key: cord-0855388-ggwcwlj3
authors: Chisolm‐Straker, Makini; Singer, Elizabeth; Strong, David; Loo, George T.; Rothman, Emily F.; Clesca, Cindy; d'Etienne, James; Alanis, Naomi; Richardson, Lynne D.
title: Validation of a screening tool for labor and sex trafficking among emergency department patients
date: 2021-10-12
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12558
sha: e5528a3088f0f2f7e3acb438a21d73c91baac022
doc_id: 855388
cord_uid: ggwcwlj3

OBJECTIVE: Patients with labor and sex trafficking experiences seek healthcare while and after being trafficked. Their trafficking experiences are often unrecognized by clinicians who lack a validated tool to systematically screen for trafficking. We aimed to derive and validate a brief, comprehensive trafficking screening tool for use in healthcare settings. METHODS: Patients were randomly selected to participate in this prospective study based on time of arrival. Data collectors administered 5 dichotomous index questions and a reference standard trafficking assessment tool that requires 30 to 60 minutes to administer. Data collection was from June 2016 to January 2021. Data from patients in 5 New York City (NYC) emergency departments (EDs) were used for tool psychometric derivation, and data from patients in a Fort Worth ED were used for external validation. Clinically stable ED adults (aged ≥18 years) were eligible to participate. Candidate questions were selected from the Trafficking Victim Identification Tool (TVIT). The study outcome measurement was a determination of a participant having a lifetime experience of labor and/or sex trafficking based on the interpretation of the reference standard interview, the TVIT. RESULTS: Overall, 4127 ED patients were enrolled. In the derivation group, the reference standard identified 36 (1.1%) as positive for a labor and/or sex trafficking experience. In the validation group, 12 (1.4%) were positive by the reference standard. Rapid Appraisal for Trafficking (RAFT) is a new 4‐item trafficking screening tool: in the derivation group, RAFT was 89% sensitive (95% confidence interval [CI], 79%–99%) and 74% specific (95% CI, 73%–76%) and in the external validation group, RAFT was 100% sensitive (95% CI, 100%–100%) and 61% specific (95% CI, 56%–65%). CONCLUSIONS: The rapid, 4‐item RAFT screening tool demonstrated good sensitivity compared with the existing, resource‐intensive reference standard tool. RAFT may enhance the detection of human trafficking in EDs. Additional multicenter studies and research on RAFT's implementation are needed.

experience. In the validation group, 12 (1.4%) were positive by the reference standard.

Rapid Appraisal for Trafficking (RAFT) is a new 4-item trafficking screening tool: in the derivation group, RAFT was 89% sensitive (95% confidence interval [CI] , 79%-99%) and 74% specific (95% CI, 73%-76%) and in the external validation group, RAFT was 100% sensitive (95% CI, 100%-100%) and 61% specific (95% CI, 56%-65%).

The rapid, 4-item RAFT screening tool demonstrated good sensitivity compared with the existing, resource-intensive reference standard tool. RAFT may enhance the detection of human trafficking in EDs. Additional multicenter studies and research on RAFT's implementation are needed.

commercialized violence, human trafficking, identification, labor trafficking, screening, sex trafficking, validation

Human trafficking is the recruitment, harboring, transportation, provision, and/or obtaining of a person, by the use of force, fraud, and/or coercion, for the purpose of labor and/or sexual exploitation. 1 Cases have been reported in all 50 states and Washington, DC. 2 People who have been trafficked seek healthcare both during and after their trafficking experience [3] [4] [5] and can experience trafficking-related health and social consequences for years after a trafficking experience. [6] [7] [8] Clinicians often fail to recognize trafficking experiences among their patients because they lack trafficking-specific training and comprehensive (labor and sex trafficking), validated screening tools. 3-5,9

Multiple healthcare institutions and organizations have developed trafficking screening tools, 9 ,10 yet only the Child Sex Trafficking

Screening Tool is validated for healthcare settings and it is explicitly for sex trafficking screening of adolescents presenting with specific chief complaints. 11 The social, and, in some states, legislative pressure to identify trafficking has led institutions to use unvalidated trafficking screening tools. 12, 13 Unvalidated tools lack sensitivity and specificity with the potential to negatively impact individual patient care and ultimately public health data collection. 14

This study's objective was to derive and externally validate a comprehensive screening tool, Rapid Appraisal for Trafficking (RAFT), to facilitate adult patient disclosures about labor and sex trafficking experiences.

This prospective study's methods, including site selection, are described in extensive detail in a prior publication. 15 

The Trafficking Victim Identification Tool (TVIT) was the first validated, comprehensive trafficking assessment tool for use in social service settings 16 and was used as the reference standard. The index test was composed of 5 candidate RAFT items (eFigure1 in the Supporting Information). These were dichotomous questions from the TVIT with the highest odds of predicting a trafficking experience on the TVIT. Prefacing, normalizing language was added to build rapport between the data collector and participant; prefaces were adopted from the Human Trafficking Interview and Assessment Measure, a trafficking assessment tool also derived from the TVIT 17 and validated for use only among homeless young adults. Index questions were posed by the data collector, and then the participant completed the reference 30-to 60minute TVIT interview with the same data collector; interviews were completed in the ED. 18 All participants were offered the opportunity to speak with an ED social worker. 15 15 Data about participant language, gender, and age was captured in the interview (self-report); race, ethnicity, and presenting complaint were self-reported upon registration, and data collectors documented from view of the electronic health record.

To identify reliable and valid labor and sexual exploitation screening 

The psychometrically identified items were predicted on the binary outcome of trafficked/not trafficked in a logistic regression model, and a receiver operator curve (ROC) was computed from this model evaluation. Sensitivity, specificity, and positive predictive value performance from participant response to the items were evaluated for effect of increasing score and analyzed by demographics (gender, race/ethnicity, language of interview, age) as planned. 15 These computations were conducted by GTL (author 4) using Statistical Analysis System 9.4 (SAS 9.4) software. 22

Of the 6290 eligible participants, 3292 ED patients from the 5 NYC EDs (derivation data set) wanted to participate and completed the TVIT interview ( Figure 1 ). The majority of NYC participants identified as women (61%), and the sample was racially and ethnically diverse opted to meet with the social worker. Participants with a trafficking experience presented to the ED with a variety of complaints ( Figure 2 ).

Of the 1677 eligible participants at the Fort Worth site (external validation data set), 835 randomly selected patients wanted to participate and completed the interview (Figure 1 ). About 54% of the participants identified as men, and a larger proportion identified as White (Table 1 ).

In this sample, 1.4% had a lifetime experience of labor or sex trafficking, with 8 cases being labor trafficking and 4 cases being sex trafficking. In both the NYC and Fort Worth data sets, all participants with a trafficking experience completed the reference standard interview.

In the NYC sample, CFA models AIC, BIC, and log likelihood supported The difference in parameters across settings is presented in eTable2

in the Supporting Information, which also indicates when 95% or more of the comparisons were <0. The "unsafe work" item had slope and threshold parameters that differed in >95% of the comparisons, although absolute differences in parameters suggest that these effects were unlikely to impact overall scores. The relative severity of exploitation reflected by the "forced work" item differed across settings, although again magnitudes of the difference were small.

Of the 4 items ("forced work," "threats at work," and "payment for sex"), 3 were associated with trafficking (eTable5 in the Supporting Information). All 4 items contributed to a robust C-statistic (area under the curve) equal to 0.90 using data in both data sets (eFigure2 in the Supporting Information). Using data in both data sets, affirmation to any 1 of the 4 items yielded a sensitivity of 92% and a specificity of 72% (Table 2) . Sensitivity and specificity for planned subgroups (gender, race/ethnicity, language of interview, age) are shown in eTable6 in the Supporting Information; the range in sensitivity (75%-96%) is good to strong throughout the spectrum of stratified demographics. Note: Participants self-identified upon emergency department registration and could select >1 racial and/or ethnic category. Both electronic health record systems use "Hispanic/Latino" rather than the most contemporary and inclusive term, "Latinx."

Although this is the largest study of its kind, given the low prevalence of trafficking experiences, a larger multicenter investigation may offer more information about the proposed tool. In addition, TVIT interrater reliability was not tested; the "raters" were the interviewers and the reference standard interviews were time intensive (30- and yielded a precision of < 0.11 instead of the goal of < 0.10. In addition, 48% and 50% of the NYC and Fort Worth eligible patients, respectively, declined to participate ( Figure 1 ); it is difficult to assess the direction, if any, of bias introduced by patients who declined participation. RAFT should be validated in other EDs and other kinds of areas, including rural settings, reservations, and free-standing EDs.

Most participants with a trafficking experience in this study were not in their situation at the time of the interview, but previous literature demonstrates that a connection to health-based or communitybased organization (CBO) services may still be desirable or beneficial, and the ED is the most accessible route of connection for many survivors. [3] [4] [5] [6] [7] [8] 25 Finally, RAFT's specificity is 72%. This means that some people will screen falsely positive, but the patient implications of a false screen on RAFT are fairly benign and may still be beneficial to such patients: patients who screen positive can be offered the opportunity to connect with local antitrafficking organizations for further assessment. If a CBO determines that the person does not have a trafficking experience, they can be connected to other relevant resources.

To our knowledge, this is the first study to externally validate a trafficking screening tool for use in a healthcare setting. 9 and Cindy Clesca received salary support or consulting fees for data management or analysis. No other author received consulting fees or honoraria, fees for participation in review activities such as data monitoring boards or statistical analysis, payment for writing or reviewing the manuscript, and/or provision of writing assistance, medicines, equipment, or administrative support in connection with this study.

Makini Chisolm-Straker is the primary investigator for the study, she Makini Chisolm-Straker takes responsibility for the paper as a whole.

Makini Chisolm-Straker MD, MPH https://orcid.org/0000-0001-5182-5772

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