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Postnatal depression (PND) is recognised as a common maternal health problem, but little evidence examines PND among refugee, asylum seeker and immigrant women in developed country settings. This review aimed to identify the rates of PND and highlight common risk factors among this group of women. An iterative and dynamic literature search was conducted across ten databases to identify published articles on PND among immigrant, asylum-seeking and refugee women in developed country settings. Medical Subject Headings (MeSH) and ‘free text’ search terms, as well as thesaurus terms, acronyms and truncation were used where appropriate. Findings suggest that PND may affect up to 42% of migrant women, compared to around 10–15% of native-born women. Common risk factors for PND among migrant women include history of stressful life events, lack of social support and cultural factors. With a growing number of babies born to immigrant mothers, greater awareness of PND among this group is needed in order to respond to their particular maternal mental health needs. Maternity care providers should regard all recent immigrants as at high risk of PND and give closer observation and support as necessary.

International guidance provides advice on safe and appropriate treatment In April 2009, the Council of Europe Convention on Action against Trafficking in Human Beings came into force in the United Kingdom.1 The convention requires the state to provide minimum standards of care, including medical services, to all people identified as “trafficked.” Meeting the needs and protecting the safety of such people can be a challenge for doctors. Human trafficking involves the movement of people by force, coercion, or deception into situations of exploitation.2 Trafficked persons are often subjected to physical violence, sexual abuse, psychological violence, and severe deprivation. Trafficking of women and girls for sexual exploitation receives the greatest attention, but men, women, and children are also trafficked and exploited in, for example, agriculture, construction, contract cleaning, and domestic service.3 Usually, trafficked persons agree to a job opportunity and are misled about their pay, work, conditions, or repayment obligations, and they find themselves in situations akin to “slavery.”4 Globally, about 2.5 million people are estimated to be in situations of forced labour as a result of trafficking,3 …

Human trafficking is a phenomenon that has now been documented in most regions in the world. Although trafficking of women and girls for sexual exploitation is the most commonly recognised form of trafficking, it is widely acknowledged that human trafficking also involves men, women and children who are trafficked for various forms of labour exploitation and into other abusive circumstances. Despite the violence and harm inherent in most trafficking situations, there remains extremely little evidence on the individual and public health implications of any form of human trafficking. The Brazilian government has recently launched a national plan to combat human trafficking. However, because the health risks associated with human trafficking have not been well-recognised or documented, there is extremely limited reliable data on the health needs of trafficked persons to inform policy and practices.. Brazilian policy-makers and service providers should be encouraged to learn about the likely range of health impacts of trafficking, and incorporate this into anti-trafficking protection and response strategies. As well as prevention activities, the government, international and local organisations should work together with the public health research community to study the health needs of trafficked persons and explore opportunities to provide safe and appropriate services to victims in need of care.

An increasing amount of research is beginning to offer a global overview of the extent of violence against women. In this paper we discuss the magnitude of some of the most common and most severe forms of violence against women: intimate partner violence; sexual abuse by non-intimate partners; trafficking, forced prostitution, exploitation of labour, and debt bondage of women and girls; physical and sexual violence against prostitutes; sex selective abortion, female infanticide, and the deliberate neglect of girls; and rape in war. There are many potential perpetrators, including spouses and partners, parents, other family members, neighbours, and men in positions of power or influence. Most forms of violence are not unique incidents but are ongoing, and can even continue for decades. Because of the sensitivity of the subject, violence is almost universally under-reported. Nevertheless, the prevalence of such violence suggests that globally, millions of women are experiencing violence or living with its consequences.

Introduction A recent systematic review found a high prevalence of violence and mental distress among women trafficked for sexual exploitation; no data were identified for trafficked men and children. Objectives To describe the clinical characteristics of trafficked people in contact with a large inner city mental health service compared with a non-trafficked cohort. Aims To investigate whether, compared with a non-trafficked cohort, trafficked people would be significantly more likely to have co-morbid disorders and have significantly smaller improvements in functioning at the end of an episode of care. Methods Study population: mental health service users who had been trafficked for exploitation and a non-trafficked service user cohort matched for gender and age. Data source: The South London and Maudsley NHS Trust (SLaM) Biomedical Research Centre Case Register Interactive Search (CRIS) database of anonymised full patient records (2006–2012). Results We identified case records of 135 people who had been trafficked. 104 (77%) were female; age at first SLaM contact ranged from 8 to 49 years (mean 23.6, SD 8.0). 38 (28%) of the trafficked service users received psychiatric care from an emergency department. Depression (28.1%, n = 38), PTSD (19.3%, n = 26), non-affective psychoses (12.6%, n = 17) were the most frequently recorded diagnoses among trafficked service users. Further analysis is in progress and scheduled for completion by March 2013. Conclusions Significant numbers of trafficked people were seen in an inner-city mental health service; services therefore need to understand their complex needs.

Background The UNAIDS Modes of Transmission (UNAIDSMoT) model is increasingly being used to inform national-level HIV priority setting. Although the model is simple to use, important factors may be omitted. Using the UNAIDSMoT model, with Uganda and Cambodia as case studies, we explored the influence of the incorporation of additional factors. Methods A detailed review of the UNAIDSMoT model was conducted, including reviewing the model structure, data requirements, parameters and assumptions. Country-specific literature reviews were undertaken, along with field visits involving key-informant interviews, to identify the main features of the HIV epidemic in each setting. Adaptations were made to the UNAIDSMoT model to explore the sensitivity of the model projections to these revisions. Results A key limitation of the original UNAIDSMoT model is that it does not allow an individual9s multiple sources of risk to be considered. The model was adapted to incorporate important multiple risk sources (including injecting drug use), and the effects of the 2008 change in Cambodian law on human trafficking which led to brothel closures, the migration of many sex workers into entertainment venues, and the discontinuation of numerous outreach and condom distribution programmes. As illustrated in Abstract P1-S4.16 figure 1, the revised model projects lower percentages of new HIV infections occurring among sex workers (2% vs 5%) and the regular female partners of men who buy sex (5% vs 48%) than the original model, primarily replaced with new infections occurring in the new groups: entertainment workers who sell sex (38%), and injecting drug users and their sexual partners (5%). In Uganda, the high prevalence of HIV infection among women means that the static model predicts men are more at risk of infection from their female partners than women are from their male partners. This fails to reflect the dynamic chain of HIV transmission. Conclusions Our analysis highlights the limitations of the UNAIDSMoT model, and the potential dangers of over-interpretation of a relatively simplistic and static reflection of a dynamic HIV epidemic (and prevention priorities) at a particular time-point. It is important to regularly re-structure and re-parameterise models according to new data and changes in patterns of risk behaviours. Further research to test the validity, sensitivity and robustness of the UNAIDSMoT model projections in different epidemic settings is needed.

The trafficking of women and girls into forced prostitution and other slavery-like or exploitative conditions is a gross violation of human rights. So dehumanising is this crime that one 17-year-old Romanian woman who was trafficked to the UK and forced to sell sex explained that while being sold from country to country and client to client she felt like a “piece of meat with two eyes." The WHO Ethical and Safety Recommendations on Interviewing Trafficked Women released in October 2003 addresses many ethical and safety issues related to meeting with and gathering information from trafficked women. (excerpt)

BACKGROUND: Trafficking is a crime of global proportions involving extreme forms of exploitation and abuse. Yet little research has been done of the health risks and morbidity patterns for men, women, and children trafficked for various forms of forced labour. METHODS: We carried out face-to-face interviews with a consecutive sample of individuals entering 15 post-trafficking services in Cambodia, Thailand, and Vietnam. We asked participants about living and working conditions, experience of violence, and health outcomes. We measured symptoms of anxiety and depression with the Hopkins Symptoms Checklist and post-traumatic stress disorder with the Harvard Trauma Questionnaire, and used adjusted logistic regression models to estimate the effect of trafficking on these mental health outcomes, controlling for age, sector of exploitation, and time in trafficking. FINDINGS: We interviewed 1102 people, of whom 1015 reached work destinations. Participants worked in various sectors including sex work (329 [32%]), fishing (275 [27%]), and factories (136 [13%]). 481 (48%) of 1015 experienced physical violence, sexual violence, or both, with 198 (35%) of 566 women and girls reporting sexual violence. 478 (47%) of 1015 participants were threatened and 198 (20%) were locked in a room. 685 (70%) of 985 who had data available worked 7 days per week and 296 (30%) of 989 worked at least 11 hours per day. 222 (22%) of 983 had a serious injury at work. 61·2% (95% CI 58·2-64·2) of participants reported symptom of depression, 42·8% (39·8-45·9) reported symptoms of anxiety, and 38·9% (36·0-42·0) reported symptoms of post-traumatic stress disorder. 5·2% (4·0-6·8) had attempted suicide in the past month. Participants who experienced extremely excessive overtime at work, restricted freedom, bad living conditions, threats, or severe violence were more likely to report symptoms of depression, anxiety, and post-traumatic stress disorder. INTERPRETATION: This is the first health study of a large and diverse sample of men, women, and child survivors of trafficking for various forms of exploitation. Violence and unsafe working conditions were common and psychological morbidity was associated with severity of abuse. Survivors of trafficking need access to health care, especially mental health care. FUNDING: Anesvad Foundation and International Organization for Migration International Development Fund.

Young people who have been trafficked may have experienced significant trauma and violence but little is known about their health and healthcare needs. This UK study aimed to address that gap. It included a health survey and qualitative interviews with 29 young people aged 16–21 trafficked into the UK from other countries who were recruited through voluntary organisations and children’s social services. These data were supplemented by interviews with relevant professionals. Over half the young people had been trafficked for sex work but sexual violence had also been experienced by those trafficked for domestic servitude and labour exploitation. Physical violence, threats, restrictions of liberty and deprivation were also widespread, as were experiences of physical and sexual violence prior to being trafficked. Five young women had become pregnant whilst trafficked; three were parents when interviewed. Two-thirds screened positive for high levels of psychological distress, including PTSD. Twelve reported suicidal thinking. Whilst some were keen for opportunities to talk to health professionals confidentially and wanted practitioners to treat their accounts as credible, others wanted to forget abusive experiences. Complex gatekeeping systems, language barriers and practitioners who failed to take them seriously limited access to healthcare. Support and advocacy were helpful in assisting these young people to navigate healthcare systems. Health professionals need to recognise and respond appropriately to trafficked young people’s often complex mental health needs and refer them to relevant services, as well as facilitating care at later times when they might need support or be more ready to receive help.

Background: The European Union (EU) Migrant-Friendly Hospital (MFH) Initiative, introduced in 2002, promotes the adoption of care approaches adapted to meet the service needs of migrants. However, for paediatric hospitals, no specific recommendations have been offered for MFH care for children. Using the Swiss MFH project as a case study, this paper aims to identify hospital-based care needs of paediatric migrants (PMs) and good service approaches. Methods: Semi-structured interviews were conducted with principal project leaders of five paediatric hospitals participating in the Swiss MFH project. A review of the international literature on non-clinical hospital service needs and service responses of paediatric MFHs was conducted. Results: Paediatric care can be complex, usually involving both the patient and the patient’s family. Key challenges include differing levels of acculturation between parents and children; language barriers; cultural differences between patient and provider; and time constraints. Current service and infrastructural responses include interpretation services for PMs and parents, translated information material, and special adaptations to ensure privacy, e.g., during breastfeeding. Clear standards for paediatric migrant-friendly hospitals (P-MFH) are lacking. Conclusions: International research on hospital care for migrant children is scarce. The needs of paediatric migrants and their families may differ from guidance for adults. Paediatric migrant needs should be systematically identified and used to inform paediatric hospital care approaches. Hospital processes from admission to discharge should be revised to ensure implementation of migrant-sensitive approaches suitable for children. Staff should receive adequate support, such as training, easily available interpreters and sufficient consultation time, to be able to provide migrant-friendly paediatric services. The involvement of migrant groups may be helpful. Improving the quality of care for PMs at both policy and service levels is an investment in the future that will benefit native and migrant families.

BACKGROUND: Evidence from armed conflict settings points to high levels of intimate partner violence (IPV) against women. Current knowledge on how to prevent IPV is limited-especially within war-affected settings. To inform prevention programming on gender-based violence in settings affected by conflict, we evaluated the impact of adding a targeted men's intervention to a community-based prevention programme in Côte d'Ivoire. METHODS: We conducted a two-armed, non-blinded cluster randomized trial in Côte d'Ivoire among 12 pair-matched communities spanning government-controlled, UN buffer, and rebel-controlled zones. The intervention communities received a 16-week IPV prevention intervention using a men's discussion group format. All communities received community-based prevention programmes. Baseline data were collected from couples in September 2010 (pre-intervention) and follow-up in March 2012 (one year post-intervention). The primary trial outcome was women's reported experiences of physical and/or sexual IPV in the last 12 months. We also assessed men's reported intention to use physical IPV, attitudes towards sexual IPV, use of hostility and conflict management skills, and participation in gendered household tasks. An adjusted cluster-level intention to treat analysis was used to compare outcomes between intervention and control communities at follow-up. RESULTS: At follow-up, reported levels of physical and/or sexual IPV in the intervention arm had decreased compared to the control arm (ARR 0.52, 95% CI 0.18-1.51, not significant). Men participating in the intervention reported decreased intentions to use physical IPV (ARR 0.83, 95% CI 0.66-1.06) and improved attitudes toward sexual IPV (ARR 1.21, 95% CI 0.77-1.91). Significant differences were found between men in the intervention and control arms' reported ability to control their hostility and manage conflict (ARR 1.3, 95% CI 1.06-1.58), and participation in gendered household tasks (ARR 2.47, 95% CI 1.24-4.90). CONCLUSIONS: This trial points to the value of adding interventions working with men alongside community activities to reduce levels of IPV in conflict-affected settings. The intervention significantly influenced men's reported behaviours related to hostility and conflict management and gender equitable behaviours. The decreased mean level of IPV and the differences between intervention and control arms, while not statistically significant, suggest that IPV in conflict-affected areas can be reduced through concerted efforts to include men directly in violence prevention programming. A larger-scale trial is needed to replicate these findings and further understand the mechanisms of change. TRIAL REGISTRATION: clinicaltrials.gov NCT01803932.

Background\ud Trafficked people experience high levels of physical and psychological morbidity, but little is known about trafficked people’s experiences of accessing and using healthcare services during or after their trafficking experiences. \ud \ud Aim\ud To explore trafficked people’s access to and use of healthcare during and after trafficking\ud \ud Design\ud Mixed methods study (cross-sectional survey comprising of a structured interview schedule and open-ended questions).\ud \ud Setting\ud Trafficked people’s accommodation or support service offices in locations across England. \ud \ud Method\ud Participants were asked open-ended questions regarding their use of healthcare services during and after trafficking. Interviews were conducted with professionally qualified interpreters where required. Thematic analysis was used to analyse the data.\ud \ud Results \ud 136 trafficked people participated, 91 (67%) female and 45 (33%) male. Participants reported being trafficked for domestic servitude (n=40; 30%) sexual exploitation (n=41; 31%) and labour exploitation (e.g., agriculture, factor work) 52 (39%). One-fifth (n=26, 19%) reported access to health care services while trafficked, most often general practitioners (GPs) surgeries and walk-in-centres. Many reported that traffickers restricted access to services, accompanied them or interpreted for them during consultations. Requirements to present identity documents to register for care and poor access to interpreters were barriers to care during and after trafficking. Advocacy and assistance from support workers were critical to health service access for trafficked people.\ud \ud Conclusions\ud Trafficked people access health services during and after the time they are exploited, but encounter significant barriers. GPs and other practitioners would benefit from guidance on how trafficked people can be supported to access care, especially where they lack official documentation.