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This paper examines the relationship between child labour and educational attainment and explores the distinction between harmful and non-harmful agricultural cocoa work. We conduct a secondary analysis of data on 3,338 children who reported attending school in 2018 across cocoa growing regions of Ghana and Côte d’Ivoire. To address differences between harmful and non-harmful child labour, we differentiated work completed by a child by hazardous activity engagement. These groups of child labour were then modelled against educational attainment, defined by a whether or not the child needed to repeat a class. We then conducted mediation analysis to assess whether injury mediates this relationship. Our results show that hazardous child labour increases the odds of repeating a class and work-related injury compared to non-hazardous labour. The effect of hazardous child labour on academic attainment was also found to be mediated by work-related injuries by 14%. Educational attainment is associated with hazardous labour activities and the odds of injury and not the act of participation in agricultural labour alone. Programmes based on strong measures of harmful work will foster better protection for children who are most at risk and may inform global debates around the benefits versus the risks of child labour.

Abstract Background The growth of labour migration and associated risks of human trafficking and exploitation remain significant global human rights and health challenges. There is increasing policy interest in addressing structural determinants of adverse migration outcomes such as migrants’ use of informal employment recruiters. In Ethiopia, “safe migration” policies have introduced regulations for registered private employment agencies and penalties for anyone else placing migrants into work overseas. Yet migrants continue to use informal facilitators who are often demonised as traffickers without evidence of their motivations, experiences or perceptions. We conducted qualitative interviews with 28 informal facilitators as part of a study into how recruitment practices shape risks for female migrants seeking domestic work in the Middle East and Gulf States. We present the realities of irregular recruitment on the ground, and how these practices are affected by policies that dichotomise recruiters into legal/safe and illegal/unsafe categories. Results We identified four main themes. First, arranging migration from rural areas differs from in the capital, Addis Ababa, where laws and regulations originate. Outside Addis Ababa, registration was difficult for facilitators to arrange, with little incentive to do so due to its lack of importance to prospective migrants. Second, the ability to circumvent legal requirements was considered an advantage of informal facilitators because it reduced costs and expedited migrants’ departure. Third, facilitators did not work alone but operated in long “chains” of diverse actors. This meant migrants’ safety was not determined by any given individual, but spread across numerous people involved in sending a migrant abroad, some of whom might be registered and others not. And finally, facilitators did not believe they could realistically safeguard migrants once they were outside of Ethiopia and working under different laws and employers. Conclusions Findings from this study add to a growing body of work demonstrating the diversity of people involved in the migration process, and consequent oversimplification of popular policy solutions. A more effective approach might be to constructively engage informal facilitators and identify ways they could assist with referring migrant workers to registered agencies and safe employment, rather than criminalising their participation.

This paper reflects on the development process (2015–2020) of the Learning Initiative for Norms, Exploitation, and Abuse (LINEA) Intervention. The LINEA Intervention is a multi-component social norms intervention to prevent age-disparate transactional sex in Tanzania. This paper aims to: (1) critically reflect on the LINEA Intervention development process by retrospectively comparing it with a pragmatic, phased framework for intervention development in public health, the Six Essential Steps for Quality Intervention Development (6SQuID); and (2) discuss the usefulness and applicability of this framework to guide intervention development for gender-based violence prevention. This paper contributes to a growing field of intervention development research to improve the designs of interventions to prevent gender-based violence. Findings showed that the LINEA Intervention development approach mostly aligned with the steps in 6SQuID framework. However, the LINEA Intervention development process placed particular emphasis on two phases of the 6SQuID framework. First, the LINEA Intervention development process included significant investment in formative research, feasibility testing, and refinement; and second, the LINEA Intervention was informed by a clearly articulated behavior change theory—social norms theory. Beyond the 6SQuID framework the LINEA Intervention development process: (i) followed a non-linear, iterative process; (ii) applied ongoing feasibility testing to refine the intervention, and (iii) relied on co-development with local implementers and participants. This paper suggests future components for a robust intervention development process, highlighting beneficial additions to the 6SQuID approach, a well-recognized intervention development sequence. Particularly useful additions include incorporating sufficient time, flexibility, and resources to foster meaningful collaborations and iteration on the intervention design.

Abstract Background International labour migration has become a crucial livelihood strategy, especially in countries where decently paid employment opportunities are limited. Such opportunities come with many potential benefits but also many stressors that challenge migrants’ coping skills, especially when they are in a foreign environment away from their normal support network. This paper explores how labour migrants coped with migration-related stressors using a sample of male Nepali migrants. Methods Qualitative life histories were conducted in Kathmandu among returnee male migrants. Coping responses were categorised based Skinner and Zimmer-Gembeck’s coping typologies. The interview scripts were transcribed in Nepali and translated into English for analysis. Each interview script was open coded and then categorised according to the 12 core coping families. Data were analysed thematically to explore relationships across and within coping and stressors. Results Forty-two men were interviewed who mainly worked in low- and semi-skilled jobs in Malaysia, and the Gulf States. The coping strategies most commonly used belonged to the families of problem-solving, support-seeking, negotiation and helplessness. Men used these either individually or collectively with other migrants. Those who sought assistance from authorities or civil society organisations did not always receive the help needed and there were mixed messages as to when and what types of assistance were available. Some stressors involved multiple coping strategies simultaneously, others described changing strategies following unsuccessful earlier attempts. The coping families of helplessness and social isolation reflected migrants’ limited power in challenging certain stressors. The choice of coping strategies was also moderated by factors such as outstanding loans, language difficulties, or not wanting to cause their family distress. Some coping strategies used led to new stressors. Conclusions Migrants need greater clarifications on their rights with respect to contract discrepancies, the types of support available, how and from whom to access them once in destination. Improvements to the support mechanisms migrants can access as well as strengthening migrant-led initiatives in destination countries to support labour migrants' in managing stressors are needed. These may contribute to reducing the experiences and impact of such stressors, which may ultimately lead to more successful migration outcomes. As labour migration from Nepal is likely to continue, government and CSOs need to ensure migrants have the support they need to cope with the challenges they may encountered along the way.

Child labour is a common financial coping strategy in poor households, especially in low-and middle-income countries with many children working under hazardous conditions. Little is known about the linkages between hazardous work conditions and psycho-social and educational outcomes. We analysed the Bangladesh Multiple Indicator Cluster Survey (BMICS) round 6 to assess the association between the exposure variables, including child labour, hazardous child labour (HZCL) and hazardous work, and outcome variables, including psychosocial functioning difficulty and school dropout, in children aged 5 to 17 years. We conducted bivariable and multivariable analyses to examine the association. In the adjusted analyses, children engaged in HZCL had increased odds of psychosocial functioning difficulty (aOR: 1.41; 95% CI: 1.16–1.72) and school dropout (aOR: 5.65; 95% CI: 4.83–6.61) among 5–14-year-olds compared to children who did not engage in child labour and hazardous work. Other independent factors associated with psychosocial functioning difficulty and school dropout included being male, living in a deprived neighbourhood, being exposed to violent punishment, the caregiver’s attitude towards physical punishment, the mother’s functional difficulty and lower maternal education. The linkages between hazardous work and psychosocial functioning difficulty appear more prominent among children not in school. Further, the evidence on the relationship between hazardous work and school dropout is stronger among children with psychosocial functioning difficulty. Policies and programmes that target the most hazardous forms of work are likely to have the greatest benefits for children’s mental health, social well-being and educational attainment.

Abstract Conflict-related sexual violence (CRSV) against women and girls has been the subject of increasing research and scholarship. Less is known about the health of men, boys and lesbian, gay, bisexual, transgender (LGBT) and other gender non-binary persons who survive CRSV. This paper is the first systematic realist review on medical, mental health and psychosocial support (MHPSS) interventions that focusses on male and LGBT survivors of CRSV. The review explores the gender differences in context, mechanisms and outcomes that underpin interventions addressing the health and psychosocial wellbeing of male and LGBT survivors. The aim is to contribute to the design and delivery of gender-sensitive and, when needed, gender-specific approaches for interventions that respond to specific needs of different groups of all survivors. We conducted a systematic search of academic and grey literature to identify medical and MHPSS interventions that included men, boys and LGBT survivors. We identified interventions specifically targeting women and girls that we used as comparators. We then purposively sampled studies from the fields of gender and health, and sexual abuse against men and LGBT people for theory building and testing. We identified 26 evaluations of interventions for survivors of CRSV. Nine studies included male survivors, twelve studies focussed exclusively on female survivors and one study targeted children and adolescents. No intervention evaluation focussed on LGBT survivors of CRSV. The interventions that included male survivors did not describe specific components for this population. Results of intervention evaluations that included male survivors were not disaggregated by gender, and some studies did not report the gender composition. Although some mental health and psychosocial consequences of sexual violence against men and boys may be similar among male and female survivors, the way each process trauma, display symptoms, seek help, adhere to treatment and improve their mental health differ by gender. Initiatives targeting male and LGBT survivors of CRSV need to be designed to actively address specific gender differences in access, adherence and response to MHPSS interventions. Models of care that are gender-sensitive and integrated to local resources are promising avenues to promote the health of male and LGBT survivors of CRSV.

Preventing modern slavery is of global interest, but evidence on interventions remains weak. This paper presents findings from a 5-year theory-based evaluation of an empowerment and knowledge-building intervention to prevent the exploitation of South Asian female migrant workers. The evaluation used realist evaluation techniques to examine the intervention mechanisms, outcomes, and context. Findings from qualitative and quantitative data from Nepal, India, and Bangladesh indicate that the intervention mechanisms (trainings) were not well-targeted, not delivered by appropriate trainers, and did not address participants' expectations or concerns. The outcomes of empowerment and migration knowledge were not achieved due to poor integration of context-related factors, flawed assumptions about the power inequalities, including barriers preventing women from asserting their rights. Ultimately, interventions to prevent exploitation of migrant workers should be developed based on strong evidence about the social, political, and economic realities of their migration context, especially in destination settings.

Labour migration has become a crucial livelihood strategy in settings where employment options are limited. Such opportunities come with potential benefits but also introduce stressors. This study explores migration-related stressors amongst returnee male Nepali international labour migrants. We conducted a qualitative study in Kathmandu amongst 42 returnee male international labour migrants. We explored migration decisions, processes, experiences in destination and on return. The participants worked in low- and semi-skilled jobs in Malaysia, Qatar, and Saudi Arabia. Men reported stressors representing five broad areas: workplace/employer, family, recruitment, environment and legal. Most belonged to the workplace/employer category such as exploitative practices of document confiscation, contract discrepancies and poor working conditions. Family stressors were often due to disagreements about whether to migrate, and once in destination, being absent during illness and death in the family. Recruitment stressors were linked to the migration process and costs. Environmental stressors included over-crowdedness and poor hygiene, and poor security at the accommodation and in the wider town. Legal stressors were related to the lack of documentation, and negative encounters with the local police. Multiple stressors were often experienced simultaneously or in succession. Male labour migrants from Nepal who had worked in various countries and job-sectors reported multiple types of stress. The majority of stressors belong to the workplace category, where migrants may have limited power to challenge problems with their employers. The cumulative effect of such experiences may negatively impact on migrants’ wellbeing. Future research should explore migrants’ ability to cope with the many stressors encountered.

Background: Human trafficking is a recognized human rights violation, and a public health and global development issue. Violence is often a hallmark of human trafficking. This study aims to describe documented cases of violence amongst persons identified as victims of trafficking, examine associated factors throughout the trafficking cycle and explore prevalence of abuse in different labour sectors. Methods and findings: The IOM Victim of Trafficking Database (VoTD) is the largest database on human trafficking worldwide. This database is actively used across all IOM regional and country missions as a standardized anti-trafficking case-management tool. This analysis utilized the cases of 10,369 trafficked victims in the VoTD who had information on violence. Results: The prevalence of reported violence during human trafficking included: 54% physical and/or sexual violence; 50% physical violence; and 15% sexual violence, with 25% of women reporting sexual violence. Experiences of physical and sexual violence amongst trafficked victims were significantly higher amongst women and girls (AOR 2.48 (CI: 2.01,3.06)), individuals in sexual exploitation (AOR 2.08 (CI: 1.22,3.54)) and those experiencing other forms of abuse and deprivation, such as threats (AOR 2.89 (CI: 2.10,3.98)) and forced use of alcohol and drugs (AOR 2.37 (CI: 1.08,5.21)). Abuse was significantly lower amongst individuals trafficked internationally (AOR 0.36 (CI: 0.19,0.68)) and those using forged documents (AOR 0.64 (CI: 0.44,0.93)). Violence was frequently associated with trafficking into manufacturing, agriculture and begging (> 55%). Conclusions: An analysis of the world's largest data set on trafficking victims indicates that violence is indeed prevalent and gendered. While these results show that trafficking-related violence is common, findings suggest there are patterns of violence, which highlights that post-trafficking services must address the specific support needs of different survivors.

Prompted by reports of ‘sea slavery’ in the fishing industry and threats of sanctions, Thailand has faced pressure to eradicate human trafficking the fishing sector. Although the Thai government has responded with anti-trafficking policies, there remains little understanding about their implementation. Specifically, little is known about how government agencies, NGOs or industry perceive “trafficking”, and no research examines how trafficked fishermen are identified and assisted. This study aimed to: 1) explore how stakeholders described trafficking in the fishing sector and their perceptions of trafficking indicators; and 2) identify challenges encountered by frontline responders to identify and assist trafficked fishermen. We conducted interviews with 33 key informants, which were analysed thematically. Findings indicate that authorities and industry representatives believed migrant brokers caused employers to “inadvertently” traffic men. Trafficking was perceived to take place primarily outside of Thai waters, beyond the government's jurisdiction. Most stakeholders considered violence and being confined as key indicators of trafficking. Officials expressed confusion about whether debt bondage and document confiscation “counted” as indicators. Ambiguity and confusion about trafficking indicators in screening forms, combined with perceived “deservingness” of official victim status, underpinned frontline responders’ decisions about who was a victim of trafficking (VoT). Practical and structural constraints included interpreter shortages, and expanded civil servant remits without commensurate staff increases, which hindered officials’ responses to trafficking. This study addresses a critical knowledge gap on the implementation of anti-trafficking policies and offers findings to assist policymakers to address the challenges faced by frontline responders to improve victim identification and assistance.

BackgroundAwareness-raising and pre-migration training are popular strategies to prevent human trafficking. Programmatic theories assume that when prospective migrants are equipped with information about risks, they will make more-informed choices, ultimately resulting in safe migration. In 2016, India was estimated to have 8 million people in modern slavery, including those who migrate internally for work. Work in Freedom (WiF) was a community-based trafficking prevention intervention. This study evaluated WiF's pre-migration knowledge-building activities for female migrants in Odisha to prevent future labour-related exploitation.MethodsPre- and post- training questionnaires were administered to women (N = 347) who participated in a two-day pre-migration training session. Descriptive analysis and unadjusted analyses (paired t-tests, McNemar's tests, Wilcoxon signed ranks tests) examined differences in women's knowledge scores before and after training. Adjusted analyses used mixed effects models to explore whether receiving information on workers' rights or working away from home prior to the training was associated with changes in scores. Additionally, we used data from a household survey (N = 4,671) and survey of female migrants (N = 112) from a population sample in the same district to evaluate the intervention's rationale and implementation strategy.ResultsFemale participants were on average 37.3 years-old (SD 11) and most (67.9%) had no formal education. Only 11 participants (3.2%) had previous migration experience. Most participants (90.5%) had previously received information or advice on workers' rights or working away from home. Compared to female migrants in the population, training participants were different in age, caste and religion. Awareness about migration risks, rights and collective bargaining was very low initially and remained low post-training, e.g. of 13 possible migration risks, before the training, participants named an average of 1.2 risks, which increased only slightly to 2.1 risks after the training (T(346) = -11.64, pConclusionThe apparent low effectiveness of the WiF short-duration migration training may be linked to the assumption that individual changes in knowledge will lead to shifts in social norms. The narrow focus on such individual-level interventions may overestimate an individual's agency. Findings indicate the importance of intervention development research to ensure activities are conducted in the right locations, target the right populations, and have relevant content. Absent intervention development research, this intervention suffered from operating in a site that had very few migrant women and a very small proportion migrating for domestic work-the focus of the training. To promote better development investments, interventions should be informed by local evidence and subjected to rigorous theory-based evaluation to ensure interventions achieve the most robust design to foster safe labour migration for women.

Abstract Background Human trafficking is a pervasive global crime with important public health implications that entail fundamental human rights violations in the form of severe exploitation, violence and coercion. Sex-specific associations between types of violence or coercion and mental illness in survivors of trafficking have not been established. Methods We conducted a cross-sectional study with 1015 female and male survivors of trafficking (adults, adolescents and children) who received post-trafficking assistance services in Cambodia, Thailand or Vietnam and had been exploited in various labor sectors. We assessed anxiety and depression with the Hopkins Symptoms Checklist (HSCL-25) and post-traumatic stress disorder (PTSD) symptoms with the Harvard Trauma Questionnaire (HTQ), and used validated questions from the World Health Organization International Study on Women’s Health and Domestic Violence to measure physical and sexual violence. Sex-specific modified Poisson regression models were estimated to obtain prevalence ratios (PRs) and their 95% confidence intervals (CI) for the association between violence (sexual, physical or both), coercion, and mental health conditions (anxiety, depression and PTSD). Results Adjusted models indicated that for females, experiencing both physical and sexual violence, compared to not being exposed to violence, was a strong predictor of symptoms of anxiety (PR = 2.08; 95% CI: 1.64–2.64), PTSD (PR = 1.55; 95% CI: 1.37–1.74), and depression (PR = 1.57; 95% CI: 1.33–1.85). Among males, experiencing physical violence with additional threats made with weapons, compared to not being exposed to violence, was associated with PTSD (PR = 1.59; 95% CI: 1.05–2.42) after adjustment. Coercion during the trafficking experience was strongly associated with anxiety, depression, and PTSD in both females and males. For females in particular, exposure to both personal and family threats was associated with a 96% elevated prevalence of PTSD (PR = 1.96; 95% CI: 1.32–2.91) and more than doubling of the prevalence of anxiety (PR = 2.11; 95% CI: 1.57–2.83). Conclusions The experiences of violence and coercion in female and male trafficking survivors differed and were associated with an elevated prevalence of anxiety, depression, and PTSD in both females and males. Mental health services must be an integral part of service provision, recovery and re-integration for trafficked females and males.

Abstract Background Little is known about the health of GMS commercial fishers and seafarers, many of whom are migrants and some trafficked. This systematic review summarizes evidence on occupational, physical, sexual and mental health and violence among GMS commercial fishers/seafarers. Methods We searched 5 electronic databases and purposively searched grey literature. Quantitative or qualitative studies reporting prevalence or risk of relevant outcomes were included. Two reviewers independently screened articles. Data were extracted on nationality and long/short-haul fishing where available. Results We identified 33 eligible papers from 27 studies. Trafficked fishers/seafarers were included in n=12/13 grey literature and n=1/20 peer-reviewed papers. Among peer-reviewed papers: 11 focused on HIV/AIDS/sexual health; nine on occupational/physical health; one study included mental health of trafficked fishers. Violence was quantitatively measured in eight papers with prevalence of: 11-26% in port convenience samples; 68-100% in post-trafficking service samples. Commercial fishers/seafarers whether trafficked or not worked extremely long hours; trafficked long-haul fishers had very limited access to care following injuries or illness. Lesser-known risks reported among fishers included penile oil injections and beriberi. We found just one work safety intervention study and inconclusive evidence for differences in the outcomes by nationality. Findings are limited by methodological weaknesses of primary studies. Conclusion Results show an absence of high-quality epidemiological studies beyond sexual health. Formative and pilot intervention research on occupational, physical and mental health among GMS commercial fishers and seafarers is needed. Future studies should include questions about violence and exploitation. Ethical and reporting standards of grey literature should be improved. Trial Registration Review registration number: PROSPERO 2014: CRD42014009656.

Abstract Background Human trafficking in the fishing industry or “sea slavery” in the Greater Mekong Subregion is reported to involve some of the most extreme forms of exploitation and abuse. A largely unregulated sector, commercial fishing boats operate in international waters far from shore and outside of national jurisdiction, where workers are commonly subjected to life-threatening risks. Yet, research on the health needs of trafficked fishermen is sparse. This paper describes abuses, occupational hazards, physical and mental health and post-trafficking well-being among a systematic consecutive sample of 275 trafficked fishermen using post-trafficking services in Thailand and Cambodia. These findings are complemented by qualitative interview data collected with 20 key informants working with fishermen or on issues related to their welfare in Thailand. Results Men and boys trafficked for fishing (aged 12–55) were mainly from Cambodia (n = 217) and Myanmar (n = 55). Common physical health problems included dizzy spells (30.2%), exhaustion (29.5%), headaches (28.4%) and memory problems (24.0%). Nearly one-third (29.1%) reported pain in three or more areas of their body and one-quarter (26.9%) reported being in “poor” health. Physical health symptoms were strongly associated with: severe violence; injuries; engagement in long-haul fishing; immigration detention or symptoms of mental health disorders. Survivors were exposed to multiple work hazards and were perceived as disposable when disabled by illness or injuries. Employers struggled to apply internationally recommended Personal Protective Equipment (PPE) practices in Thailand. Non-governmental organizations (NGOs) encountered challenges when trying to obtain healthcare for uninsured fishermen. Challenges included fee payment, service provision in native languages and officials siding with employers in disputes over treatment costs and accident compensation. Survivors’ post-trafficking concerns included: money problems (75.9%); guilt and shame (33.5%); physical health (33.5%) and mental health (15.3%). Conclusion Fishermen in this region are exposed to very serious risks to their health and safety, and their illnesses and injuries often go untreated. Men who enter the fishing industry in Thailand, especially migrant workers, require safe working conditions and targeted protections from human trafficking. Survivors of the crime of sea slavery must be provided with the compensation they deserve and the care they need, especially psychological support.

Abstract Background Bride-trafficking has been a growing phenomenon in Southeast Asia, particularly in China, where one-child policies have resulted in demographic imbalances favoring males. Yet, empirical evidence about women and girls sold into marriage in China remains sparse. Methods This study describes the experiences of 51 Vietnamese women and girls as young as 14 in post-trafficking services who were sold into marriage in China. A consecutive sample of individuals from five services in Vietnam were invited to be interviewed within the first 2 weeks of admission. It is part of a wider dataset for research on the health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam, the largest study to date on human trafficking and health. We calculated proportions for all variables and conducted bivariate analyses using Fisher Exact Tests for their associations with mental health disorders symptoms. Results Before leaving home, 31% (n = 15) participants were married. Participants reported high levels of sexual violence (n = 43; 86%) while trafficked and59% (n = 30) spent time in detention before returning to Vietnam. Once in post-trafficking care 52.9% (n = 27) reported probable depression, anxiety or post-traumatic stress disorders (PTSD), two women (4%) attempted suicide in the past month and 38 (75%) remained afraid of their trafficker. Ten (22%) became pregnant while trafficked, and seven (16%) were pregnant at the interview. Conclusions The cross-border bride trade between Vietnam and China raises complex policy issues, including questions about detention and immigration rights and strategies for supported return processes, including maternal and child health services. As the repercussions of China’s absent female population will persist, Vietnam and China must grapple with the political and social conditions to implement prevention strategies, and resources for women who fall prey to this cross-border bride trade.

Abstract Background International migration has become a global political priority, with growing concern about the scale of human trafficking, hazardous work conditions, and resulting psychological and physical morbidity among migrants. Ethiopia remains a significant “source” country for female domestic workers to the Middle East and Gulf States, despite widespread reports of exploitation and abuse. Prior to introduction of a “safe migration” intervention, we conducted formative research to elicit lessons learned by women who had worked as domestic workers abroad. The aim of the study was to identify realistic measures future migrants could take to protect themselves, based on the collective insights and experience of returnees. Methods We conducted a qualitative assessment among returnee domestic labour migrants in Amhara Region, Ethiopia, an area considered a “hotspot” for outmigration. We conducted in-depth interviews and focus group discussions with a total of 35 female returnees, exploring risk and protective factors experienced by Ethiopian women during domestic work abroad. We used thematic content analysis to identify practical messages that could improve prospective migrants’ preparedness. Results Returnees described the knowledge and skills they acquired prior to departure and during migration, and shared advice they would give to prospective migrants in their community. Facilitators of positive migration included conforming to cultural and behavioural expectations, learning basic Arabic, using household appliances, and ensuring safety in employers’ homes. Respondents also associated confidence and assertiveness with better treatment and respect, and emphasized the importance of access to external communication (e.g. a mobile phone, local sim card, and contact details) for help in an emergency. Following their own challenging or even traumatic experiences, returnees were keen to support resilience among the next wave of migrants. Conclusions There is little evidence on practices that foster safer migration, yet attention to human trafficking has led to an increase in pre-migration interventions. These require robust evidence about local risk and protective factors. Our findings identify knowledge, skills, attributes and resources found useful by returnee domestic workers in Amhara region, and have been used to inform a community-based programme aiming to foster better decision-making and preparation, with potential to offer insights for safer migration elsewhere.

Summary: Background: Globally, there are more than 150 million international migrant workers—individuals who are employed outside of their country of origin—comprising the largest international migrant group. A substantial number of migrants work in hazardous and exploitative environments, where they might be at considerable risk of injury and ill health. However, little data on occupational health outcomes of migrant workers exist, with which to inform global policy making and delivery of health services. Methods: For this systematic review and meta-analysis, we searched Embase, MEDLINE, Ovid Global Health, and PsychINFO databases for primary research published between Jan 1, 2008, and Jan 24, 2018, reporting occupational health outcomes among international migrant workers (defined as individuals who are or have been employed outside their country of origin), without language or geographical restrictions. We excluded studies containing mixed cohorts of migrants and native workers in which migrant data could not be disaggregated, and studies that did not explicitly report migrant status. The main outcome was prevalence of occupational health outcomes (defined as any injury, mortality, or physical or psychiatric morbidity due to an individual's work or workplace environment) among international migrant workers. Summary estimates were calculated using random-effects models. The study protocol has been registered with PROSPERO, number CRD42018099465. Findings: Of the 1218 studies identified by our search, 36 studies were included in our systematic review, and 18 studies were included in the meta-analysis. The systematic review included occupational health outcomes for 12 168 international migrant workers employed in 13 countries and territories, mostly employed in unskilled manual labour. Migrant workers originated from 25 low-income and middle-income countries, and worked in the following sectors: agriculture; domestic, retail, and service sectors; construction and trade; and manufacturing and processing. Migrant workers had various psychiatric and physical morbidities, and workplace accidents and injuries were relatively common. In the meta-analysis, among 7260 international migrant workers, the pooled prevalence of having at least one occupational morbidity was 47% (95% CI 29–64; I2=99·70%). Among 3890 migrant workers, the prevalence of having at least one injury or accident, including falls from heights, fractures and dislocations, ocular injuries, and cuts was 22% (7–37; I2=99·35%). Interpretation: International migrant workers are at considerable risk of work-related ill health and injury, and their health needs are critically overlooked in research and policy. Governments, policy makers, and businesses must enforce and improve occupational health and safety measures, which should be accompanied by accessible, affordable, and appropriate health care and insurance coverage to meet the care needs of this important working population. Funding: Wellcome Trust.

In an Editorial, Ligia Kiss and Cathy Zimmerman discuss the need for research on the prevention of human trafficking and mitigation of its effects.

Mental health professionals have opportunities to intervene and provide care for trafficked people. Research shows that mental health problems – including depression, anxiety and post-traumatic stress disorder – are prevalent among trafficked people, and that at least some trafficked people come into contact with secondary mental health services in England.

In this collection review, Cathy Zimmerman and colleague introduce the PLOS Medicine Collection on Human Trafficking, Exploitation and Health, laying out the magnitude of the global trafficking problem and offering a public health policy framework to guide responses to trafficking.

Although trafficked women and adolescents are at risk of unprotected or forced sex, there is little research on maternity care among trafficking survivors. We explored health care needs, service use and challenges among women who became pregnant while in the trafficking situation in the United Kingdom (UK) and clinicians' perspectives of maternity care for trafficked persons.Cross-sectional survey and qualitative interviews with trafficking survivors recruited from statutory and voluntary sector organisations in England and qualitative interviews with maternity clinicians and family doctors undertaken to offer further insight into experiences reported by these women.Twenty-eight (29%) of 98 women who took part in a large study of trafficking survivors reported one or more pregnancies while trafficked, whose data are reported here. Twelve (42.8%) of these women reported at least one termination of pregnancy while in the trafficking situation and 25 (89.3%) experienced some form of mental health disorder. Nineteen (67.9%) women experienced pre-trafficking physical abuse and 9 (32.%) sexual abuse. A quarter of women were trafficked for sexual exploitation, six for domestic servitude and two for manual labour. Survivors and clinicians described service challenges, including restrictions placed on women's movements by traffickers, poor knowledge on how to access maternity care, poor understanding of healthcare entitlements and concerns about confidentiality. Maternity care clinicians recognised potential indicators of trafficking, but considered training would help them identify and respond to victims. Main limitations include that findings reflect women who had exited the trafficking situation, however as some had only recently exited the trafficking situation, difficulties with recall were likely to be low.More than one in four women became pregnant while trafficked, indicating that maternity services offer an important contact point for identification and care. Given the prevalence of sexual exploitation and abuse among trafficking survivors, clinicians should ensure antenatal care and screening for sexually transmitted infections can be readily accessed by women. Clinicians require specialised training alongside designated pathways and protocols with clear referral options to ensure confidential maternity care tailored to each woman's needs.

Migration and displacement are pivotal determinants of urban health, influencing both direct and indirect health outcomes. Migrants may face unique health risks, often exacerbated by economic, social, and environmental factors encountered during transit or upon resettlement. As migration patterns shift due to geopolitical, climatic, and economic pressures, they reshape the global and urban policy landscapes in unpredictable ways, presenting challenges that will continue to evolve in the coming decades. Current legal frameworks, in many cases, do not adequately account for migrant populations, hindering policy responses and complicating the protection of migrant health. Therefore, effective urban health interventions must be inclusive of migrant populations and expand beyond healthcare services. A systems-thinking approach that recognizes the broader determinants of health—including housing, employment, social services, and urban infrastructure—is essential to address the intersecting challenges migrants face. Despite these challenges, migration remains crucial to the functioning of urban environments. Migrant workers consistently contribute to the healthy operation of cities, underpinning key infrastructure and services. However, to optimize policy responses and improve urban health outcomes, more robust data and evidence on the health risks and outcomes of migrants, as well as the structural drivers of migration, are needed. Moreover, macro factors such as climate change, future pandemics, and geopolitical shifts are likely to influence both migration dynamics and migrant health. To anticipate and respond to these evolving challenges, a systems-informed and holistic vision of urban health is required—one that integrates migration into the broader urban policy and planning frameworks to foster healthier, more resilient cities.

For the 2016 end-of-the-year editorial, the PLOS Medicine editors asked 7 global health leaders to discuss developments relevant to the equitable provision of medical care to all populations. The result is a collection of expert views on ethical trial design, research during outbreaks, high-burden infectious diseases, diversity in research and protection of migrants.

Men comprise nearly two-thirds of trafficked and forced labourers in common low-skilled labour sectors including fishing, agriculture and factory work. Yet, most evidence on human trafficking has focused on women and girls trafficked for sex work, with scant research on trafficked men and boys.We analyse survey data from the largest systematic consecutive sample of trafficked people collected to date to describe the prevalence of violence, occupational health risks and injuries and associated factors. Participants were labour-trafficked men and boys using post-trafficking support services in Thailand, Cambodia and Vietnam.Data are presented on 446 males aged 10-58. Men and boys were mainly trafficked for fishing (61.7%), manufacturing (19.1%) and begging (5.2%). Fishermen worked extensive hours (mean 18.8 hours/day, SD 5.9) and factory workers worked on average 11.9 hours/day (SD 2.9). 35.5% of male survivors had been injured while trafficked; 29.4% received no personal protective equipment (e.g. gloves). The most commonly reported injuries among all males were deep cuts (61.8%) and skin injuries (36.7%), injuries for which fewer than one-quarter reported receiving medical care. Six fishermen lost body parts, none of whom received medical care. Most males (80.5%) had no or very few rest breaks. One-third (37.8%) experienced severe violence. Work-related injuries were associated with severe violence (AOR 3.44, CI:1.63-7.26), being in the fishing sector, (AOR 4.12, CI:2.39-7.09) and threats (AOR 2.77, CI:1.62-4.75). Experiencing any violence was associated with threats (AOR 26.86, CI:14.0-51.23), being in the fishing sector (AOR 18.53, CI:8.74-39.28) and fluency in language of destination country (AOR 0.39, CI:0.20-0.75).This study highlights the abuse and extreme occupational hazards suffered by trafficked men and boys. Occupational health and safety interventions are urgently needed to protect male migrant labourers working in high-risk sectors, particularly fishing.

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.

There is very limited evidence on the health consequences of human trafficking. This systematic review reports on studies investigating the prevalence and risk of violence while trafficked and the prevalence and risk of physical, mental, and sexual health problems, including HIV, among trafficked people.We conducted a systematic review comprising a search of Medline, PubMed, PsycINFO, EMBASE, and Web of Science, hand searches of reference lists of included articles, citation tracking, and expert recommendations. We included peer-reviewed papers reporting on the prevalence or risk of violence while trafficked and/or on the prevalence or risk of any measure of physical, mental, or sexual health among trafficked people. Two reviewers independently screened papers for eligibility and appraised the quality of included studies. The search identified 19 eligible studies, all of which reported on trafficked women and girls only and focused primarily on trafficking for sexual exploitation. The review suggests a high prevalence of violence and of mental distress among women and girls trafficked for sexual exploitation. The random effects pooled prevalence of diagnosed HIV was 31.9% (95% CI 21.3%-42.4%) in studies of women accessing post-trafficking support in India and Nepal, but the estimate was associated with high heterogeneity (I² = 83.7%). Infection prevalence may be related as much to prevalence rates in women's areas of origin or exploitation as to the characteristics of their experience. Findings are limited by the methodological weaknesses of primary studies and their poor comparability and generalisability.Although limited, existing evidence suggests that trafficking for sexual exploitation is associated with violence and a range of serious health problems. Further research is needed on the health of trafficked men, individuals trafficked for other forms of exploitation, and effective health intervention approaches.

Social scientists are working with epidemiologists to produce evidence that questions traditional epidemiological HIV ‘core group’ models.