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2442 | Research and Practice | Peer Reviewed | Hossain et al. American Journal of Public Health | December 2010, Vol 100, No. 12
RESEARCH AND PRACTICE
prior to and during the period when they were posttrafficking needs (e.g., acute medical or were used, and mental health professionals
trafficked and symptoms of common mental mental health needs) and the provision of who were fluent in the target languages
disorders. assistance in accessing a range of support, checked the resulting questionnaires and ad-
Given the absence of evidence on common including social work, counseling, health care, justed them for cultural equivalency. Each
mental disorders in the posttrafficking care and legal and immigration advice. Specific participant was asked about abuses prior to
setting, we decided a priori to measure anxiety, approaches to posttrafficking care varied being trafficked (including experiences of
depression, and PTSD separately. Specifically, among study sites. physical and sexual violence), the duration and
given our earlier developmental work,4 we Because of the numerous ethical and safety circumstances of her trafficking experience
wanted to test whether posttrafficking mental concerns associated with interviewing traf- (including risks, violence, and freedoms), and
health symptoms could be explained by traffick- ficked persons, we contacted and interviewed physical and mental health symptoms within
ing-related exposures to violence, independent of only those girls and women who had already the 2 weeks prior to the interview.
experiences of violence before trafficking. We entered a service setting; no one was inter-
also wanted to explore the extent to which any of viewed while still in a trafficking situation.19 Measures
the trafficking-related exposures were associated Given the unpredictable and fluctuating number We chose to use screening instruments that
with anxiety, depression, or PTSD. This is the of clients entering posttrafficking services, re- were relatively easy to translate and had
first study to test such associations among a co- strictions on research time, and limitations on been validated and used among diverse pop-
hort of girls and women entering posttrafficking resources, we opted to extend consecutive in- ulations in low- and middle-income countries
assistance centers and to consider the implica- vitations to participate to every eligible girl or (or that had a closely related version that had
tions for policies and services that respond to the woman who entered a study-site service setting been validated and used in that way). To
needs of this vulnerable and often stigmatized between January 2004 and June 2005. Girls and measure mental health symptoms, we used 2
group.4 women were eligible to participate if they had instruments: (1) the depression and anxiety
been sexually exploited while in a trafficking subscales of the Brief Symptom Inventory20
METHODS situation and if a trained support worker deemed (BSI; a short, validated alternative to its parent
them emotionally capable of engaging in an instrument, the SCL-90-R20,21), which is closely
From January 2004 through June 2005, we interview. related to another widely used tool, the Hopkins
conducted face-to-face interviews with women A total of 220 girls and women were eligible Symptom Checklist,22,23 and (2) the posttrau-
and adolescent girls (aged 1545 years) who and were invited to participate. Seven of the matic symptom subscale from the Harvard
had been trafficked and sexually exploited 220 declined, and 9 interviews were excluded Trauma Questionnaire (HTQ).24 Both instru-
and were currently accessing posttrafficking either because the respondents were trafficked ments have been used among diverse popula-
services provided by a nongovernmental or for other purposes (i.e., panhandling, petty tions and in studies of other marginalized
international organization. Interviews were theft), interviews were terminated early, or groups.25,26
conducted in Belgium, Bulgaria, the Czech interviews were incomplete. A total of 204 girls Brief Symptom Inventory. The BSI depre-
Republic, Italy, Moldova, Ukraine, and the and women were included in this analysis, ssion and anxiety symptom subscales comprise
United Kingdom. Four of the study sites were the majority of whom were interviewed in 6 items each. Participants were asked how
locations where organizations provided post- Ukraine and Moldova. Trained counselors much the experiences described in each item
trafficking services in destination or transit obtained written consent from each participant had distressed or disturbed them in the prior
countries (Belgium, the Czech Republic, Italy, and carried out face-to-face interviews to en- week, with responses coded on a 5-point scale
and the United Kingdom). At these 4 sites, sure that any participant requiring follow-up ranging from not at all (zero) to extremely
participants were most commonly referred to had access to medical care, that all participants (4). The overall raw score is calculated by
posttrafficking care by law enforcement, legal were observed for distress, and that partici- summing each item score and dividing the sum
services, or any of a variety of nongovern- pants experiencing distress received appropri- by the total number of questions answered. All
mental organizations. The other 3 study sites ate follow-up care.19 The multicountry design raw scores range from zero to 4. Depression
were support centers in participants countries was adopted to reflect the global nature of was measured by the following items: (1) no
of origin (Bulgaria, Ukraine, and Moldova). trafficking and to improve the representation of interest in things, (2) hopelessness about the
At these 3 sites, participants were primarily trafficked womens and girls experiences within future, (3) worthlessness feelings, (4) loneliness,
referred to posttrafficking services by groups Europe. (5) very sad, and (6) suicidal thoughts. Anxiety
in destination settings as part of a return- was measured by the following items: (1)
and-reintegration process. More rarely, some Translation and Data Collection fearful, (2) tense or keyed up, (3) terror/panic
participants self-referred to a posttrafficking The study questionnaire was developed in spells, (4) restlessness, (5) scared suddenly
organization. collaboration with the posttrafficking service without reason, and (6) nervousness or shaki-
Posttrafficking services provide care to providers and was translated from English into ness inside.20
women following a trafficking experience. This Italian, Russian, Ukrainian, Bulgarian, Czech, The BSI provides 3 populations against
care generally includes an assessment of Polish, and Lithuanian. Professional translators which to standardize: psychiatric outpatients,
December 2010, Vol 100, No. 12 | American Journal of Public Health Hossain et al. | Peer Reviewed | Research and Practice | 2443
RESEARCH AND PRACTICE
psychiatric inpatients, and nonpatients. We against the participants family or loved ones, (6) participants originated from Moldova and
selected the psychiatric outpatient population restricted freedom of movement and activity Ukraine (Table 1), reflecting a higher client intake
as the referent group because (1) the psycho- (how free the participant felt to do what she at these 2 sites rather than the geographical
logical symptoms reported among trafficked wanted or go where she wanted), and (7) severe distribution of trafficked girls and women.
women have been found to be present at levels injury during trafficking. Participants reported high levels of physical
well above those found among a general and sexual violence both prior to and during
population,27 and (2) participants in the current Statistical Analysis the trafficking experience. During the traffick-
study had received or were receiving various We used basic descriptive techniques and ing period, more than 80% of participants had
physical or psychological health interventions calculated odds ratios (ORs) to describe the been subjected to sexual violence, threats of
from the assistance centers, suggesting a similar- frequency and distribution of all exposures and harm to themselves, and persistently restricted
ity to a patient population. We used a raw score their individual relationships to the 3 mental freedom. Fifteen percent had experienced
cutpoint of 1.87 or higher to define high levels health outcomes of interest. All plausible ex-
of depression symptoms, and we used a raw posures chosen for inclusion were checked for
score cutpoint of 1.71 or higher to define high logistic regression assumptions.30 Because of
TABLE 1Characteristics of Trafficked
levels of anxiety symptoms. These cutpoints are the small sample size, all exposures were coded
and Sexually Exploited Girls and
equal to or greater than the 50th percentile of into dichotomous form. Variables considered for
Women (n = 204): Posttrafficking Care
scores for a referent group of female psychiatric inclusion were those described above as pre-
Sites in 7 European Countries,
outpatients.4,20 trafficking and trafficking-related exposures.
20042005
Harvard Trauma Questionnaire. We used The mental health outcome variables were
the PTSD subscale of the HTQ to assess divided into dichotomous variables (negative/ Characteristics No. (%)
participants presenting with symptoms of positive) on the basis of the cutpoints described
Countries of origin
PTSD. The HTQ includes 16 items that are above. We used multiple logistic regression
Moldova 71 (34.8)
based on the Diagnostic and Statistical Manual analysis to develop the hypothesis model and
Ukraine 52 (25.5)
of Mental Disorders, Third Edition, Revised, explore which pretrafficking, trafficking, and
Other Europeana 59 (28.9)
and the Diagnostic and Statistical Manual of duration exposures were most significantly
West African, Caribbeanb 13 (6.4)
Mental Disorders, Fourth Edition.28 A mean associated with high levels of depression, high
No data 9 (4.4)
score of 2.0 or higher was considered indicative levels of anxiety, or possible PTSD symptoms.
Interview countries
of probable PTSD symptoms, in accordance To create reduced and parsimonious models,
Belgium 3 (1.5)
with guidelines presented in the HTQ user we created backward stepwise logistic regres-
Bulgaria 20 (9.8)
manual.29 sion models to calculate ORs and 95% confi-
Czech Republic 5 (2.5)
dence intervals (CIs) for the association be-
Italy 26 (12.7)
Exposures to Pretrafficking and tween each individual mental health outcome
Moldova 74 (36.3)
Trafficking-Related Trauma and exposures and to adjust for potential
Ukraine 50 (24.5)
To select the exposures tested in the analysis, confounders, including exposure to pretraf-
United Kingdom 26 (12.7)
we used conceptual models established during ficking violence (physical violence at any age
Age, y, at interview
our previous work among trafficked women.6 [yes or no] and sexual violence at any age [yes
1517 24 (11.8)
Risk exposures comprised pretrafficking trauma or no]). Exposures were included in the model
1820 44 (21.6)
and trafficking-related trauma. Questions about if the covariate showed an association (P < .2)
2125 86 (42.2)
pretrafficking trauma sought information on: (1) and contributed to the overall fit of the model
2630 34 (16.7)
sexual abuse that occurred when the participant (P < .05). To confirm the final model fit, we
3145 14 (6.9)
was younger than 15 years or sexual violence checked model discrimination using the Akaike
No data 2 (1.0)
(forced sex) that occurred when the participant Information Criterion,31 in which covariates are
Marital status before trafficking
was aged 15 years or older but before being removed until the model with the lowest Akaike
Single 147 (72.1)
trafficked, and (2) physical violence that occurred value is retained.
Married/living as married 23 (11.3)
at any age before the participant was trafficked. We used Stata/IC version 10.1 (StataCorp LP,
Separated/divorced 32 (15.7)
Participants were also asked if they had experi- College Station, TX) to conduct data analyses.32
Widowed 1 (0.5)
enced any of the following types of abuse, which
No data 1 (0.5)
are commonly associated with trafficking situa- RESULTS
a
tions: (1) sexual violence (forced or coerced sex), Bulgaria, Czech Republic, Kyrgyzstan, Lithuania,
(2) physical violence (being hit, kicked, or phys- The 204 girls and women in this study Romania, Russian Federation, and Slovakia. Euro-
pean was defined as a member state of the
ically hurt), (3) physical violence with a weapon originally came from 12 different countries, 9 Organization for Security and Co-operation in Europe.
b
(being assaulted with a weapon), (4) threats of in eastern Europe and 3 in west Africa and the Cameroon, Nigeria, and Jamaica.
harm against the participant, (5) threats of harm Caribbean.4 The greatest proportion of
2444 | Research and Practice | Peer Reviewed | Hossain et al. American Journal of Public Health | December 2010, Vol 100, No. 12
RESEARCH AND PRACTICE
child sexual abuse, and 25% had experienced 48% met our criteria for high levels of anxiety evidence gap. As one of the first studies on the
sexual violence in adulthood prior to being symptoms, and 77% had possible PTSD. As mental health of trafficked girls and women, our
trafficked. Pretrafficking violence and abuse shown in Table 3, many, but not all, of the research has a number of limitations. First,
were not significantly correlated with traffick- trafficking-related exposures were more com- despite the diversity of those who participated in
ing-related exposures to trauma (P > .05). monly reported among those participants with our study, we cannot be certain of the extent to
We found good internal consistency with the mental health symptoms. Reported injuries which the findings might be representative of
mental health scales we used. The Cronbach a during trafficking were significantly associated a more general population of trafficked girls
reliability coefficient33 of internal-consistency re- with all 3 mental health outcomes. Sexual and women, especially those who do not access
liability was estimated to be 0.89 for the BSI violence during trafficking was associated with services. There are currently no data on the
depression subscale, 0.90 for the BSI anxiety PTSD, and physical violence (being hit or larger population of trafficked persons. In addi-
subscale, and 0.94 for the HTQ PTSD subscale. kicked) during trafficking was positively asso- tion, we were not able to conduct full diagnostic
Table 2 shows that 80% of participants ciated with anxiety symptoms (Table 3). Only assessments of specific mental disorders and
scored above the cutpoint for at least 1 of the 2 trafficking exposures were associated with instead relied on screening instruments that
disorders measured. Among these participants, comorbidity of all 3 mental health outcomes: have been validated among populations simi-
57% were comorbid for all 3 mental health sexual violence and injuries during trafficking larly exposed to chronic abuse or traumatic
outcomes. No participants with high levels of (data not shown). events.25,26,34
both depression and anxiety scored below the Several trafficking-related trauma exposures The sample size was constrained by unpre-
cutpoint for PTSD. were more common in certain mental health dictable levels of client intake and the great
Fifty-five percent of participants met our symptom categories but did not show a statisti- amount of resources required to carry out
criteria for high levels of depression symptoms, cally significant association, such as exposure to multisite studies of this type. This constraint in
physical violence, threats against the partici- turn limited our ability to examine the distri-
pant, restricted freedoms, and at least 6 months butions of trafficking-related risk factors, men-
spent in the trafficking situation (Table 3). tal health symptoms, and potential clustering.
TABLE 2Prevalence and Overlap of Logistic regression models indicate that Although the study instruments were trans-
High Levels of Mental Health participants who had been in the trafficking lated and adapted to reflect cultural and lin-
Symptoms Among Trafficked and situation for at least 6 months had approxi- guistic differences, the tools may not have
Sexually Exploited Girls and Women mately 2 times the odds of having higher levels captured the full cultural diversity of symptoms
(n = 204): Posttrafficking Care Sites in of depression and anxiety symptoms com- experienced by this cohort.35 Instead, our
7 European Countries, 20042005 pared with those who had spent less time in findings demonstrate common symptom pat-
trafficking (after taking account of other traf- terns and associations. The high prevalence of
Mental Health Symptoms No (%)
ficking-related exposures and pretrafficking comorbidity suggests the need for further exam-
Prevalence of symptoms abuse; Table 4). Those participants who had ination through modeling of risks for comorbid
Depression 112 (54.9) left the trafficking situation at least 3 months conditions. Despite these limitations, we believe
Anxiety 98 (48.0) before their interviews were at lower risk of that our study offers valuable information to
PTSD 157 (77.0) depression (adjusted OR [AOR] = 0.40; 95% inform service provision and to act as a basis for
Overlap of symptoms CI = 0.2, 0.8) and anxiety (AOR = 0.39; 95% much-needed intervention research.
Depression only 2 (1.3) CI = 0.2, 0.8) than were those who had left the This analysis reiterates disturbing findings on
Anxiety only 1 (0.6) trafficking situation more recently. Restricted the extremely high level of violence experienced
PTSD only 41 (25.6) freedom during trafficking was associated with by this group, both during and prior to traffick-
Depression + anxiety 0 (0.0) increased odds of anxiety. Sexual violence ing, and our analysis highlights the extent of
Depression + PTSD 19 (11.9) during trafficking was associated with in- psychological morbiditywhich, for many girls
Anxiety + PTSD 6 (3.8) creased risk of PTSD. and women, represented normal reaction to
Depression + anxiety + PTSD 91 (56.9) extraordinary stress. PTSD levels found among
DISCUSSION this population (77%) were, for example, slightly
Note. PTSD = posttraumatic stress disorder. Partici-
pants were found to have high levels of mental health higher than were levels identified in a meta-
symptoms on the basis of their responses to the Brief Findings from this study provide impor- analysis of associations between intimate partner
Symptom Inventory (BSI) subscales for depression and tant new information for the emerging field violence and PTSD (63%)36 and in studies of
anxiety and to the Harvard Trauma Questionnaire
(HTQ) for PTSD. Cutpoints for determining high levels of posttrafficking mental health care. To date, persons fleeing war or mass violence (38%
of each symptom were as follows: depression BSI the development of policies and service ap- 65%).37 This higher level of PTSD suggests the
score 1.87; anxiety BSI score 1.71; PTSD HTQ proaches has relied primarily on qualitative need for future research to test whether inter-
score 2.0. The 7 posttrafficking care sites were
located in Belgium, Bulgaria, the Czech Republic, reports and case examples without the contri- vention approaches for girls and women sub-
Italy, Moldova, Ukraine, and the United Kingdom. bution of more robust research on symptom jected to partner violence or war trauma might
patterns. Our findings begin to fill this significant be beneficial for trafficked girls and women.38
December 2010, Vol 100, No. 12 | American Journal of Public Health Hossain et al. | Peer Reviewed | Research and Practice | 2445
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December 2010, Vol 100, No. 12 | American Journal of Public Health Hossain et al. | Peer Reviewed | Research and Practice | 2447
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About the Authors 5. International Organization for Migration, United 21. Derogatis L, Lipman R, Rickels K, Uhlenhuth E, Covi
Mazeda Hossain, Cathy Zimmerman, Miriam Light, and States Agency for International Development. Budapest L. The Hopkins Symptom Checklist (HSCL): a self-report
Charlotte Watts are with the Gender, Violence and Health declaration on public health and trafficking in human symptom inventory. Behav Sci. 1974;19(1):115.
Centre, London School of Hygiene & Tropical Medicine, beings. Resolution passed at: Regional Conference on 22. Bolton P. Cross-cultural validity and reliability
London, UK. Melanie Abas is with the Health Service and Public Health and Trafficking in Human Beings in testing of a standard psychiatric assessment instrument
Population Research Department, Institute of Psychiatry, Central, Eastern and Southern Europe; March 1921, without a gold standard. J Nerv Ment Dis. 2001;189(4):
Kings College, London, UK. 2003; Budapest, Hungary. 238242.
Correspondence should be sent to Mazeda Hossain, 6. Zimmerman C, Yun K, Watts C, et al. The Health 23. Lee B, Kaaya S, Mbwambo J, Smith-Fawzi M,
London School of Hygiene & Tropical Medicine, Keppel St, Risks and Consequences of Trafficking in Women and Leshabari MT. Detecting depressive disorder with the
London WC1E 7HT, UK (e-mail: Mazeda.Hossain@lshtm. Adolescents: Findings From a European Study. London, Hopkins Symptom Checklist-25 in Tanzania. Int J Soc
ac.uk). Reprints can be ordered at http://www.ajph.org by England: London School of Hygiene & Tropical Medi- Psychiatry. 2008;54(1):720.
clicking the Reprints/Eprints button. cine, Daphne Programme; 2003.
This article was accepted December 10, 2009. 24. Mollica R, Caspi-Yavin Y, Lavelle J, et al. Harvard
7. Saporta J, van der Kolk BA. Psychobiological con- Trauma Questionnaire (HTQ) Manual: Cambodian, Lao,
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C. Zimmerman conceptualized and coordinated the England: Cambridge University Press; 1992.
25. El-Bassel N, Schilling RF, Irwin KL, et al. Sex trading
study under supervision by C. Watts. M. Hossain and 8. Basoglu M, Mineka S. The role of uncontrollable and and psychological distress among women recruited from
M. Light led the analysis. M. Hossain, C. Zimmerman, unpredictable stress in post-traumatic stress responses in the streets of Harlem. Am J Public Health. 1997;87(1):
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Acknowledgments 9. Breslau N. Epidemiologic studies of trauma, post- 2003;362(9397):17211723.
Funding for this study was provided by the European traumatic stress disorder, and other psychiatric disorders.
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Commissions Daphne Programme, with additional
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Migration and the Sigrid Rausing Trust. Oromo refugees: correlates of torture and trauma history.
Special gratitude is offered to all of the trafficking Am J Public Health. 2004;94(4):591598. 28. American Psychiatric Association. Diagnostic and
survivors who participated in this study and to their Statistical Manual of Mental Disorders, Fourth Edition.
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