A qualitative needs assessment of human trafficking in Ethiopia: recommendations for a comprehensive, coordinated response

Ethiopia is a landlocked country in Eastern Africa within close proximity to the Middle East. It is the second most populous country in Africa [10]. Ethiopia is currently categorized as a low-and-middle income country; however, with significant growth it is poised to become a middle-income country within the next decade [10]. Ethiopia has continued to see growth in agriculture, industry, and service which has spurred a decline in poverty, particularly in urban areas [11]. Rural areas of Ethiopia are impacted by weather conditions unsuitable to agricultural activities, lower rates of secondary education among youth (14% versus 22% of rural youth ages 15–24 years old have a secondary education compared to those in urban areas), and lower rates of industry [11]. In Ethiopia, both migrants and residents are at risk for trafficking-related human rights violations driven by an exploitation of vulnerabilities for the men, women, boys, and girls who are trafficked [12, 13]. The popular media often focuses on Ethiopia as a transit location for women and girls being trafficked out of the country, but in reality, the problem is much broader in scope. Men, boys, women, and girls can all be exploited through various forms of both domestic and international trafficking [13, 14]. Human trafficking has been documented in begging, weaving, farm labor, and in brothels throughout Ethiopia [13]. Echoing these concerns, the 2018 United States Trafficking in Persons Report indicated that the Ethiopian government had not adequately addressed the problem of internal, within country trafficking, specifically lacking standardized protocols for frontline workers caring for survivors [15].

Research investigating human trafficking within and from Ethiopia indicates that trafficking often has severe consequences for survivors in all dimensions of their lives. Although studies in trafficked populations in Ethiopia are limited, case reports and small descriptive studies suggest that survivors frequently experience physical injuries, infectious disease, mental health disorders, shame, social stigma, and physical, sexual, and emotional abuse [16‐23]. Often, finding post-trafficking support services and reintegrating back into communities are key challenges for survivors, with few resources available to aid survivors in this process [12]. As in many other regions of the world, services for human trafficking survivors are often pieced together from different agencies. There are no countrywide formalized, or coordinated processes of reintegration, networks of response, or systems of comprehensive service delivery to aid survivors of human trafficking in Ethiopia, all of which are needed to address the complex needs of trafficking survivors that are being observed [12]. In 2017, a non-governmental organization (NGO) working in Addis Ababa documented providing care to survivors of transnational human trafficking and there are other known care centers focused on in-country sex trafficking, but the care system remains severely underdeveloped with few known services for survivors outside of urban centers [15].

Furthermore, there are limited levels of awareness about human trafficking throughout the country, particularly in rural areas and among youth [24, 25]. One study focused exclusively on sex trafficking in northwestern Ethiopia found that 60% of participants had heard or read about sex trafficking and the most frequently reported source was television [24]. Ethiopia uses television, billboards, and word of mouth to increase awareness about human trafficking, but as these studies suggest, not everyone receives those messages. Given the lack of research in this area and the limited capacity of current survivor services, the purpose of this study was to conduct a qualitative assessment of the potential service needs and response options for human trafficking in Ethiopia. We sought to identify resources and delivery methods that key stakeholder groups—including service providers, academics, lawyers, and NGO workers—in Ethiopia believed would be most effective in meeting the complex needs of this vulnerable population.

This study was a qualitative needs assessment that used content analysis with an aim of understanding the potential service needs and response options for human trafficking in Ethiopia from service provider, academic, lawyer, and NGO perspectives [26]. We chose a qualitative approach because human trafficking in Ethiopia is a relatively new, emerging area of research. A literature review revealed no intervention studies to date and few studies that have identified service needs and response options for this population [12]. This qualitative needs assessment study was the first step directed towards comprehensively identifying the needs of human trafficking survivors and eventual intervention development.

The needs assessment was conducted during two timeframes and in two locations: (1) interviews with service providers, academics, and NGO workers with expertise in human trafficking in the summer of 2015 in urban areas; and (2) interviews with an additional lawyer and service provider in the northern rural region of Ethiopia in spring of 2016. The data collected in 2015 were considered exempt from Institutional Review Board (IRB) regulation because it involved interviews in which human subjects could not be identified directly or through identifiers linked to the subjects. For the data collected in the spring of 2016 we received ethical approval from the University of Michigan Health Sciences and Behavioral Sciences IRB [HUM00113823] and Aksum University.

The interviews were conducted in two regions of Ethiopia, around the capital city of Addis Ababa and in the northern region near Aksum. We selected these two interview sites to capture participants from both urban and rural settings where trafficking may occur in different ways.

Purposive and snowball sampling were used to identify participants. We targeted participants from four key stakeholder groups: (1) service professionals (e.g., nurses, physicians, social workers), (2) academics, (3) lawyers, and (4) NGO personnel with expertise related to human trafficking. We chose these groups to gather information from experts with direct knowledge or experience with human trafficking and the cultural, political, and social context of Ethiopia.

Participants were contacted via email or telephone depending on which method of contact was available and invited to participate in the study. Potential participants were identified from online searches of published reports on human trafficking in Ethiopia, referrals from our in-country collaborators, and through snowball sampling. Inclusion criteria included: (1) Adults (age ≥ 18 years old); (2) English speaking (because post-secondary education in Ethiopia is conducted exclusively in English, the population of professionals we sought to sample was English-speaking); (3) self-identify as a service provider, academic, lawyer, or NGO advocate working with human trafficking survivors; and (4) available for a telephone or in-person interview in the summer of 2015 or spring of 2016. When participants responded positively to invitations, an in-person or telephone interview time was scheduled.

Data were collected using semi-structured interviews with participants in a location of their choosing (private or public interview locations were offered). Comprehensive verbal informed consent was obtained prior to data collection and all participants had the choice to opt out of audio-recording. These interviews were audio-recorded and transcribed and lasted approximately thirty minutes (range 20–40 min). Two interviewers conducted each session in English and asked follow-up questions as needed. One interviewer used a guide to ask the participant questions, and the other interviewer made field notes during the conversation and monitored the well-being of the participant due to the sensitive nature of the topic. Interview questions focused on the topics of: resources and services available and used by human trafficking survivors; what services should be available to human trafficking survivors; and how those in the health system could be involved in the prevention, education, and delivery of care for human trafficking survivors.

The interview transcripts and notes were coded by four members of the research staff (KC, DB, MK, MMK) using the constant comparative method, which is an inductive coding process for comparing and categorizing qualitative data [27, 28]. All transcripts were transferred to Microsoft Word and the research staff used color coding and comments to create categories and notes. First, each interview was read and analyzed independently by two coders using an inductive approach, which first involved an open coding process or allowing the codes to appear naturally without a pre-defined coding schema [27]. Next, the coders met to compare the resulting coding categories for agreement [27]. These open codes were compiled into a single analytical memo and were combined into four major categories [27]. Then two coders returned to the interview data to ensure that the major categories accurately represented all of the data. Once data saturation was reached, the themes were reviewed by all authors for validity [29]. Themes were derived directly from the data, and equal weight was given to the responses of all subjects in developing the themes.

The availability of mental health services was perceived to be inadequate for those survivors of human trafficking impacted by mental illness. Survivors of human trafficking were perceived to implicitly have mental illness following their trafficking experience. Multiple participants perceived that mental illness is generally under-resourced, under-treated, and under-reported in Ethiopia and situated the mental health needs of trafficking survivors within the overall context of Ethiopian mental health system challenges. As noted by one academic, “In general, mental health services in Ethiopia are very limited. It’s not only for the human trafficking survivors but in general for every citizen [who] will have mental health challenges.” There were concerns raised about the tendency towards nondisclosure of mental illness in Ethiopia regardless of an individual’s experience with human trafficking. As stated by one physician, “I believe there is a great deal of underreporting and under-diagnosing of mental health issues in general.” Participants also underscored the challenge of strong cultural stigma related to mental illness and worried that it could affect survivor perceptions of mental health services, as noted by an academic participant: “...It’s kind of a taboo here. If you have a problem of mental [illness], the stigma that the society levels on you [makes it] very difficult for the people to seek mental health services...”

In addition to the cultural stigma surrounding mental health, participants also discussed the cultural tendency to attribute mental illness to magic, witchcraft, or spiritual forces. The attribution of mental illness to non-medical causes was illustrated as determining a path to care that often began with religious or spiritual leaders rather than healthcare professionals and may delay survivor help-seeking for mental health care. As stated by a service provider: “When you look at the flow of the patient, initially most of the patients before they came to hospitals or health facility [ies], they visit the religious and traditional healers in religious areas like [a] mosque or church first.” Presenting for care at a health facility was seen as the last resort that people sought for mental illness, with the perception that trafficking survivors with mental health challenges would only be brought to healthcare providers if their needs escalated and became unmanageable by other means. According to participants, psychological symptoms are often expressed in terms of physical complaints, another factor that may delay or prevent survivors from seeking mental health care. This was echoed by one academic who stated that, “much of mental illness [is] more expressed in terms of somatization.”

The second theme to emerge among participants was about perceived barriers and facilitators to providing services to survivors of human trafficking. Participants seemed to describe two levels of barriers: individual and systemic. In the area of individual barriers, participants highlighted concerns related to the potential for survivors to be unaware of their needs or the possibility that they may qualify for assistance. Per one academic, “one, there is a lack of awareness, secondly those victims do not come forward to expose their problem and seek advice.” This is consistent with literature about human trafficking and other forms of gender-based violence around the world, many participants do not identify themselves as victims [30]. Participants suggested that survivors may face shame and isolation upon their exit from a trafficking situation when they could not provide their families and communities with the financial gain that is expected from those who work abroad. As one nurse stated:

“It’s not only mental, it’s not only economical, what about the social? They need to reintegrate because they are not [the] only [one] who is going with expectations … their relative [s] and parents have expectations. If they don’t send the money in time, if they come [back] handicap [ped] with some illness, that means they will be a burden to their family.”

These individual-level issues were seen as key barriers to survivor help-seeking.

In regards to systemic barriers, it was noted that broader societal issues such as poverty and high rates of migration are factors that may complicate the provision of services for survivors. Participants discussed the socio-cultural environment that they perceived poverty to create in Ethiopia, where in some areas people may consider migration their only choice for a chance at education or gainful employment, making them especially vulnerable to trafficking. An academic stated:

“In some societies, migration of girls, intentional migration of girls to the Middle East was not part of the culture. There was no history of international migration to the Middle East. But before the ban, before three or four years, it has become a culture and everybody’s dream is to migrate and to come with some money. Even if you’re going to join the university or preparatory school, that is the only option, migration. Sometimes it is related to being unsuccessful with family schooling. Sometimes it is family poverty.”

This participant’s reference to a ‘ban’ refers to Ethiopia’s attempts to halt migration to countries in the Middle East enacted in 2013 [31]. The overall challenge of managing trafficking amidst a culture of migration was echoed by another participant, who considered migration as a contributing factor to human trafficking to be an inevitable part of Ethiopia’s society: “The government is of the view that we can stop migration. I say no. I think that we [can] better manage migration, but we can’t stop it.” This participant viewed migration as a systemic, societal factor that was impossible to stop, but instead should be managed to facilitate prevention of human trafficking and provision of survivor services. Likewise, poverty and economic challenges were identified as key systemic barriers to trafficking survivors. Participants emphasized that trafficking survivors often are lured into exploitative situations out of economic desperation and the belief that they can make money abroad; as one participant stated, “The first need is to be economically strengthened; if they were strengthened economic [ally] they may not be violated.” Another participant described her surprise that survivors are focused on financial and economic challenges even in the midst of other serious needs upon return to Ethiopia:

“At the beginning I was saying, ‘ … Their bodies are more important than money. All other abuses are more difficult than salary.’ But when they go, they have determined that they will be in all this pain to get money, come back and get money to do their own business. When they return, still they focus on economic issues.”

The systemic presence of a culture of migration and poverty in Ethiopia were perceived to both contribute to risk for trafficking and to complicate service provision for survivors.

Participants identified a variety of cultural and country-specific strengths that may be facilitators to providing survivor services (Table 2). Facilitators to providing survivor services at the individual level included developing mobile or texting-based services to take advantage of Ethiopia’s expanded capacity for mobile phone access; creating opportunities for story-telling, narrative therapies, and peer connection within local communities; integrating spiritual, religious, and traditional healing practices into professional care; and developing and involving health extension workers in service provision in areas with limited availability of service professionals. Health extension workers are individuals that have limited training to meet healthcare needs in rural or underserved areas by providing education and basic services related to such conditions as hygiene and sanitation, family planning, and disease prevention and control. They are similar to community health workers and are more widely available in some underserved areas of Ethiopia than service professionals.

In addition, all participants discussed addressing mental and/or physical health care needs as a priority. Service professionals and NGO personnel focused on survivor needs such as counseling. One physician stated,

“...Starting from health, I would recommend counseling, counseling is the best thing that they need right now. After that, of course there are also other health issues, the sexual abuse, and if they have contracted any kind of transmitted diseases, of course they need immediate health service [s].”

Another participant added: “Some of them may be physically injured and others are those who lost their legs, hands, who are amputated, who are face is disfigured. And again, most of them are sexually abused, so there can be possibility of getting Human Immunodeficiency Virus (HIV).”

It was also noted that the stigma for survivors of human trafficking and the lack of awareness as to the kinds of legal services that may benefit them are prohibitive to survivors receiving legal support. All participants specifically referenced the need for legal services for gender-based violence and safe migration but did not specifically allude to what these services might look like. They did discuss a need for peer support from others who had experienced trafficking, provisions for immediate physical safety (e.g., shelter, food, clothing), and longer-term stabilization (e.g., housing, employment, financial support, skills training, stigma reduction) as modalities for reintegration. An academic summarized this sentiment by stating,

“First they have to be socially integrated. Then the physical, psychosocial, even the mental than the physical health. So step by step, we need to address all dimensions of health problems related to the returnees. But the first priority should be given [to the] social well-being of these returnees.”

This perspective illustrates the importance of “social healing systems” for trafficking survivors in Ethiopia given their cultural context.

There was a common theme among all participants that offering care for survivors of human trafficking through a comprehensive model would be the optimal approach. Participants emphasized the importance of working together in terms of system change and integrated interventions rather than piecemeal solutions. As one physician stated,

“I think the most important thing is to work in terms of systems, rather than crisis interventions...So we have to take into consideration, every step of intervention. So when they come here, what about providing them food, and shelter, and other things that are really necessary. Then what about screening? What type of instruments should we use? Then, to whom should we send these patients?”

This sentiment was reiterated by other participants. They recommended community-based interventions and utilizing community resources and social structures to deliver interventions, which include awareness and prevention efforts. A service provider suggested, “to tackle or to defend for [this] challenge, so at [the] community level some awareness in intervention is needed in [the] community to prevent that.”

This study was conducted among a relatively small group of self-selected respondents who were willing to discuss human trafficking in Ethiopia, by a collaborative team based in the United States and Ethiopia. The representativeness of the sample is limited due to convenience sampling. Respondents were referred from local contacts, announcements, and then through word of mouth (snowball sampling). All interviews were conducted in English. Although our target population of professionals was expected to be fluent in English because of educational requirements in Ethiopia, those for whom English was a second language or those who felt uncomfortable speaking English may have refused participation in the study. Our study may have left out some stakeholder groups (e.g., government officials, transportation workers, employers) that may have valuable perspectives on post-trafficking service delivery in Ethiopia, and as such, future research should explore an expanded range of stakeholder perspectives.

Despite these limitations, this study provides a broad, initial assessment of the potential service needs and response options for human trafficking in Ethiopia and provides directions for service delivery, research, and policy action with this population. We sampled participants from four important stakeholder groups, and future studies may consider incorporating survivor voices in studying human trafficking. The study included participants from both rural and urban areas, and we found consistent evidence across all stakeholder groups and settings for the themes described above.