‘procedural uncertainty’ and felt that the consequence of unfamiliarity and complacency was practice ‘blindness’, which impedes the care of those in modern slavery.
These findings are supported quantitatively as 87% of health professionals have been found to have insufficient knowledge to identify a person being exploited and 78% felt that they did not know the protocols to assist victims (Ross et al, 2015).
This knowledge is especially beneficial for paramedics as they may be assessing patients in their home environment. This could expose further evidence of trafficking and confirm the clinician's suspicions that trafficking is occurring. This is significant as it may be the only opportunity to remove them from the situation.
Need for training and education
One way to address this apparent lack of knowledge is through training and education. Although there was no clear conclusion regarding the form the training should take, all of the included studies recommended it.
To resolve the lack of training provided for health professionals on modern slavery, Metcalf and Selous (2020) designed and implemented training for 242 final-year medical students in Wales. A significant improvement in confidence was reported after the training and 93% of the students felt that it should be a compulsory component of their course. Despite this, only 16% of UK medical schools have compulsory modern slavery teaching (Metcalf and Selous, 2019).
Though the research shows deficits in the medical curriculum, the lack of knowledge on the subject demonstrated by a variety of health professionals indicates that a cautious generalisation of findings may be appropriate. A supporting study found that only 1.5% of the 94 responding acute care trusts in England provided training, separate from safeguarding, on the topic (Thompson et al, 2017). This is a concern as modern slavery has specific indicators and research shows that clinicians have previously mistaken victims of trafficking as sex workers (Broad and Turnbull, 2019).
Metcalf and Selous (2020) suggest improvements to their proposed training, including the integration of e-learning and partnership with anti-slavery networks, which mirror Helle and Steele's (2019) recommendations.
The incorporation of compulsory e-learning into healthcare and medical curricula would be one option to increase clinicians' awareness and knowledge of modern slavery, although it is clear that simply providing training is only part of the solution.
The training is not without its critics; Helle and Steele (2019) assessed the quality and uptake of the ‘Identifying and supporting victims of modern slavery’ e-learning, and found that the absence of collaboration with survivors and supporting organisations may have led to discrepancies.
They also found the resource to be limited in its representation of sex, sexuality and nationality, which may perpetuate the stereotype that only a specific type of person is trafficked and may contribute to the continued concealment of those not represented in the training. The strong focus on sexual exploitation and forced labour, the most prevalent forms of slavery in the UK, is acknowledged but not expanded upon. Elaboration on common employment roles such as those in nail bars, cleaning, construction, car washes and restaurants would be beneficial as many health professionals do not know that the problem affects their area (Chisolm-Straker et al, 2012) so may miss the indicators.
Additionally, although the national referral mechanism (NRM) is mentioned in the e-learning, the ‘MS1: notification of potential victim of modern slavery’ is not. The MS1 is used, in conjunction with a police referral, when an adult declines referral into the NRM. Despite being anonymous, this process is important for safeguarding, prevention and detection of crime, and improving the database, ergo, influencing policy (Thompson et al, 2017). Although staff should have an awareness of the NRM and the MS1 referrals, the NHS is not included in the organisations designated to refer directly into the NRM. NHS staff may, however, refer indirectly through the police, local safeguarding leads or certain charitable organisations.
Trauma-informed practices
All of the studies included in the current review stress the importance of knowledge of policies relating to modern slavery. Some focus on patient interaction and trauma-informed care while others focus on referral mechanisms; these are equally important as one focuses on patient care in the moment and the other in the future.
Testa (2020) emphasises the importance of implementing trauma-informed policies and having comprehensively trained health professionals at the first point of contact. This is particularly relevant to paramedics as they are often the first point of contact, and knowledgeable and empathetic responses have been shown to support disclosures (Hathaway et al, 2002).
Based on the Substance Abuse and Mental Health Services Administration's (2014) four key principles for a trauma-informed approach, which are perceived to be crucial to care, policy informed by knowledge on trauma is beneficial to patient care, as well as in providing clarity for health professionals on the stages of care. These key principles are: realising the impact of trauma; recognising symptoms; integrating knowledge into practice; and resisting re-traumatisation to facilitate patient empowerment. The principles of the trauma-informed approach reflect the recommendations of papers reviewed and support the proposed role of the paramedic in identifying modern slavery.
Discussion
While paramedics are in an optimal position to recognise and intervene in modern slavery, training is likely to be needed to address the apparent deficits in knowledge on this topic. The literature recommends implementing training guided by survivors of trafficking to better understand the barriers to healthcare this marginalised group experiences. Additionally, this will allow all health professionals to learn from past mistakes where clinicians have overlooked the indicators of exploitation. Paramedics should have the knowledge and capability to implement trauma-informed practices to facilitate survivor-centred care.
It is evident from the literature that policy specific to paramedics on their responsibilities regarding human trafficking is inadequate. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) clinical guidelines (Association of Ambulance Chief Executives, 2019) are key for paramedics, yet include only a definition of modern slavery and describe the risk factors for child sexual exploitation in the adult and children safeguarding sections respectively. In the absence of comprehensive guidelines detailing where slavery occurs and to whom, detection may be prevented through the perpetuation of stereotypes. It is evident that provision of further research is needed to create an evidence base from which practice and the development of policies can be guided.
Despite the lack of targeted guidance, the general requirements of a paramedic, which are outlined in the Health and Care Professions Council (2014) standards of proficiency and continuing professional development, can be applied. The standards highlight the need to maintain up-to-date knowledge in the light of changing contexts to be able to understand the need for assessment of both health and social care and the ability to identify appropriate care pathways for patients (HCPC, 2014).
There are a variety of appropriate resources for health professionals to consult on the subject of modern slavery. An example is the e-learning course which, despite its limitations, is still a beneficial and convenient resource, and the duty to notify fact sheet and posters (Home Office, 2016), which include information and a flowchart detailing the processes to follow in cases of suspected slavery. All of the available resources feature elements of the information required for paramedics to assess and safeguard patients. Information from a variety of sources (such as the ones mentioned in the article), and included in the JRCALC clinical guidelines pocketbook would be ideal but, in the absence of this, a pocket card such as the Royal College of Nursing's (2017) Modern Slavery Wheel could be used.
Studies have shown that there are areas of commonality in approaching care for hard-to-reach populations such as victims of modern slavery and intimate partner violence (IPV) to minimise barriers to healthcare access (Flanagan and Hancock, 2010). Approaches proposed include: respectful treatment of patients; establishing trust; partnership with other organisations; and promoting service user involvement (Flanagan and Hancock, 2010; Sawyer et al, 2015).
In addition to these recommendations, Sawyer et al (2015) suggest that failing to address disparities in knowledge and policy may cause paramedics to become a further barrier to healthcare access for these hard-to-reach populations. This reinforces the need for urgent training on these groups for frontline clinicians such as paramedics (Sawyer et al, 2014).
In a study on the adequacy of the preparation paramedics have for identifying IPV, 90% of participants reported encountering at least one case of IPV in 2013 (Sawyer et al, 2014) compared with 12.5% of nurses who had knowingly encountered modern slavery (Such et al, 2017). This contrast in perceived encounters is likely to be because IPV is a more common crime (Office for National Statistics, 2019) than modern slavery and consequentially is also more widely and publicly acknowledged. For this reason, there is more evidence-based training on IPV and therefore greater awareness and vigilance regarding the offence in healthcare settings.
The implications of these studies are:
Limitations
The present review concentrates on the intersection of paramedics and victims of modern slavery and, as a consequence, the research available on the topic is limited. Although the studies included are applicable to paramedics, they are not aimed at the profession and therefore can be said to apply synthetically rather than empirically to paramedic practice. While this is a limitation of this review, the lack of research on the topic identifies a gap in the literature and suggests that there are opportunities for primary research in this area.
Additionally, the interpretation of the findings may be subject to questions of bias as they reflect the authors' own understanding of the themes identified in the literature. However, the critical appraisal undertaken for each study and the comparative analysis employed may increase confidence and allow readers to cautiously relate the findings of this review to their own practice.
This review can also be used to advise the need for further research. Two key areas have been highlighted where there is little or no research:
Addressing these gaps in the literature may allow targeted guidance to be developed to aid paramedics in the identification, reporting and combating of modern slavery.
Conclusion
Modern slavery is a hidden crime in society that has a variety of negative impacts on the mental and physical health of its victims. The role of the paramedic in the recognition of modern slavery is not entirely identified by this review but areas where further research is needed have been distinguished. The review provides opportunity for reflection on and discussion of current practice for those of us who, with the benefit of hindsight, retrospectively recognise examples of modern slavery from previous practice.
Paramedics have a unique but limited opportunity to identify modern slavery, but the development of appropriate and comprehensive training is necessary to maximise the utility of the health professional in this area.