Identifying and Addressing the Healthcare Needs of Women Survivors of Sex Trafficking: A Qualitative Analysis of the Barriers and Facilitators to Self-Efficacy for Primary Care Providers Open Access

Segebrecht, Jane Whitney (2017)

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Background: Sex trafficking is a complex public health challenge with unique ramifications for health conditions. Trafficked individuals utilize a variety of healthcare settings, including primary care, but may encounter providers for whom readiness to identify trafficking and respond to healthcare needs is varied. Increasing primary care providers' self-efficacy to address sex trafficking can strengthen primary care settings as key public health points of intervention to address sex trafficking.

Objectives: The primary aim of this qualitative study is to identify barriers and facilitators to self-efficacy for primary care providers to respond to the healthcare needs of women survivors of sex trafficking. Additionally, this study seeks to inform policy or program development to strengthen approaches for primary care providers to respond to sex trafficking.

Methods: After conducting a review of the literature, 11 providers in seven states, representing distinct healthcare settings, were recruited to participate in semi-structured interviews. Providers interviewed for this study included physicians and nurse practitioners currently addressing the primary care needs of survivors of sex trafficking in practice. Survivors were defined in this study as women currently or formerly in sex trafficking and older than 18 years of age. Purposive chain-referral sampling of provider networks was employed as a recruitment technique until data saturation was achieved. The Braun and Clarke (2006) six-phase approach to thematic analysis was used to generate themes; an adaptation of the Gist and Mitchell (1992) Self-Efficacy-Performance Relationship Model served as the theoretical framework to organize themes.

Results: Multiple barriers and facilitators to self-efficacy were identified for providers to respond to sex trafficking. Opportunities identified in this study to support self-efficacy include: building upon an existing primary care culture which addresses social determinants of health and intersectionality; ensuring role clarity for providers; employing team-based and trauma-informed care approaches; learning experientially in practice and through discourse with social service providers, peers, professional networks, and mentors; addressing vicarious trauma through resiliency-supportive techniques; establishing practice-based safety planning; and utilizing protocols. The primary barriers to self-efficacy were challenges in addressing the mental health needs of survivors, visit length, and navigating coverage for care. Connections beyond the practice also were key to support self-efficacy and include engaging a multi-disciplinary network of referral providers and forming partnerships with social service providers and legal services.

Conclusion: Study findings suggest there are multiple barriers and facilitators to self-efficacy for primary care providers to identify and respond to the unique healthcare needs of survivors of sex trafficking. Respondents generally expressed a high self-estimation of confidence to address sex trafficking; however, their noted barriers demonstrate opportunities to strengthen approaches in primary care and the healthcare delivery system to support providers to address sex trafficking. The methods designed to encourage facilitators and reduce barriers identified in this study can be integrated into public health interventions to support primary care provider responses for survivors of sex trafficking.

Table of Contents

Chapter 1: Introduction and Context of the Problem [1]

1.1 Introduction to the Issue [1]

1.2 Problem and Purpose Statement [5]

1.3 Research Questions [7]

1.4 Theoretical Framework [7]

1.5 Key Terms [12]

Chapter 2: Background Research and Review of the Literature [16]

2.1 Overview of the Sex Trafficking Landscape [16]

2.2 Health Outcomes and Sex Trafficking [24]

2.3 Healthcare Utilization by Survivors of Sex Trafficking [29]

2.4 Provider Role in Identifying and Treating Survivors of Sex Trafficking [32]

2.5 Training and Preparing Providers to Address Sex Trafficking [42]

2.6 Addressing Sex Trafficking in Primary Care [47]

2.7 Summary of Current Problem and Study Relevance [51]

Chapter 3: Methodology [53]

3.1 Research Design [53]

3.2 Population and Sample [55]

3.3 Instrument [56]

3.4 Thematic Analysis [59]

Chapter 4: Results [63]

4.1 Introduction [63]

4.2 Gist and Mitchell Lever of Influence: Foundational (Development of Self-Efficacy) [69]

4.3 Gist and Mitchell Lever of Influence: Cognitive Appraisal (Integration of Learning) [89]

4.4 Gist and Mitchell Lever of Influence: Consequences (Established Self-Efficacy) [111]

Chapter 5: Discussion [116]

5.1 Discussion of Research Questions [116]

5.3 Limitations [133]

5.4 Recommendations [133]

5.5 Conclusion [138]

Bibliography [139]

Appendix [148]

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