Training Experiences of Emergency Department Providers in the Recognition of Child Trafficking.

OBJECTIVE: Trafficked children face challenges to obtaining appropriate health care that may be addressed by clinician training. We evaluated emergency department (ED) staff's training experiences regarding child trafficking and attitudes toward educational efforts to provide informed recommendations for improvement in the recognition and evaluation of trafficked children in the ED setting. METHODS: In this cross-sectional study of general and pediatric ED staff across 6 cities in the United States, participants completed a 25-question, online anonymous survey. Differences in proportions between categorical data were examined using χ2/Fisher exact tests. Differences in means were evaluated using Student t test and 1-way analysis of variance. RESULTS: The 484 participants included physicians (33.0%), nurses (27.4%), resident physicians (12.2%), and social workers (10.1%). Only 12.4% reported being very confident in recognizing child trafficking. Barriers to recognition included lack of awareness and training on child sex trafficking (37.4%, 58.3%) and labor trafficking (38.4%, 50.6%), sensitivity of the topic (44.4%), lack of institutional guidelines (29.8%) and social work coverage (26.0%), and the assumption that children will not disclose victimization (16.5%). Although 62.2% of the respondents had prior training in child sex trafficking, only 13.3% reported that it was adequate. Barriers to training included lack of easy access (82.5%), belief that prior training was adequate (13.3%), poor-quality curricula (5.1%), and low priority of topic (4.1%). Recommendations for training included a 1-hour module/webinar/lecture (43.1%), rounds (40.5%), written guidelines (9.8%), and individualized, case-based learning (6.6%). CONCLUSIONS: We found that although most ED providers stated that they had prior training in the recognition of child trafficking, few expressed confidence in their ability to recognize and evaluate trafficked children. Barriers to education included a lack of awareness of and access to available curricula. Providers supported a variety of formats for further education. Strategies for improving educational access are discussed.

Global Health Crisis, Global Health Response: How Global Health Experiences Prepared North American Physicians for the COVID-19 Pandemic.

The COVID-19 pandemic plunged hospital systems into resource-deprived conditions unprecedented since the 1918 flu pandemic. It brought forward concerns around ethical management of scarcity, racism and distributive justice, cross-disciplinary collaboration, provider wellness, and other difficult themes. We, a group of medical educators and global health educators and clinicians, use the education literature to argue that experience gained through global health activities has greatly contributed to the effectiveness of the COVID-19 pandemic response in North American institutions. Support for global health educational activities is a valuable component of medical training, as they build skills and perspectives that are critical to responding to a pandemic or other health system cataclysm. We frame our argument as consideration of three questions that required rapid, effective responses in our home institutions during the pandemic: How can our health system function with new limitations on essential resources? How do we work at high intensity and volume, on a new disease, within new and evolving systems, while still providing high-quality, patient-centered care? And, how do we help personnel manage an unprecedented level of morbidity and mortality, disproportionately affecting the poor and marginalized, including moral difficulties of perceived care rationing?

Sexual Violence Against Children.

Sexual violence against children is a gross violation of children's rights during their formative years and will likely interfere with their developmental trajectory and long-term quality of life. As a result, this form of violence includes commercial sexual exploitation of children, sexual abuse, child marriages, and female genital mutilation. The evidence shows that violence prevention is worth the investment; however, prioritizing this agenda to ensure funding through government spending remains low. Despite funding realities, research and advocacy efforts need to continue, with a focus on promoting effective practices for mitigation.

Domestic Violence and Its Effects on Women, Children, and Families.

Men and women experience severe domestic violence (DV) and intimate partner violence (IPV); however, women and children remain especially vulnerable. Violence along the DV/IPV continuum has been recognized as a type of child maltreatment and a child's awareness that a caregiver is being harmed or at risk of harm is sufficient to induce harmful sequelae. Consequences of these abusive behaviors are associated with mental and physical health consequences. Health care professionals can screen, identify, and manage this pathology in affected families while educating communities to these pernicious effects.

The Acculturation Toolkit: An Orientation for Pediatric International Medical Graduates Transitioning to the United States Medical System.

Introduction: International medical graduates (IMGs) consistently contribute to the US physician workforce. In fact, 25% of practicing pediatricians in the US are IMGs, highlighting the needs of IMG trainees. IMGs face unique challenges with acculturation compared to their peers due to unfamiliarity with the US medical system, especially the dynamics around patient-centered care. The literature supports the need for formal acculturation curricula. Methods: A cohort of program directors who train pediatric IMGs coupled findings from the literature with local themes from IMG focus groups to identify topics for an acculturation curriculum. Three small-group workshops utilized didactics, discussion, and role-play to cover topics related to patient-centered care, challenging communication with patients, complex psychosocial histories, and health literacy. The pilot was modified based on feedback and to enhance generalizability. The resulting four-module curriculum with presentations and supplemental materials is presented here. Results: After a 3-year pilot with 36 PGY 1 trainees, postcurriculum surveys reported 8.1 out of 10 in workshop satisfaction, plus increased knowledge and skills related to patient-centered care and communication with patients. Role-plays were the favorite activity. A 1-year follow-up survey reported the workshops to be influential on satisfaction with patient relationships and easing transition to residency. Discussion: A pilot acculturation curriculum addressing needs of pediatric IMG trainees was well received by participants and improved their comfort level in addressing challenging patient-communication scenarios. Pediatric programs that train IMGs can incorporate this curriculum to aid residents' transition to clinical practice in the US.

Multi-level prevention of human trafficking: The role of health care professionals.

As a major public health issue, human trafficking (HT) affects individuals, families, communities, and societies around the world. A public health approach to combating HT has been advocated. Such an approach seeks to prevent HT by engaging diverse stakeholder groups in addressing risk factors at multiple levels. As a key stakeholder group, health care professionals (HCPs) play a critical role in HT prevention. Herein, we use the Centers for Disease Control (CDC) Social-Ecological Model as a framework to present potential HT prevention strategies for health care professionals. As clinicians, HCPs may deliver tailored interventions to patients and families to address individual- and relationship-level risk factors for HT in the health care setting. As educators, advocates, and researchers, HCPs may collaborate across sectors to implement community- and society-level prevention strategies. Such strategies may include enhancing awareness of HT through education; advocating for local and national policies that promote community health and wellness; combating social or cultural norms that contribute to HT; and building a strong evidence-base to guide future HT prevention programs. Guided by the CDC Social-Ecological Model, we recommend that HCPs use their diverse skills to target risk factors for HT at multiple levels and thereby expand their impact in preventing this form of exploitation.

Empowering trainees to promote professionalism.

BACKGROUND: Unprofessional behaviour can interfere with patient care. Empowering trainees to address each other's unprofessional behaviour can help address a larger number of incidents that may not be witnessed by supervisors, as well as promote a culture of professionalism in a teaching programme. The goal of the study was to teach trainees to effectively address observed unprofessional behaviour and to assess the impact of this exercise on the percentage of cases directly addressed, reported or ignored 6-12 months after the initial training. METHODS: Eighty-four trainees participated in objective structured clinical examination (OSCE) cases designed to address a colleague's inappropriate behaviour. Baseline and follow-up surveys performed 6-12 months after the OSCE were completed detailing the number of incidents witnessed in colleagues and the method employed to address those incidents: personally address (with level of satisfaction), report or ignore. RESULTS: There was a significant increase in the number of unprofessional incidents identified after the OSCE (pre-OSCE, 1.12 per resident; post-OSCE, 1.69 per resident; t = 2.27, p = 0.029). Of the 72 incidents at baseline, 43 per cent were addressed directly and 43 per cent of those had a satisfactory resolution. Of the 71 incidents described 6-12 months later, 61 per cent were addressed directly and 79 per cent of those had a satisfactory resolution. Trainees were more likely to address rather than to report unprofessional behaviour χ2 (2, 58) = 13, p = 0.001. Empowering trainees to address each other's unprofessional behaviour can help promote a culture of professionalism DISCUSSION: The intervention had a significant impact on the percentage of trainees that addressed any observed unprofessional behaviour, and the rate of satisfaction after doing so. It did not change the percentage of cases that were neither addressed nor reported.

An Experimental Study of Implicit Racial Bias in Recognition of Child Abuse.

OBJECTIVES: We evaluated whether implicit racial bias influences pediatricians' suspicion of child abuse. METHODS: Child abuse experts developed 9 injury vignettes. Pediatricians (N = 342) were randomly assigned one of 2 versions to rate for suspicion of abuse, with the child's race in each vignette varying between white and black. Data were collected online and anonymously. RESULTS: There were no statistically significant differences in suspicion for an abuse-related injury based on the race of the child. We adjusted for pediatrician race/ethnicity, years since graduation, location, and gender and did not find race effects. CONCLUSIONS: We demonstrated an experimental approach to study the influence of implicit racial bias on recognition of child abuse. Though we failed to find an effect, it is too early to conclude that none exists. The relationship among human cognition, behavior, and healthcare disparities is complex. Studies are needed that incorporate diverse approaches, clinical contexts and scenarios, patient and physician characteristics, and validated measures if we are to understand how it might be used to reduce healthcare disparities.

Children neglected: Where cumulative risk theory fails.

Neglected children, by far the majority of children maltreated, experience an environment most deficient in cognitive stimulation and language exchange. When physical abuse co-occurs with neglect, there is more stimulation through negative parent-child interaction, which may lead to better cognitive outcomes, contrary to Cumulative Risk Theory. The purpose of the current study was to assess whether children only neglected perform worse on cognitive tasks than children neglected and physically abused. Utilizing LONGSCAN archived data, 271 children only neglected and 101 children neglected and physically abused in the first four years of life were compared. The two groups were assessed at age 6 on the WPPSI-R vocabulary and block design subtests, correlates of cognitive intelligence. Regression analyses were performed, controlling for additional predictors of poor cognitive outcome, including socioeconomic variables and caregiver depression. Children only neglected scored significantly worse than children neglected and abused on the WPPSI-R vocabulary subtest (p=0.03). The groups did not differ on the block design subtest (p=0.4). This study shows that for neglected children, additional abuse may not additively accumulate risk when considering intelligence outcomes. Children experiencing only neglect may need to be referred for services that address cognitive development, with emphasis on the linguistic environment, in order to best support the developmental challenges of neglected children.

Caregiver perceptions of sexual abuse and its effect on management after a disclosure.

OBJECTIVE: The aim of the study was to examine caregiver management strategies for child sexual abuse (CSA) when presented with hypothetical scenarios that vary in physical invasiveness. METHODS: One hundred fifty three caregivers were given 3 scenarios of CSA with 7 management strategies presented in the 21-item Taking Action Strategies (TAS) scale. Caregivers were asked to rate strategies according to their willingness to carry out each action with rating of 5=greater likelihood of carrying out the action specified while a rating of 1=a lower likelihood of carrying out that action. CSA scenarios included exposure to pornography/masturbation, fondling, and penetration while management strategies including fighting the accused, blaming the child, and outreaching to the authorities. Repeated measures ANOVA was used to compare mean TAS scores for the management strategies across CSA scenarios. RESULTS: The difference between TAS scores across the abuse scenarios was statistically significant (p<.001). Mean TAS scores reflected greater preference for taking action if the abusive act was perceived as more physically intrusive (exposure to pornography/masturbation-TAS 3.5, fondling-TAS 3.7, penetration-TAS 3.8). Caregivers reported being less willing to handle a disclosure of CSA without outreach (TAS 2.5 and 2.0 for fighting and blaming the child, respectively) and more willing to manage a disclosure with outreach to authorities (TAS 3.8, 4.5, and 4.7 for outreaching to Child Protective Services [CPS], to the child's healthcare provider and police, respectively). A predictor of caregiver outreach to authorities identified was the caregiver having past interactions with CPS. CONCLUSION: Perception of the physical invasiveness of CSA and demographic factors can impact caregiver management strategies after a disclosure. PRACTICE IMPLICATIONS: Results suggest that several factors influence caregiver management of sexual abuse. These factors warrant further study, as they are potential contributors to declining trends in CSA cases observed. Other implications include the need for educational efforts targeting caregivers. These interventions should focus on dispelling myths about the perceived physical invasiveness of CSA. These perceptions should not mitigate a caregiver's decision to involve the authorities in their management after a disclosure. Lastly, despite criticisms of the child protective systems, caregivers with past encounters with CPS view these related agencies as valuable resources.