1.96 is the critical value of the z distribution for a two-tailed test at the 0.05 level of significance.

**2.2 Scaling interventions: How many individuals need to be reached and with what**

**effectiveness to achieve desired outcomes for various population sizes?**

community-based intervention.

the effectiveness of the intervention or project.

of 3,212 multiplied by 1.96, or 111 events.

In some cases, seemingly "successful" asthma interventions may cause some outcome indicators to shift in an unintended direction. For example, providing asthma education to individuals who were previously unaware of asthma's seriousness or unfamiliar with its symptoms may lead to greater emergency department utilization or symptom reporting. A parent of a toddler with asthma, upon learning for the first time that asthma can be fatal, or about what happens to the airways during an asthma episode, may be more inclined to take her pre-verbal child to the emergency department upon hearing a wheeze.

Furthermore, the desirable direction for an indicator can be ambiguous. For example, most asthma interventions have aimed to increase use of inhaled corticosteroids (to prevent asthma episodes) and to decrease bronchodilator use (to relieve existing symptoms). Since bronchodilators are taken by individuals to relieve asthma symptoms, they are used as a marker of poorly controlled asthma. However, some individuals, prior to an intervention, do not have access to bronchodilators or are not using them prior to exercise or when they actually need them. For those individuals, filling a prescription for a bronchodilator and using one may be a positive change. Likewise, increased use of inhaled corticosteroids could mean better adherence to the asthma management plan by the patient or better adherence to clinical guidelines by the provider, but it may also mean a larger percentage of a population is developing persistent, as opposed to intermittent, asthma.

Outpatient visits as a measure of an asthma intervention's effectiveness can be ambiguous to interpret as well. One hopes to reduce urgent, unscheduled asthma visits and increase routine "well" visits, but many data systems do not make a distinction between the two types of visit. The reduction of emergency department visits is a common measure of success for asthma interventions but this reduction may also lead to an increase in nonemergent outpatient services as people shift to more appropriate preventive care. Although this shift should be seen as a positive behavioral change, it could appear to be "harmful" or costly if not viewed in the proper context.

Similarly, most patients hospitalized for asthma present at the emergency department. When someone is hospitalized for asthma, even if the patient initially presents at the emergency department, the hospital records this as an inpatient visit and not an emergency department visit. Thus, if a smaller percentage of patients are presenting to the emergency department with symptoms necessitating hospitalization it could actually work to increase emergency department visits, and vice versa.

Reduction of the cost of asthma is a derivative measure that may be paramount for some stakeholders.

Successful asthma interventions will decrease some preventable costs (e.g. acute care visits), but may lead to increased costs elsewhere (e.g. increased use of inhaled corticosteroids, preventative office visits). Public institutions and coalitions should be aware that stakeholders may not all agree on how to target costs. Cost shifting hospitalizations may cause acrimony between two otherwise well-intentioned organizations. For example, an asthma intervention that reduces asthma-related hospitalizations may help a health plan's bottom line, but may hurt the hospital's bottom line depending on the characteristics of the particular patient (private or public insurance, capitated or not capitated). Ultimately, the "best" measures to evaluate an intervention will depend on what is available as well as what the particular goals of the stakeholders are.

In some cases, seemingly "successful" asthma interventions may cause some outcome indicators to shift in an unintended direction. For example, providing asthma education to individuals who were previously unaware of asthma's seriousness or unfamiliar with its symptoms may lead to greater emergency department utilization or symptom reporting. A parent of a toddler with asthma, upon learning for the first time that asthma can be fatal, or about what happens to the airways during an asthma episode, may be more inclined to take

Furthermore, the desirable direction for an indicator can be ambiguous. For example, most asthma interventions have aimed to increase use of inhaled corticosteroids (to prevent asthma episodes) and to decrease bronchodilator use (to relieve existing symptoms). Since bronchodilators are taken by individuals to relieve asthma symptoms, they are used as a marker of poorly controlled asthma. However, some individuals, prior to an intervention, do not have access to bronchodilators or are not using them prior to exercise or when they actually need them. For those individuals, filling a prescription for a bronchodilator and using one may be a positive change. Likewise, increased use of inhaled corticosteroids could mean better adherence to the asthma management plan by the patient or better adherence to clinical guidelines by the provider, but it may also mean a larger percentage of a population

Outpatient visits as a measure of an asthma intervention's effectiveness can be ambiguous to interpret as well. One hopes to reduce urgent, unscheduled asthma visits and increase routine "well" visits, but many data systems do not make a distinction between the two types of visit. The reduction of emergency department visits is a common measure of success for asthma interventions but this reduction may also lead to an increase in nonemergent outpatient services as people shift to more appropriate preventive care. Although this shift should be seen as a positive behavioral change, it could appear to be "harmful" or

Similarly, most patients hospitalized for asthma present at the emergency department. When someone is hospitalized for asthma, even if the patient initially presents at the emergency department, the hospital records this as an inpatient visit and not an emergency department visit. Thus, if a smaller percentage of patients are presenting to the emergency department with symptoms necessitating hospitalization it could actually work to increase

Reduction of the cost of asthma is a derivative measure that may be paramount for some

Successful asthma interventions will decrease some preventable costs (e.g. acute care visits), but may lead to increased costs elsewhere (e.g. increased use of inhaled corticosteroids, preventative office visits). Public institutions and coalitions should be aware that stakeholders may not all agree on how to target costs. Cost shifting hospitalizations may cause acrimony between two otherwise well-intentioned organizations. For example, an asthma intervention that reduces asthma-related hospitalizations may help a health plan's bottom line, but may hurt the hospital's bottom line depending on the characteristics of the particular patient (private or public insurance, capitated or not capitated). Ultimately, the "best" measures to evaluate an intervention will depend on what is available as well as

her pre-verbal child to the emergency department upon hearing a wheeze.

is developing persistent, as opposed to intermittent, asthma.

costly if not viewed in the proper context.

emergency department visits, and vice versa.

what the particular goals of the stakeholders are.

stakeholders.

#### **2.2 Scaling interventions: How many individuals need to be reached and with what effectiveness to achieve desired outcomes for various population sizes?**

To produce change at the population level, the number of individuals reached and the effectiveness of the intervention(s) must be commensurate with population size. Even the most effective interventions will not result in population-level change unless enough people are affected. For example, even if a hypothetical intervention that is 100% effective at preventing a subsequent asthma hospitalization for one year were given to every patient hospitalized for asthmain a large city in an entire year, it would reduce hospitalizations the following year by only a small amount (Holgate 1999), as only a fraction of hospital admissions for asthma in a population in a given year are readmissions (Centers for Disease Control and Prevention 1997).Estimating the number of individuals who must be reached, and with what effectiveness, to demonstrate significant change in a particular population-level outcome is an important step in planning a community-based intervention.

This task differs from power calculations used to determine the minimal sample size or experimental group necessary to achieve statistical significance in a study. That calculation requires estimates of the population parameters. The intent here is to achieve an actual change in the population parameter itself. Estimating the number of individuals who must be reached to achieve that change requires the following three pieces of data: the prevalence of asthma in the population; the frequency of the event to be measured among those with asthma (e.g., the rate of hospitalizations, emergency visits, or office visits); and the random variation associated with that event. The change in the number of events that must be achieved in a given population (in order to exceed random variation and thus reach significance) can be calculated. The intended direction of change can be either positive or negative. The number of people who must be reached to achieve that change can be calculated from the change in the number of events needed, the frequency of that event, and the effectiveness of the intervention or project.

For example, recent national data indicate that the prevalence of asthma is 7.3% and approximately 66 office visits, 8.8 emergency department visits, and 2.5 hospitalizations occur per 100 persons with current asthma (Moorman et al., 2007). As shown in Table 1, in a hypothetical population of 500,000 (the approximate size of CAACP target populations), one would expect 36,500 people with current asthma (500,000 X 0.073); 24,090 office visits (36.500 X 0.66); 3,212 emergency department visits (36,500 X 0.088); and 913 hospitalizations (36,500 X 0.025) for asthma annually. Estimating the change in the number of events needed to achieve significance requires multiplying the standard error of that event by 1.96.#**1**In Table 1, the standard error is approximated by taking the square root of the number of events in the population. This approximation, based on the Poisson distribution, is derived from the formula for relative standard error used for mortality data (Arias et al, 2003). Thus, in a population of 500,000, the number of emergency department visits that must be eliminated to reach significance (p < .05) is the square root of 3,212 multiplied by 1.96, or 111 events.

# 1.96 is the critical value of the z distribution for a two-tailed test at the 0.05 level of significance.

Addressing Asthma from a Public Health Perspective 543

100 % 461 (304/0.66) 1,262 (111/ 0.088) 2,360 (59/0.025) 50 % 921 2,522 4,720 25 % 1,842 5,045 9,440

\* Number needed = (number needed to change / rate of event) / effectiveness, e.g., for an intervention

These calculations, although rough estimates, permit planners to determine whether the fit between target population size, available resources, and the outcome to be measured is realistic.

A variety of external factors and changes over time can influence asthma-related outcomes. These factors may include but are not limited to demographic and economic changes, revision of reimbursement or coding policies, changes in Medicaid eligibility requirements, closing or opening of safety-net health service providers, concurrent interventions, changes in environmental exposures, and fluctuation in the intensity of cold/flu seasons (Johnston et al., 1996). Changes in a community that improve access to quality medical care or reduce environmental asthma triggers, for example, may make it difficult to attribute improved asthma outcomes to a project. Conversely, changes in external factors that negatively impact

Population movement out of a project area, a common occurrence, can theoretically affect outcome measures in a variety of ways. Each year 14% of people in the U.S. change their address with the rate tending to be higher in lower socioeconomic neighborhoods (U.S. Census Bureau 2010). Although individuals and families participating in asthma interventions may continue to benefit after leaving a project area, their improved outcomes would not be reflected in a population-based measure. Because asthma prevalence varies among ethnic groups (Davis et al., 2006), a change in racial or ethnic distribution may result in different rates of healthcare utilization that mirror a demographic shift rather than project impact. While the direction of change in asthma outcomes due to demographic changes is difficult to predict, increasing the estimated "number needed to reach" to accommodate the potential loss to follow up of individuals

Over the seven-year CAACP project period, a number of external factors that had the potential to affect hospitalization rates and other outcome measures occurred in the CAACP sites. For example, new management at the major hospital at one of the sites relaxed the threshold for hospitalizing an asthma patient in order to fill more beds, effectively

**2.3 What external contextual factors are likely to influence the effectiveness of the**

50% effective in reducing emergency department (ED) visits for asthma, number needed =

Table 2. Number of participants with asthma needed for a population of 500,000 By effectiveness of the intervention (assuming 7.3% prevalence of asthma)

persons with asthma may mask the accomplishments of an asthma intervention.

and families would be a conservative approach.

Office visits for asthma

Effectiveness of the intervention

(111/0.088)/0.50 = 2522

**intervention(s)?**

Number of participants with asthma needed to demonstrate significant change in the event of interest\*

> ED visits for asthma

Hospitalizations for asthma

† Based on a prevalence of 7.3%

‡ Based on a rate of 66 per 100 with asthma

§ Based on a rate of 8.8 per 100 with asthma

¶ Based on a rate of 2.5 per 100 with asthma

\*\* Change = 1.96 · Standard Error; Standard Error ~ Square Root (number of expected events)

Table 1. Expected and associated change in the number of events required to reach significance in populations of various sizes\*2

The number of individuals who must be reached to achieve the necessary change in number of events can be estimated by dividing the needed change in number of events by the rate for the event. Table 2 illustrates this calculation for a population of 500,000. As stated above, to significantly reduce the population-based emergency department visit rate for asthma, at least 111 visits must be eliminated by the intervention(s). If the intervention is 100% effective in eliminating emergency department visits among those with asthma and there are 8.8 emergency department visits for every 100 with current asthma, then approximately 111 / 0.088 or 1,261 participants with current asthma must be reached. If less than 100% effective, that number is divided by the estimated effectiveness. An intervention that is 50% effective will need twice as many participants. Continuing with the above example, if the intervention eliminates half the emergency department visits among those enrolled, then 2,522 must be reached (1,261 / 0.50 = 2,522) to significantly decrease the emergency department visit rate for asthma. Further adjustments may be needed to allow for dropouts and incomplete participation, for population mobility (people who received the intervention moving out of the area, people who did not receive it moving in) as well as the uneven distribution of events in the population (some people having frequent events, others having none). Furthermore, directing interventions to populations most likely to experience the adverse event the intervention seeks to reduce would serve to decrease the total number of individuals who need to be reached.

\*Refers to count of events such as a hospitalization, ED visit, or office visit

Population Number Office visits ED visits Hospitalizations

5,000,000 365,000 240,900 962 32,120 351 9,125 187 2,500,000 182,500 120,450 680 16,060 248 4,563 132 1,000,000 73,000 48,180 430 6,424 157 1,825 84 500,000 36,500 24,090 304 3,212 111 913 59 250,000 18,250 12,045 215 1,606 79 456 42 100,000 7,300 4,818 136 642 50 183 26 50,000 3,650 2,409 96 321 35 91 19

\*\* Change = 1.96 · Standard Error; Standard Error ~ Square Root (number of expected events) Table 1. Expected and associated change in the number of events required to reach

The number of individuals who must be reached to achieve the necessary change in number of events can be estimated by dividing the needed change in number of events by the rate for the event. Table 2 illustrates this calculation for a population of 500,000. As stated above, to significantly reduce the population-based emergency department visit rate for asthma, at least 111 visits must be eliminated by the intervention(s). If the intervention is 100% effective in eliminating emergency department visits among those with asthma and there are 8.8 emergency department visits for every 100 with current asthma, then approximately 111 / 0.088 or 1,261 participants with current asthma must be reached. If less than 100% effective, that number is divided by the estimated effectiveness. An intervention that is 50% effective will need twice as many participants. Continuing with the above example, if the intervention eliminates half the emergency department visits among those enrolled, then 2,522 must be reached (1,261 / 0.50 = 2,522) to significantly decrease the emergency department visit rate for asthma. Further adjustments may be needed to allow for dropouts and incomplete participation, for population mobility (people who received the intervention moving out of the area, people who did not receive it moving in) as well as the uneven distribution of events in the population (some people having frequent events, others having none). Furthermore, directing interventions to populations most likely to experience the adverse event the intervention seeks to reduce would serve to decrease the total number of

asthma† for asthma‡ for asthma§ for asthma¶

number change\*\* number change number change

Size with

† Based on a prevalence of 7.3%

‡ Based on a rate of 66 per 100 with asthma § Based on a rate of 8.8 per 100 with asthma ¶ Based on a rate of 2.5 per 100 with asthma

individuals who need to be reached.

\*Refers to count of events such as a hospitalization, ED visit, or office visit

significance in populations of various sizes\*2

\* Number needed = (number needed to change / rate of event) / effectiveness, e.g., for an intervention 50% effective in reducing emergency department (ED) visits for asthma, number needed = (111/0.088)/0.50 = 2522

Table 2. Number of participants with asthma needed for a population of 500,000 By effectiveness of the intervention (assuming 7.3% prevalence of asthma)

These calculations, although rough estimates, permit planners to determine whether the fit between target population size, available resources, and the outcome to be measured is realistic.

#### **2.3 What external contextual factors are likely to influence the effectiveness of the intervention(s)?**

A variety of external factors and changes over time can influence asthma-related outcomes. These factors may include but are not limited to demographic and economic changes, revision of reimbursement or coding policies, changes in Medicaid eligibility requirements, closing or opening of safety-net health service providers, concurrent interventions, changes in environmental exposures, and fluctuation in the intensity of cold/flu seasons (Johnston et al., 1996). Changes in a community that improve access to quality medical care or reduce environmental asthma triggers, for example, may make it difficult to attribute improved asthma outcomes to a project. Conversely, changes in external factors that negatively impact persons with asthma may mask the accomplishments of an asthma intervention.

Population movement out of a project area, a common occurrence, can theoretically affect outcome measures in a variety of ways. Each year 14% of people in the U.S. change their address with the rate tending to be higher in lower socioeconomic neighborhoods (U.S. Census Bureau 2010). Although individuals and families participating in asthma interventions may continue to benefit after leaving a project area, their improved outcomes would not be reflected in a population-based measure. Because asthma prevalence varies among ethnic groups (Davis et al., 2006), a change in racial or ethnic distribution may result in different rates of healthcare utilization that mirror a demographic shift rather than project impact. While the direction of change in asthma outcomes due to demographic changes is difficult to predict, increasing the estimated "number needed to reach" to accommodate the potential loss to follow up of individuals and families would be a conservative approach.

Over the seven-year CAACP project period, a number of external factors that had the potential to affect hospitalization rates and other outcome measures occurred in the CAACP sites. For example, new management at the major hospital at one of the sites relaxed the threshold for hospitalizing an asthma patient in order to fill more beds, effectively

Addressing Asthma from a Public Health Perspective 545

**Influencing Policy and Legislation**

Occupational regulations

 Information systems Local school policies

Educating pharmacists

**Clinical Care/Treatment**

categorize(Cohen & Swift, 1999).

impact.

Telehealth applications

**Promoting Community Education**

 Healthcare delivery and financing **Strengthening Social/Organizational Practices**  Quality improvement initiatives

**Educating/Training Healthcare Providers**  Educating primary care providers

Group asthma education in schools

Specialized training for medical residents

In-services for school and childcare center staff

Group asthma education in community settings

Social marketing, public service announcements

Patient education in hospitals and emergency rooms

Specialty asthma or allergy clinics, mobile clinics

Box 1. Types of asthma interventions using the Spectrum of Prevention as a framework to

The effectiveness of any intervention is dependent upon context (Wang et al., 2006). In their comprehensive review of community based public health interventions, Sorensen, Emmons, and Dobson present a persuasive argument that the efficacy-based research paradigm that dominates in research journals may not be the most appropriate way to evaluate public health interventions (Sorenson et al., 1998), and tend to produce interventions that are intensive and expensive. Efficacious interventions conducted under rigorous study design with carefully screened and motivated participants, by the most skillful professionals, may prove ineffective in other settings (Glasgow et al., 1999; Sorenson et al., 1998; Starfield 1998). Even if they are highly effective, they will have little population based impact if they cannot be widely adopted (Glasgow et al., 1999).Planners should give greater weight to interventions that have proven effective in similar environments and circumstances and where applicable and when possible, pilot test them on the population the planners hope to

**Strengthening Individual Skills and Knowledge**  Case management (home, school, clinic)

Phone follow up or nurse monitoring

 Clean outdoor air policies and legislation Clean indoor air policies and legislation

increasing the number of asthma hospitalizations quite significantly. When interpreted out of context, one could reasonably conclude that asthma in that community was getting worse and that the various interventions at that site were at best, not effective, and at worst, harmful. The sites addressed the complexity of external factors in a variety of ways. Davis et al. analyzed pharmacy-fill data using multiple complementary techniques (time trends, comparison of the project area with similar areas in the city, analysis by age group) to provide different perspectives and strengthen the attribution of improved patterns to the project (Centers for Disease Control and Prevention 2001). In the final analysis of hospitalization data, all sites will superimpose a contextual analysis of significant changes over the timeline of the projects' interventions and trends in hospitalization data. Although no analytic techniques can completely control for contextual factors, documenting and acknowledging them can facilitate a realistic interpretation of outcome data.

## **3. Selection of interventions**

#### **3.1 What criteria should be considered when choosing interventions to achieve population-level outcomes?**

Reaching large numbers of people, in a variety of settings, in complementary and synergistic ways, and at reasonable cost, requires interventions at multiple levels(National Heart Lung and Blood Institute 2007). The Spectrum of Prevention (Box 1) (Cohen & Swift 1999) is one framework for categorizing the levels and types of interventions for asthma. Selecting interventions that are most likely to be effective is a critical part of the local planning process. Asthma clinical guidelines, review papers, and meta-analyses provide an overview of the evidence base behind different types of interventions, and are based on a systematic review of multiple studies. These publications typically give greater weight to randomized, controlled trials, and to studies with large sample sizes. Planners should also base their assessment of effectiveness on individual papers and when possible, discussions with authors and program staff of the intervention(s) being considered. When doing so, a critical assessment of the methodology and data collection methods of published studies is important.

For example, many published evaluations of asthma interventions rely on self-reported behaviors or symptoms. The accuracy and precision of self-report is likely to vary by the type of question, the person collecting the information, time transpired since the reported event, and provider of the information (e.g., a patient or guardian) (Mathiowetz & Dipko 2000). Evaluations that do not have a control or comparison group might show a positive change based on a phenomenon called "regression to the mean," meaning that, when a series of events is tracked, the events will tend to return to a predictable mean on their own even without intervention (Tinkelman & Wilson 2004). Regression to the mean can lead to an incorrect conclusion that attributes an asthma outcome to an intervention when it was actually due to chance. This effect might be especially pronounced in asthma interventions that focus on individuals with a recent event, or with high utilization at baseline (Tinkelman & Wilson 2004).For example, if a given patient is recruited into an intervention as a result of a recent asthma hospitalization, statistically it is unlikely that this same patient would have re-experienced another asthma hospitalization during or after the study period. Hospitalizations due to asthma are relatively uncommon, even among those with previous asthma hospitalizations.

increasing the number of asthma hospitalizations quite significantly. When interpreted out of context, one could reasonably conclude that asthma in that community was getting worse and that the various interventions at that site were at best, not effective, and at worst, harmful. The sites addressed the complexity of external factors in a variety of ways. Davis et al. analyzed pharmacy-fill data using multiple complementary techniques (time trends, comparison of the project area with similar areas in the city, analysis by age group) to provide different perspectives and strengthen the attribution of improved patterns to the project (Centers for Disease Control and Prevention 2001). In the final analysis of hospitalization data, all sites will superimpose a contextual analysis of significant changes over the timeline of the projects' interventions and trends in hospitalization data. Although no analytic techniques can completely control for contextual factors, documenting and

acknowledging them can facilitate a realistic interpretation of outcome data.

methodology and data collection methods of published studies is important.

**3.1 What criteria should be considered when choosing interventions to achieve**

Reaching large numbers of people, in a variety of settings, in complementary and synergistic ways, and at reasonable cost, requires interventions at multiple levels(National Heart Lung and Blood Institute 2007). The Spectrum of Prevention (Box 1) (Cohen & Swift 1999) is one framework for categorizing the levels and types of interventions for asthma. Selecting interventions that are most likely to be effective is a critical part of the local planning process. Asthma clinical guidelines, review papers, and meta-analyses provide an overview of the evidence base behind different types of interventions, and are based on a systematic review of multiple studies. These publications typically give greater weight to randomized, controlled trials, and to studies with large sample sizes. Planners should also base their assessment of effectiveness on individual papers and when possible, discussions with authors and program staff of the intervention(s) being considered. When doing so, a critical assessment of the

For example, many published evaluations of asthma interventions rely on self-reported behaviors or symptoms. The accuracy and precision of self-report is likely to vary by the type of question, the person collecting the information, time transpired since the reported event, and provider of the information (e.g., a patient or guardian) (Mathiowetz & Dipko 2000). Evaluations that do not have a control or comparison group might show a positive change based on a phenomenon called "regression to the mean," meaning that, when a series of events is tracked, the events will tend to return to a predictable mean on their own even without intervention (Tinkelman & Wilson 2004). Regression to the mean can lead to an incorrect conclusion that attributes an asthma outcome to an intervention when it was actually due to chance. This effect might be especially pronounced in asthma interventions that focus on individuals with a recent event, or with high utilization at baseline (Tinkelman & Wilson 2004).For example, if a given patient is recruited into an intervention as a result of a recent asthma hospitalization, statistically it is unlikely that this same patient would have re-experienced another asthma hospitalization during or after the study period. Hospitalizations due to asthma are relatively uncommon, even among those with previous

**3. Selection of interventions**

**population-level outcomes?**

asthma hospitalizations.

Box 1. Types of asthma interventions using the Spectrum of Prevention as a framework to categorize(Cohen & Swift, 1999).

The effectiveness of any intervention is dependent upon context (Wang et al., 2006). In their comprehensive review of community based public health interventions, Sorensen, Emmons, and Dobson present a persuasive argument that the efficacy-based research paradigm that dominates in research journals may not be the most appropriate way to evaluate public health interventions (Sorenson et al., 1998), and tend to produce interventions that are intensive and expensive. Efficacious interventions conducted under rigorous study design with carefully screened and motivated participants, by the most skillful professionals, may prove ineffective in other settings (Glasgow et al., 1999; Sorenson et al., 1998; Starfield 1998). Even if they are highly effective, they will have little population based impact if they cannot be widely adopted (Glasgow et al., 1999).Planners should give greater weight to interventions that have proven effective in similar environments and circumstances and where applicable and when possible, pilot test them on the population the planners hope to impact.

Addressing Asthma from a Public Health Perspective 547

site worked at the policy level to support smoking bans and the regulation of power

CAACP sites noted an implicit tradeoff between designating comprehensive resources to a smaller number of people (i.e., high intensity) or fewer resources per person to a greater number of people (i.e., high reach). High-intensity interventions included, for example, individualized home-based medical and social support for families, and practice-based systems-change interventions for healthcare providers. High-reach interventions included

As noted by Glasgow, the "high intensity" attributes that help to make interventions efficacious in a research setting—time, expertise, resources, commitment-- may actually work *against* the likelihood that they will be effective in less ideal settings (Glasgow et al., 1999). In contrast, low intensity interventions that can be delivered to large numbers of people may have a more pervasive public health impact (Hatziandrew et al., 1995; Vogt et al., 1998). Conceptually, it is helpful to define the impact (I) of an intervention as the product of an intervention's efficacy (E) and its reach (R) (the percent of the population receiving an intervention): I=R\*E (Abrams et al., 1996). Even within the context of one type of intervention there are considerations about reach and intensity. For example, among CAACP sites, the number of hours dedicated to group training of medical providers ranged from 1–8 hours, and length of home-based support for families ranged from 1–18 visits. Intensive interventions, although generally effective for participating individuals or families, cost more per person and may have had a limited effect on population measures when the number of people or clinics reached is a small proportion of the population (Glasgow et al., 1999). Low-intensity interventions may not be effective in changing behaviors or achieving outcomes, or may take many years to demonstrate an effect

Glasgow's RE-AIM framework expanded on the I=R\*E equation by adding three additional dimensions that more fully capture the real-world impact of an intervention. The additional dimensions are: adoption ("A", the percentage of organizational settings that will adopt an intervention), implementation ("I", the extent to which the intervention is implemented as intended in the real world), and maintenance ("M", the extent to which an intervention is sustained over time) (Glasgow et al., 1999). Traditional intervention trials emphasize only the efficacy component at the exclusion of the other components. Although efficacy may be of most interest to clinicians, it is insufficient to evaluate the impact of an intervention in a population. The RE-AIM framework provides a conceptual public health model for determining what programs are worth sustained investment in

**4.1 What factors should be considered when deciding which individuals or groups of**

Asthma is a complex and heterogeneous condition with multiple phenotypes. It can be described in terms of its control and severity, types of symptoms, frequency and intensity of exacerbations, impairment, and responsiveness to medications. Furthermore, these

**4. Targeting and reaching individuals and communities**

**individuals to target within a given community or project area?**

group trainings and classes, policy-based interventions, and mass media.

plants and demolition sites.

Local political considerations may prove be more influential in the final selection of the intervention than the literature. The CAACP sites selected their interventions during a planning process that involved reviewing the literature on asthma interventions, conducting a needs assessment, soliciting stakeholder interests, and performing small pilot studies of proposed interventions. Some coalitions reached agreement on the mix of interventions through consensus; others followed structured procedures. As documented in annual reports, the Minneapolis/St Paul site actively engaged 115 people in intervention selection. Six workgroups met monthly for seven months to move through a formal process that resulted in a prioritized list of interventions, an evaluation plan, and a proposed budget. A leadership team then identified areas of overlap and synergy from the six plans to compose a strategic project plan. All sites had a coalition-based process that balanced local needs and resources, stakeholder preferences, and evidence supporting intervention effectiveness.

While most interventions were evidence-based, CAACP sites implemented some interventions for which an evidence base was not yet available. They justified these interventions with logic models that linked the interventions and desired outcomes (Cheadle et al., 2003). For example, the St. Louis site's needs assessment identified healthcare system fragmentation as one of the target area's major challenges. The site implemented the Asthma Friendly Pharmacy intervention, although not supported by preexisting evidence, because it appeared to be a critical link in a communications network among patients and their families, healthcare providers, and schools. Evaluation of that intervention focused on its success in establishing and maintaining those lines of communication (Berry et al., 2011) and now contributes to the evidence base for pharmacy interventions.

#### **3.2 How should resources be allocated across multiple asthma interventions?**

Little practical guidance exists for allocating public health resources for asthma across the range of interventions listed in Box 1, and no studies have tested the effectiveness of different combinations of interventions. Given the number of possible combinations of interventions, differences in communities, timing of interventions, and variations in external factors affecting outcomes, an empirical answer to the question of the most effective mix of interventions is unlikely.

The CAACP projects chose interventions that addressed different levels of the Spectrum of Prevention. All sites provided individualized family and home asthma services that focused on asthma self-management training and indoor-trigger reduction. The Philadelphia, Richmond, and Minneapolis/St.Paul sites reached out to parents and community members by providing asthma classes in community settings; Philadelphia site staff made extensive use of local communication networks (radio, newsletters, newspapers) to increase community awareness of asthma and the CAACP. Training for primary healthcare providers on NAEPP guideline implementation was also included in all strategic plans. The Oakland and Minneapolis/St Paul sites implemented interventions to institutionalize the reinforcement of key asthma messages into routine care for hospitalized and emergency department patients respectively, and the Northern Manhattan, Minneapolis/St Paul, and Oakland sites succeeded in institutionalizing asthma-friendly policies and procedures in their respective school systems. The Chicago

Local political considerations may prove be more influential in the final selection of the intervention than the literature. The CAACP sites selected their interventions during a planning process that involved reviewing the literature on asthma interventions, conducting a needs assessment, soliciting stakeholder interests, and performing small pilot studies of proposed interventions. Some coalitions reached agreement on the mix of interventions through consensus; others followed structured procedures. As documented in annual reports, the Minneapolis/St Paul site actively engaged 115 people in intervention selection. Six workgroups met monthly for seven months to move through a formal process that resulted in a prioritized list of interventions, an evaluation plan, and a proposed budget. A leadership team then identified areas of overlap and synergy from the six plans to compose a strategic project plan. All sites had a coalition-based process that balanced local needs and resources, stakeholder preferences, and evidence

While most interventions were evidence-based, CAACP sites implemented some interventions for which an evidence base was not yet available. They justified these interventions with logic models that linked the interventions and desired outcomes (Cheadle et al., 2003). For example, the St. Louis site's needs assessment identified healthcare system fragmentation as one of the target area's major challenges. The site implemented the Asthma Friendly Pharmacy intervention, although not supported by preexisting evidence, because it appeared to be a critical link in a communications network among patients and their families, healthcare providers, and schools. Evaluation of that intervention focused on its success in establishing and maintaining those lines of communication (Berry et al., 2011) and now contributes to the evidence base for pharmacy

**3.2 How should resources be allocated across multiple asthma interventions?**

Little practical guidance exists for allocating public health resources for asthma across the range of interventions listed in Box 1, and no studies have tested the effectiveness of different combinations of interventions. Given the number of possible combinations of interventions, differences in communities, timing of interventions, and variations in external factors affecting outcomes, an empirical answer to the question of the most effective mix of

The CAACP projects chose interventions that addressed different levels of the Spectrum of Prevention. All sites provided individualized family and home asthma services that focused on asthma self-management training and indoor-trigger reduction. The Philadelphia, Richmond, and Minneapolis/St.Paul sites reached out to parents and community members by providing asthma classes in community settings; Philadelphia site staff made extensive use of local communication networks (radio, newsletters, newspapers) to increase community awareness of asthma and the CAACP. Training for primary healthcare providers on NAEPP guideline implementation was also included in all strategic plans. The Oakland and Minneapolis/St Paul sites implemented interventions to institutionalize the reinforcement of key asthma messages into routine care for hospitalized and emergency department patients respectively, and the Northern Manhattan, Minneapolis/St Paul, and Oakland sites succeeded in institutionalizing asthma-friendly policies and procedures in their respective school systems. The Chicago

supporting intervention effectiveness.

interventions.

interventions is unlikely.

site worked at the policy level to support smoking bans and the regulation of power plants and demolition sites.

CAACP sites noted an implicit tradeoff between designating comprehensive resources to a smaller number of people (i.e., high intensity) or fewer resources per person to a greater number of people (i.e., high reach). High-intensity interventions included, for example, individualized home-based medical and social support for families, and practice-based systems-change interventions for healthcare providers. High-reach interventions included group trainings and classes, policy-based interventions, and mass media.

As noted by Glasgow, the "high intensity" attributes that help to make interventions efficacious in a research setting—time, expertise, resources, commitment-- may actually work *against* the likelihood that they will be effective in less ideal settings (Glasgow et al., 1999). In contrast, low intensity interventions that can be delivered to large numbers of people may have a more pervasive public health impact (Hatziandrew et al., 1995; Vogt et al., 1998). Conceptually, it is helpful to define the impact (I) of an intervention as the product of an intervention's efficacy (E) and its reach (R) (the percent of the population receiving an intervention): I=R\*E (Abrams et al., 1996). Even within the context of one type of intervention there are considerations about reach and intensity. For example, among CAACP sites, the number of hours dedicated to group training of medical providers ranged from 1–8 hours, and length of home-based support for families ranged from 1–18 visits. Intensive interventions, although generally effective for participating individuals or families, cost more per person and may have had a limited effect on population measures when the number of people or clinics reached is a small proportion of the population (Glasgow et al., 1999). Low-intensity interventions may not be effective in changing behaviors or achieving outcomes, or may take many years to demonstrate an effect (Glasgow et al., 1991).

Glasgow's RE-AIM framework expanded on the I=R\*E equation by adding three additional dimensions that more fully capture the real-world impact of an intervention. The additional dimensions are: adoption ("A", the percentage of organizational settings that will adopt an intervention), implementation ("I", the extent to which the intervention is implemented as intended in the real world), and maintenance ("M", the extent to which an intervention is sustained over time) (Glasgow et al., 1999). Traditional intervention trials emphasize only the efficacy component at the exclusion of the other components. Although efficacy may be of most interest to clinicians, it is insufficient to evaluate the impact of an intervention in a population. The RE-AIM framework provides a conceptual public health model for determining what programs are worth sustained investment in the real world.

## **4. Targeting and reaching individuals and communities**

#### **4.1 What factors should be considered when deciding which individuals or groups of individuals to target within a given community or project area?**

Asthma is a complex and heterogeneous condition with multiple phenotypes. It can be described in terms of its control and severity, types of symptoms, frequency and intensity of exacerbations, impairment, and responsiveness to medications. Furthermore, these

Addressing Asthma from a Public Health Perspective 549

communication 2008), in keeping with evidence that most asthma morbidity and cost can be

**4.2 How can projects effectively reach large numbers of individuals to participate in**

The efficient identification, recruitment, and retention of a large number of individuals who drive adverse outcomes are particularly important when the goal is to impact population outcomes. Although the challenges of participant recruitment and retention are not unique to public health projects, they can dramatically limit a project's ability to achieve a population-level impact. Individuals and groups who are high priority from a public health

Schools and daycare centers were logical partners for CAACP sites because they offered access to a large proportion of a community's children and had an interest in reducing absences caused by poorly controlled asthma. Three sites—Oakland, Northern Manhattan, and Chicago—used questionnaire-based case identification of students with asthma in the schools as the primary method of identifying and recruiting students for interventions. Those sites also used the frequency of self-reported symptoms as a means of prioritizing students for interventions of high intensity and cost. Oakland was successful at engaging 76% of all students identified with asthma. In the Northern Manhattan site, 35% of parents of children identified with asthma participated in at least one asthma education activity

Hospitals are potential venues for identifying and educating large numbers of patients with uncontrolled asthma(National Heart Lung and Blood Institute 2007), as patients can be easily enrolled in an intervention while in the hospital or ED without the traditional barriers of time and transportation (Castro et al., 2003; Teach et al., 2006).The Oakland CAACP site found that working with patients who were hospitalized for asthma to be an effective way

Many health plans, have an interest in reducing costs and improving performance measures, and generally have data that can be used to identify high-risk members or evaluate interventions (Hoppin et al., 2007; Kantor 2007; United States Environmental Protection Agency 2008a, 2008b). Some health plans referred children to CAACP services.Other CAACP site recruitment methods included referrals by medical providers (Chicago), distribution of flyers (Philadelphia), partnerships with social service agencies (Richmond and St Louis), outreach to parents of children in daycare (Northern Manhattan

The reduction of disparities in disease burden among socio-demographic groups is an important public health goal, and one that requires focusing resources on certain populations and communities. Although all CAACP sites were selected because their populations suffered a high, disparate burden of asthma, they received no direction about addressing disparities within the sites. Many of the children with asthma in those

and Richmond), and door-to-door solicitation (Minneapolis/St Paul).

**4.3 What are some considerations for addressing population level asthma**

attributed to relatively few individuals (Smith et al., 1997).

perspective may be the least able to participate in interventions.

**interventions?**

offered by the daycare center.

**disparities?**

to reach high risk children with asthma.

characteristics change over time for every individual with asthma. Interventions that provide a service must decide which individuals with asthma should receive the service in order to maximize the intervention's goals. In a study of limited scale, where the goal is to maximize efficacy, there is an incentive to recruit individuals that are most likely to respond favorably to the intervention. On the other hand, if the goal is to impact asthma outcomes for a population, then identifying and targeting individuals who are most at-risk for the outcome that the intervention is designed to improve is essential for maximizing the intervention's impact.Even small differences in characteristics between participants and non-participants can have a significant impact on an intervention's effectiveness when conducted on a large scale (Vogt et al., 1998).

The national asthma guidelines frequently refer to "high risk" individuals, but use the term inconsistently (National Heart Lung and Blood Institute 2007). One challenge planners face is the lack of correlation among different measures of asthma. Underlying severity and measures of current impairment, such as symptoms, functional limitations, or quality of life, are not reliable predictors of future risk of asthma exacerbation or adverse events (National Heart Lung and Blood Institute 2007). Furthermore, different adverse events may not necessarily correlate with one another; someone who frequently misses school because of asthma may not necessarily be at risk for a hospitalization.

Selecting an age group on which to focus is another consideration for maximizing the population impact of an intervention. Young children have the highest rates of asthmarelated acute visits and have likely received the greatest amount of attention from government and private funders in the US, but this risk decreases significantly in the teen and adult years (Centers for Disease Control and Prevention, 1997). It is difficult to predict which children will be at "highest risk" as they age, and therefore which ones should be the targets of intervention. Provision of resources to a given child may thus have only a shortterm impact. Senior individuals with asthma have the highest asthma-related mortality, and hospitalization costs that are on average two times that of young children per visit (Bahadoriet al., 2009)but for reasons that can only be speculated, are far less commonly the subjects of intervention trials.

Risk assessment models have used empirical data to successfully predict, in the short term, who is most at risk for various outcomes and thus most likely to have an impact on those outcomes in the future (Eisner et al., 2002; Li et al., 1995; Magid et al., 2004; Vollmer et al., 2002). These models include many variables, such as demographic data, various indicators of current asthma control, prescription patterns, and healthcare utilization history. Such models are limited because they differ for each population and require a richness of data that may not be available to the intervention planners.

Despite the fact that the CAACP sites had the same outcome goals, their definition of "high risk" and the selection criteria and methods that the different sites used for determining eligibility for interventions varied greatly. For instance, the criteria the different sites used for enrollment in a home-based asthma case management program included one or more of the following: asthma severity, various measures of asthma control, history of asthmarelated hospitalizations, socioeconomic factors, school absences, and physician referral. The more resource-intensive interventions were generally more selective (CAACP personal

characteristics change over time for every individual with asthma. Interventions that provide a service must decide which individuals with asthma should receive the service in order to maximize the intervention's goals. In a study of limited scale, where the goal is to maximize efficacy, there is an incentive to recruit individuals that are most likely to respond favorably to the intervention. On the other hand, if the goal is to impact asthma outcomes for a population, then identifying and targeting individuals who are most at-risk for the outcome that the intervention is designed to improve is essential for maximizing the intervention's impact.Even small differences in characteristics between participants and non-participants can have a significant impact on an intervention's effectiveness when

The national asthma guidelines frequently refer to "high risk" individuals, but use the term inconsistently (National Heart Lung and Blood Institute 2007). One challenge planners face is the lack of correlation among different measures of asthma. Underlying severity and measures of current impairment, such as symptoms, functional limitations, or quality of life, are not reliable predictors of future risk of asthma exacerbation or adverse events (National Heart Lung and Blood Institute 2007). Furthermore, different adverse events may not necessarily correlate with one another; someone who frequently misses school because of

Selecting an age group on which to focus is another consideration for maximizing the population impact of an intervention. Young children have the highest rates of asthmarelated acute visits and have likely received the greatest amount of attention from government and private funders in the US, but this risk decreases significantly in the teen and adult years (Centers for Disease Control and Prevention, 1997). It is difficult to predict which children will be at "highest risk" as they age, and therefore which ones should be the targets of intervention. Provision of resources to a given child may thus have only a shortterm impact. Senior individuals with asthma have the highest asthma-related mortality, and hospitalization costs that are on average two times that of young children per visit (Bahadoriet al., 2009)but for reasons that can only be speculated, are far less commonly the

Risk assessment models have used empirical data to successfully predict, in the short term, who is most at risk for various outcomes and thus most likely to have an impact on those outcomes in the future (Eisner et al., 2002; Li et al., 1995; Magid et al., 2004; Vollmer et al., 2002). These models include many variables, such as demographic data, various indicators of current asthma control, prescription patterns, and healthcare utilization history. Such models are limited because they differ for each population and require a richness of data

Despite the fact that the CAACP sites had the same outcome goals, their definition of "high risk" and the selection criteria and methods that the different sites used for determining eligibility for interventions varied greatly. For instance, the criteria the different sites used for enrollment in a home-based asthma case management program included one or more of the following: asthma severity, various measures of asthma control, history of asthmarelated hospitalizations, socioeconomic factors, school absences, and physician referral. The more resource-intensive interventions were generally more selective (CAACP personal

conducted on a large scale (Vogt et al., 1998).

subjects of intervention trials.

asthma may not necessarily be at risk for a hospitalization.

that may not be available to the intervention planners.

communication 2008), in keeping with evidence that most asthma morbidity and cost can be attributed to relatively few individuals (Smith et al., 1997).

#### **4.2 How can projects effectively reach large numbers of individuals to participate in interventions?**

The efficient identification, recruitment, and retention of a large number of individuals who drive adverse outcomes are particularly important when the goal is to impact population outcomes. Although the challenges of participant recruitment and retention are not unique to public health projects, they can dramatically limit a project's ability to achieve a population-level impact. Individuals and groups who are high priority from a public health perspective may be the least able to participate in interventions.

Schools and daycare centers were logical partners for CAACP sites because they offered access to a large proportion of a community's children and had an interest in reducing absences caused by poorly controlled asthma. Three sites—Oakland, Northern Manhattan, and Chicago—used questionnaire-based case identification of students with asthma in the schools as the primary method of identifying and recruiting students for interventions. Those sites also used the frequency of self-reported symptoms as a means of prioritizing students for interventions of high intensity and cost. Oakland was successful at engaging 76% of all students identified with asthma. In the Northern Manhattan site, 35% of parents of children identified with asthma participated in at least one asthma education activity offered by the daycare center.

Hospitals are potential venues for identifying and educating large numbers of patients with uncontrolled asthma(National Heart Lung and Blood Institute 2007), as patients can be easily enrolled in an intervention while in the hospital or ED without the traditional barriers of time and transportation (Castro et al., 2003; Teach et al., 2006).The Oakland CAACP site found that working with patients who were hospitalized for asthma to be an effective way to reach high risk children with asthma.

Many health plans, have an interest in reducing costs and improving performance measures, and generally have data that can be used to identify high-risk members or evaluate interventions (Hoppin et al., 2007; Kantor 2007; United States Environmental Protection Agency 2008a, 2008b). Some health plans referred children to CAACP services.Other CAACP site recruitment methods included referrals by medical providers (Chicago), distribution of flyers (Philadelphia), partnerships with social service agencies (Richmond and St Louis), outreach to parents of children in daycare (Northern Manhattan and Richmond), and door-to-door solicitation (Minneapolis/St Paul).

#### **4.3 What are some considerations for addressing population level asthma disparities?**

The reduction of disparities in disease burden among socio-demographic groups is an important public health goal, and one that requires focusing resources on certain populations and communities. Although all CAACP sites were selected because their populations suffered a high, disparate burden of asthma, they received no direction about addressing disparities within the sites. Many of the children with asthma in those

Addressing Asthma from a Public Health Perspective 551

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communities were considered to have a disparate burden of asthma because of low socioeconomic status (SES), unstable living situations, disorganized families, limited access to care, poor housing conditions, or some combination of these determinants of health.

Social, economic, and psychological factors are important determinants of whether an individual will benefit from an intervention (Weil et al., 1999). Individuals in challenging circumstances may have unique incentives or disincentives that affect behavior. For example, families enrolled in government insurance may have a low threshold for deciding to use the ED, which requires no appointment and whose cost is negligible to families, and may in effect use the ED as a replacement for regular primary and preventive care. This phenomenon may be a reason that so many patients present to the ED with mild symptoms (Macias et al., 2006).The economic dynamics which affect behavior likely vary by insurance provider and by extension, by state and country.

All CAACP sites offered referrals to address substance abuse, psychiatric, housing, and financial problems to the extent that those services were available locally, but varied in their efforts to actively address social determinants of health. The Richmond site was most proactive in partnering with a local agency to provide a range of social services as well as asthma education and case coordination for children "who had failed every other intervention." Similarly, the St Louis site contracted with a social service agency to address families' socioeconomic priorities to enable the families to also focus on controlling their children's asthma.

Reaching people and groups who experience health disparities primarily for social and economic reasons often requires labor-intensive, time-consuming, costly interventions. Intensive interventions focused on a small group of people may not necessarily be the most cost effective strategy if the goal is to improve asthma for a diverse population. However, if the priorities are reducing disparities and/or reaching individuals who are most "in need", then interventions that address recidivism and include social services are indicated. It is important to clarify among the stakeholders early in the planning stages if reduction of health disparities is the goal.

## **5. Conclusion**

Public health efforts aiming to improve population-level outcomes are fundamentally different from projects seeking to improve outcomes for patients or for study participants, yet little guidance exists for making choices necessary for planning and implementing public health interventions addressing asthma. Consideration of appropriate populationbased outcome measures, the number of people needed to reach to improve outcome measures, the choice and mix of interventions, and priorities in targeting and methods of recruiting participants all need to be addressed explicitly during the planning phase. The authors hope that future research will provide additional guidance on implementing projects aiming to reduce the burden of asthma at a population level.

## **6. References**

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communities were considered to have a disparate burden of asthma because of low socioeconomic status (SES), unstable living situations, disorganized families, limited access to care, poor housing conditions, or some combination of these determinants of health.

Social, economic, and psychological factors are important determinants of whether an individual will benefit from an intervention (Weil et al., 1999). Individuals in challenging circumstances may have unique incentives or disincentives that affect behavior. For example, families enrolled in government insurance may have a low threshold for deciding to use the ED, which requires no appointment and whose cost is negligible to families, and may in effect use the ED as a replacement for regular primary and preventive care. This phenomenon may be a reason that so many patients present to the ED with mild symptoms (Macias et al., 2006).The economic dynamics which affect behavior likely vary by insurance

All CAACP sites offered referrals to address substance abuse, psychiatric, housing, and financial problems to the extent that those services were available locally, but varied in their efforts to actively address social determinants of health. The Richmond site was most proactive in partnering with a local agency to provide a range of social services as well as asthma education and case coordination for children "who had failed every other intervention." Similarly, the St Louis site contracted with a social service agency to address families' socioeconomic priorities to enable the families to also focus on controlling their

Reaching people and groups who experience health disparities primarily for social and economic reasons often requires labor-intensive, time-consuming, costly interventions. Intensive interventions focused on a small group of people may not necessarily be the most cost effective strategy if the goal is to improve asthma for a diverse population. However, if the priorities are reducing disparities and/or reaching individuals who are most "in need", then interventions that address recidivism and include social services are indicated. It is important to clarify among the stakeholders early in the planning stages if reduction of

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**27**

*1South Africa*

*2USA*

**An Integrated Theoretical Framework**

Thozama Mandisa Lutya1 and Mark Lanier2

**to Describe Human Trafficking of Young**

*1Department of Social Work and Criminology, University of Pretoria, Pretoria 2Department of Criminal Justice, College of Arts & Sciences, University of Alabama, AL*

**Women and Girls for Involuntary Prostitution**

Human trafficking permeates diverse institutions whose systematic operations are entwined into a multitude of activities. A combination of theories should provide an integrated explanation of the occurrence of human trafficking. Although many forms of trafficking exist, we focus primarily on trafficking of women for involuntary prostitution. Bruckett and Parent (2002:7) are of the opinion that apart from the description of the processes, practices, and routes of human trafficking there has been a lack of consistency regarding the theoretical framework for understanding human trafficking. Conventional theory and methods suggest that strategies to conduct research on forced migrants require multi-disciplinary and interdisciplinary approaches, which at times may be divergent (Van Impe, 2000:124). The factors that enable human trafficking to occur vary and are interdependent and interconnected (Stop Violence Against Women (SVAW), 2008:1; Truong, 2001:34-35; Van Impe, 2000:117-118). It is possible that human traffickers observe trade in human beings as a profitable area to generate income, especially when considering that few human traffickers are arrested, prosecuted and sentenced for this crime. Ineffective criminal justice and community response to human trafficking strengthens the trafficking process, increases abuse of trafficked persons and allows human traffickers to generate financial proceeds from the crime. An integrated model to explain human trafficking appears to be a logical step towards an understanding of the crime. Current research explanations of the process of human trafficking are often informed by individual researchers' own theoretical framework creating an impression of human trafficking as a single-dimensional type of crime. This paper will provide a broad integrated framework which considers the stages at which human trafficking for involuntary prostitution occurs. An integrated framework should help enhance the prevention and control

strategies utilized to reduce human trafficking of women for involuntary prostitution.

Article 3 of the UN Palermo Protocol (2002:2), defines human trafficking in persons to mean: the recruitment, transportation, transfer, harboring or receipt of persons, by means of the

**1. Introduction**

**2. Definition of concepts**

**2.1 Human trafficking**

## **An Integrated Theoretical Framework to Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution**

Thozama Mandisa Lutya1 and Mark Lanier2 *1Department of Social Work and Criminology, University of Pretoria, Pretoria 2Department of Criminal Justice, College of Arts & Sciences, University of Alabama, AL 1South Africa 2USA*

## **1. Introduction**

554 Public Health – Social and Behavioral Health

Wang S, Moss JR, Hiller JE. (2006). Applicability and transferability of interventions in evidence-based public health.*Health Promot Int*. 21, 1, (March 2006), pp. 76-83. Weil CM, Wade SL, Bauman LJ, Lynn H, Mitchell H, Lavigne J. (1999).The relationship

asthma.*Pediatrics*. 104, 6, (December 1999), pp. 1274-80.

between psychosocial factors and asthma morbidity in inner-city children with

Human trafficking permeates diverse institutions whose systematic operations are entwined into a multitude of activities. A combination of theories should provide an integrated explanation of the occurrence of human trafficking. Although many forms of trafficking exist, we focus primarily on trafficking of women for involuntary prostitution. Bruckett and Parent (2002:7) are of the opinion that apart from the description of the processes, practices, and routes of human trafficking there has been a lack of consistency regarding the theoretical framework for understanding human trafficking. Conventional theory and methods suggest that strategies to conduct research on forced migrants require multi-disciplinary and interdisciplinary approaches, which at times may be divergent (Van Impe, 2000:124). The factors that enable human trafficking to occur vary and are interdependent and interconnected (Stop Violence Against Women (SVAW), 2008:1; Truong, 2001:34-35; Van Impe, 2000:117-118). It is possible that human traffickers observe trade in human beings as a profitable area to generate income, especially when considering that few human traffickers are arrested, prosecuted and sentenced for this crime. Ineffective criminal justice and community response to human trafficking strengthens the trafficking process, increases abuse of trafficked persons and allows human traffickers to generate financial proceeds from the crime. An integrated model to explain human trafficking appears to be a logical step towards an understanding of the crime. Current research explanations of the process of human trafficking are often informed by individual researchers' own theoretical framework creating an impression of human trafficking as a single-dimensional type of crime. This paper will provide a broad integrated framework which considers the stages at which human trafficking for involuntary prostitution occurs. An integrated framework should help enhance the prevention and control strategies utilized to reduce human trafficking of women for involuntary prostitution.

## **2. Definition of concepts**

#### **2.1 Human trafficking**

Article 3 of the UN Palermo Protocol (2002:2), defines human trafficking in persons to mean: the recruitment, transportation, transfer, harboring or receipt of persons, by means of the

An Integrated Theoretical Framework to

involuntary prostitution is made.

the victim vulnerability of potential victims.

concerned with receiving sexual services from sex workers.

**3.2 Demand theory**

**3.1 Rational choice theory**

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 557

trafficking for involuntary prostitution. It is pointed out by Lanier and Henry, (2004:343) that when a crime is an outcome of several different causes, an integrated framework or a conceptual absorption approach is required to analyse the sequential chain of events. In this regard, Lanier and Henry (2004) explain that the purpose of integrating theories is to present an interaction of probabilities from different theoretical perspectives that could explain the factors contributing to a person committing a crime. Eventually a recommendation of an epi-criminological standpoint as a strategy to respond to human trafficking of women for

Rational choice theories postulate that criminals are rational beings who make decisions to commit crime based on the costs and benefits involved in the process of crime perpetration. Deterministic in nature, criminal decision making process is based on free will, which necessitates observation of opportunities, circumstances and situations that could affect the successful perpetration of the planned crime, (Lanier & Henry, 2004:90). It is pointed out by Brown, Esbensen and Geis, (2008:213) that rational decision making pertaining to crime also involves the choice of the victims determined by the type of crime, modus operandi, where and when to commit it and what to do afterwards. That means the criminals may first observe the accessibility to potential victims, location, the time at which they are at most vulnerable, the appropriate method that could provide entry with ease and how to safeguard their criminal activities from criminal justice authorities and other capable guardians. However, some rational theorists have argued that criminals differ in the choices they make based on their perceptions, motives, skills and abilities to read opportunities as situations guide their decisions making processes, (Lanier & Henry 2004:90). For the purpose of this paper: rational decision making, free will, cost and benefits are three variables that will help to build an integrated framework to explain human trafficking of women and girls for involuntary prostitution. The manner in which human traffickers select their victims is based on the gains they could get from the crime and vulnerability of potential victims. Nevertheless, there needs to be another theoretical explanation to describe

The demand for prostitutes can be classified into three categories: users or purchasers of sex, profiteers from selling sex, and socio-cultural attitudes towards sex, (Hughes 2004). Users or purchasers refers to persons who pay prostitutes to render a sexual service; brothel owners and pimps comprises of profiteers from selling sex and academics and media reporting and writing about prostitutes form part of socio-cultural attitudes towards sex, Hughes (2004). The motives behind purchasing or owning prostitutes and depicting sex services in the manner in which writers do, may contribute to human trafficking of young women and girls for involuntary prostitution. The purchasers of sex, cultural attitudes associated with prostitution, and violence towards women are three factors that this paper has identified to explain the increasing demand for prostitutes. It is deduced from these factors that a certain category of users of prostitutes do not necessarily separate caged prostitutes from voluntary prostitutes but could be more

threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Consent is not necessary where exploitation, fraud, deception, and abuse of vulnerability have been involved. The various stages at which human trafficking for involuntary prostitution occurs are followed to build a multi-theoretical approach to human trafficking of young women and girls for involuntary prostitution.

## **2.2 Sexual exploitation**

Article 3 of the UN Palermo Protocol (2002:2) defines sexual exploitation to include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation such as forced marriages, sexual slavery or servitude and mail order brides. For the purpose of this paper, reference is only made to women and girls sexual exploited through involuntary prostitution.  This paper also recognizes that prostitutes could be trafficked but is concerned with young women and girls forced into prostitution by human traffickers.

## **2.3 Theory intergration**

The process theory integration entails merging of concepts from diverse disciplines and theories to explain a crime which involves a high contingent of perpetrators. Theory integration is a process of combining the best elements of existing theories to better explain the causes of criminal behaviour (Brown, Esbensen & Geis 2007:410; Lanier & Henry 2009: 382). This paper has merged concepts from, rational choice, victimology, demand theory, constitutive criminology and economic theories to explain human trafficking of young women and girls for involuntary prostitution. Human trafficking for involuntary prostitution requires a network of variables in order to construct a comprehensive view of its occurrence.

## **2.4 Women and girls**

The concept woman refers to a person of female gender above the age of 18 and a girl refers to a female child under the age of 18. In this paper, the category of women described could range between the ages of 18 and 24 and girls refer to children ranging between the ages of 10 to 18. South African research on human trafficking of women and girls has revealed that children as young as 10 are trafficked. Although young women of all ages and nationalities could be trafficked it is pointed by ILO (2005) that the demand for prostitutes prefers girls younger than 24 years.

## **3. Theoretical framework**

From the theories explicated below an integrated framework will be created to explain human trafficking of young women and girls for involuntary prostitution. Concepts from, rational choice, victim vulnerability, economic theory and constitutive theory will be selected to describe the sequences of events followed during the commitment of human trafficking for involuntary prostitution. It is pointed out by Lanier and Henry, (2004:343) that when a crime is an outcome of several different causes, an integrated framework or a conceptual absorption approach is required to analyse the sequential chain of events. In this regard, Lanier and Henry (2004) explain that the purpose of integrating theories is to present an interaction of probabilities from different theoretical perspectives that could explain the factors contributing to a person committing a crime. Eventually a recommendation of an epi-criminological standpoint as a strategy to respond to human trafficking of women for involuntary prostitution is made.

## **3.1 Rational choice theory**

556 Public Health – Social and Behavioral Health

threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Consent is not necessary where exploitation, fraud, deception, and abuse of vulnerability have been involved. The various stages at which human trafficking for involuntary prostitution occurs are followed to build a multi-theoretical approach to

Article 3 of the UN Palermo Protocol (2002:2) defines sexual exploitation to include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation such as forced marriages, sexual slavery or servitude and mail order brides. For the purpose of this paper, reference is only made to women and girls sexual exploited through involuntary prostitution.  This paper also recognizes that prostitutes could be trafficked but is concerned with young women and girls forced into

The process theory integration entails merging of concepts from diverse disciplines and theories to explain a crime which involves a high contingent of perpetrators. Theory integration is a process of combining the best elements of existing theories to better explain the causes of criminal behaviour (Brown, Esbensen & Geis 2007:410; Lanier & Henry 2009: 382). This paper has merged concepts from, rational choice, victimology, demand theory, constitutive criminology and economic theories to explain human trafficking of young women and girls for involuntary prostitution. Human trafficking for involuntary prostitution requires a network of variables in order to construct a comprehensive view of

The concept woman refers to a person of female gender above the age of 18 and a girl refers to a female child under the age of 18. In this paper, the category of women described could range between the ages of 18 and 24 and girls refer to children ranging between the ages of 10 to 18. South African research on human trafficking of women and girls has revealed that children as young as 10 are trafficked. Although young women of all ages and nationalities could be trafficked it is pointed by ILO (2005) that the demand for prostitutes prefers girls

From the theories explicated below an integrated framework will be created to explain human trafficking of young women and girls for involuntary prostitution. Concepts from, rational choice, victim vulnerability, economic theory and constitutive theory will be selected to describe the sequences of events followed during the commitment of human

human trafficking of young women and girls for involuntary prostitution.

**2.2 Sexual exploitation**

prostitution by human traffickers.

**2.3 Theory intergration**

its occurrence.

**2.4 Women and girls**

younger than 24 years.

**3. Theoretical framework**

Rational choice theories postulate that criminals are rational beings who make decisions to commit crime based on the costs and benefits involved in the process of crime perpetration. Deterministic in nature, criminal decision making process is based on free will, which necessitates observation of opportunities, circumstances and situations that could affect the successful perpetration of the planned crime, (Lanier & Henry, 2004:90). It is pointed out by Brown, Esbensen and Geis, (2008:213) that rational decision making pertaining to crime also involves the choice of the victims determined by the type of crime, modus operandi, where and when to commit it and what to do afterwards. That means the criminals may first observe the accessibility to potential victims, location, the time at which they are at most vulnerable, the appropriate method that could provide entry with ease and how to safeguard their criminal activities from criminal justice authorities and other capable guardians. However, some rational theorists have argued that criminals differ in the choices they make based on their perceptions, motives, skills and abilities to read opportunities as situations guide their decisions making processes, (Lanier & Henry 2004:90). For the purpose of this paper: rational decision making, free will, cost and benefits are three variables that will help to build an integrated framework to explain human trafficking of women and girls for involuntary prostitution. The manner in which human traffickers select their victims is based on the gains they could get from the crime and vulnerability of potential victims. Nevertheless, there needs to be another theoretical explanation to describe the victim vulnerability of potential victims.

#### **3.2 Demand theory**

The demand for prostitutes can be classified into three categories: users or purchasers of sex, profiteers from selling sex, and socio-cultural attitudes towards sex, (Hughes 2004). Users or purchasers refers to persons who pay prostitutes to render a sexual service; brothel owners and pimps comprises of profiteers from selling sex and academics and media reporting and writing about prostitutes form part of socio-cultural attitudes towards sex, Hughes (2004). The motives behind purchasing or owning prostitutes and depicting sex services in the manner in which writers do, may contribute to human trafficking of young women and girls for involuntary prostitution. The purchasers of sex, cultural attitudes associated with prostitution, and violence towards women are three factors that this paper has identified to explain the increasing demand for prostitutes. It is deduced from these factors that a certain category of users of prostitutes do not necessarily separate caged prostitutes from voluntary prostitutes but could be more concerned with receiving sexual services from sex workers.

 It appears that purchasers of sex workers prefer a person who is willing and able to render a sex service. In the meanwhile, a restricted and confined prostitute may appear more likely to render sex services with least resistance. Nevertheless, the clients interviewed in Coy, Horvath and Kelly, (2007:23) expressed a sense of discomfort with regards to accessing sex from caged women and appeared to sympathise with them rather than pursuing their motives. On the other hand, it is possible that a man who seeks sexual services for comfort would refuse sex

Profiteers imply any person who generates profits from young women and girls forced into prostitution. It could be a club, brothel owners, pimps, massage parlours or owners of rental rooms, (SALRC 2009: 43-44). Brothel owners increase workforce by purchasing young women and girls from traffickers. In turn, once they are in their control, there are variety of ways in which brothel owners maximise profits from prostitutes (Gould & Fick 2007: 14) They determine the price for which the trafficked victim should charge from a trafficker (SALRC 2009: 45-46). Brothel owners may charge agency booking, weekly fees for advertising in newspapers and benefit from the misdemeanours committed by prostitutes whilst working within their confines such as coming to work late (Gould & Fick 2007:14). Young women and girls give payment received from the clients to owners of brothels. Pimps may purchase young women and girls for involuntary prostitution and could sell girls to other pimps to increase profits. Boyfriends and relatives could manage, by force

The publicity gained by commercial sex work from the print publications such as newspapers, academic journals and internet, may create an impression that selling and purchasing sex is an acceptable form of earning a living and accessing sexual services in South Africa and the world. Mansson, (2006: 90) is of the opinion that the mass production of sexualised images of prostitutes appearing in print media could be responsible for men's thinking that as long as one is willing to pay , sexual access is possible. To add on the glamour dimension are advertisements of girls selling sex appearing in newspapers. The research results revealed by Coy, et al. (2007:13) pertaining to the access routes from where men are likely to access prostitutes, illustrate that classified sections of newspapers appeared to be favoured by most users of prostitutes. To make the situation of prostitutes more attractive and humane are human rights organisations addressing challenges encountered by prostitutes whilst executing their duties. In the meanwhile, a legal and academic debate centred on abolishment or legalisation of prostitution is currently in progress in South Africa. Although the South African criminal justice system portrays ambivalent response towards sex work, until decriminalised, regulated or partially criminalised, according to section 20 of the Sexual Offences (Act 53 of 1957) it remains an illegal form of income generation. By responding to advertisements seeking girls for normal

young female relatives as well as intimate partners to work as prostitutes.

prostitution, girls could be lured into human trafficking for sexual exploitation.

#### **3.2.1 The purchasers of sex**

The need for sex, cultural meaning associated with prostitution and violence towards trafficked victims are described in this paper as four distinguishing characteristics of users of prostitutes. Firstly, whatever reasons drawing men to prostitutes, Hughes, (2004:16) is of the opinion that the users of prostitutes are a heterogeneous group with different needs and motives towards sex with prostitutes. Of primary importance to users of prostitutes is the need to fulfil a personal inadequacy, need or desire. It is pointed out by Groom and Nandwani, (2006: 366); Hughes, (2004); Mansson, (2006:89) as well as Macleod, Farley, Anderson and Golding, (2008:14-18) that men's current intimate relationships experiences, desire for unfamiliar sex, acceptance of rape myths and sexual violence towards prostitutes, perceptions of prostitutes and prostitution, and lack of emotional connection could motivate men to solicit prostitutes. The need for prostitutes may contribute to human trafficking of young women and girls for involuntary prostitution. However, some users of prostitutes may go beyond the point of experimentation and sexual fulfilment by perpetrating acts of violence towards prostitutes such as: physical, emotional and sexual violence.

Secondly, there seems to be a cultural meaning associated with prostitution. The norms and values of men who purchase sex and the moral significance they attach to prostitution are an important contributing factor towards the demand for prostitution.   Moreover, in societies where prostitutes are seen as a moral abomination they are least likely to receive sympathy for the violence they may experience at the hands of clients. Clients perceive prostitutes as morally different from other women - free spirited, fatally flawed and seem to sell their bodies in order to get money therefore deserve violence perpetrated towards them, (Macleod, et al. 2008:21).

Thirdly, despite the intention to fulfil personal inadequacies that cannot be satisfied in a normal relationship, prostitutes seem to experience physical, emotional and sexual violence from clients. However, the gendered violence endured by trafficked victims at the hands of users should be seen differently from intimate partner violence. Within this transactional context, the victims and the perpetrators are strangers. A short term agreement is the basis of their interaction. However, similarities between intimate partner violence and violence against trafficked victims are defined by the fact that men are known to use violence against women as a strategy to reassert authority weakened by their daily experiences. On the other hand the experience of victimisation from a victim's perspective is worsened by the type of work she is forced to perform, user's violence and the violence encountered from human traffickers. Eventually, women's bodies as objects to fulfil a man's desire for sex and proneness of prostitutes to client violence are essential elements describing the vulnerability of trafficked young women and girls.

Notwithstanding the cultural significance attached to prostitution and the moral abomination of prostitutes, the question that requires empirical scrutiny is whether users would refrain from purchasing sex if they knew of the working conditions of prostitutes.  It appears that purchasers of sex workers prefer a person who is willing and able to render a sex service. In the meanwhile, a restricted and confined prostitute may appear more likely to render sex services with least resistance. Nevertheless, the clients interviewed in Coy, Horvath and Kelly, (2007:23) expressed a sense of discomfort with regards to accessing sex from caged women and appeared to sympathise with them rather than pursuing their motives. On the other hand, it is possible that a man who seeks sexual services for comfort would refuse sex from a caged person.

## **3.2.2 Profiteers of prostitution**

558 Public Health – Social and Behavioral Health

The need for sex, cultural meaning associated with prostitution and violence towards trafficked victims are described in this paper as four distinguishing characteristics of users of prostitutes. Firstly, whatever reasons drawing men to prostitutes, Hughes, (2004:16) is of the opinion that the users of prostitutes are a heterogeneous group with different needs and motives towards sex with prostitutes. Of primary importance to users of prostitutes is the need to fulfil a personal inadequacy, need or desire. It is pointed out by Groom and Nandwani, (2006: 366); Hughes, (2004); Mansson, (2006:89) as well as Macleod, Farley, Anderson and Golding, (2008:14-18) that men's current intimate relationships experiences, desire for unfamiliar sex, acceptance of rape myths and sexual violence towards prostitutes, perceptions of prostitutes and prostitution, and lack of emotional connection could motivate men to solicit prostitutes. The need for prostitutes may contribute to human trafficking of young women and girls for involuntary prostitution. However, some users of prostitutes may go beyond the point of experimentation and sexual fulfilment by perpetrating acts of

violence towards prostitutes such as: physical, emotional and sexual violence.

perpetrated towards them, (Macleod, et al. 2008:21).

of trafficked young women and girls.

Secondly, there seems to be a cultural meaning associated with prostitution. The norms and values of men who purchase sex and the moral significance they attach to prostitution are an important contributing factor towards the demand for prostitution.   Moreover, in societies where prostitutes are seen as a moral abomination they are least likely to receive sympathy for the violence they may experience at the hands of clients. Clients perceive prostitutes as morally different from other women - free spirited, fatally flawed and seem to sell their bodies in order to get money therefore deserve violence

Thirdly, despite the intention to fulfil personal inadequacies that cannot be satisfied in a normal relationship, prostitutes seem to experience physical, emotional and sexual violence from clients. However, the gendered violence endured by trafficked victims at the hands of users should be seen differently from intimate partner violence. Within this transactional context, the victims and the perpetrators are strangers. A short term agreement is the basis of their interaction. However, similarities between intimate partner violence and violence against trafficked victims are defined by the fact that men are known to use violence against women as a strategy to reassert authority weakened by their daily experiences. On the other hand the experience of victimisation from a victim's perspective is worsened by the type of work she is forced to perform, user's violence and the violence encountered from human traffickers. Eventually, women's bodies as objects to fulfil a man's desire for sex and proneness of prostitutes to client violence are essential elements describing the vulnerability

Notwithstanding the cultural significance attached to prostitution and the moral abomination of prostitutes, the question that requires empirical scrutiny is whether users would refrain from purchasing sex if they knew of the working conditions of prostitutes. It

**3.2.1 The purchasers of sex**

Profiteers imply any person who generates profits from young women and girls forced into prostitution. It could be a club, brothel owners, pimps, massage parlours or owners of rental rooms, (SALRC 2009: 43-44). Brothel owners increase workforce by purchasing young women and girls from traffickers. In turn, once they are in their control, there are variety of ways in which brothel owners maximise profits from prostitutes (Gould & Fick 2007: 14) They determine the price for which the trafficked victim should charge from a trafficker (SALRC 2009: 45-46). Brothel owners may charge agency booking, weekly fees for advertising in newspapers and benefit from the misdemeanours committed by prostitutes whilst working within their confines such as coming to work late (Gould & Fick 2007:14). Young women and girls give payment received from the clients to owners of brothels. Pimps may purchase young women and girls for involuntary prostitution and could sell girls to other pimps to increase profits. Boyfriends and relatives could manage, by force young female relatives as well as intimate partners to work as prostitutes.

### **3.2.3 Publicity of prostitution**

The publicity gained by commercial sex work from the print publications such as newspapers, academic journals and internet, may create an impression that selling and purchasing sex is an acceptable form of earning a living and accessing sexual services in South Africa and the world. Mansson, (2006: 90) is of the opinion that the mass production of sexualised images of prostitutes appearing in print media could be responsible for men's thinking that as long as one is willing to pay , sexual access is possible. To add on the glamour dimension are advertisements of girls selling sex appearing in newspapers. The research results revealed by Coy, et al. (2007:13) pertaining to the access routes from where men are likely to access prostitutes, illustrate that classified sections of newspapers appeared to be favoured by most users of prostitutes. To make the situation of prostitutes more attractive and humane are human rights organisations addressing challenges encountered by prostitutes whilst executing their duties. In the meanwhile, a legal and academic debate centred on abolishment or legalisation of prostitution is currently in progress in South Africa. Although the South African criminal justice system portrays ambivalent response towards sex work, until decriminalised, regulated or partially criminalised, according to section 20 of the Sexual Offences (Act 53 of 1957) it remains an illegal form of income generation. By responding to advertisements seeking girls for normal prostitution, girls could be lured into human trafficking for sexual exploitation.

An Integrated Theoretical Framework to

Victim vulnerability is created by repeat victimisation.

acceptance that the victim could find comforting.

human traffickers, (Van den Hoven, 2005:65).

**3.4 Consitutive theory**

**3.3.3 Lifestyle as a factor in crime victimization risk**

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 561

specific categories of people more prone to repeat victimisation than others: target vulnerability, target gratifiability and target antagonism. Target vulnerability is illustrated by victim's physical weakness, and psychological distress; whereas target gratifiability entails attributes that are attractive to the perpetrator. The presence of destructive impulses in one's personality could expose one to the risk of being victimised. With traumatic experiences unaddressed and future plans constrained by the sexual exploitation, and financial gains that could have been generated from prostitution, it is possible for former victims to either work independently as prostitutes or replicate the process by recruiting potential victims for their own benefit. Replication of human trafficking is conceptualised as second-wave trafficking. Repeat victimisation and second wave trafficking correlates.

If the victim escapes human traffickers, the chances are that she might be re-victimised. The trauma experienced through the process of being victimised at first, may generate feelings of helplessness and could see the victim back with traffickers for involuntary prostitution. With trauma left unresolved, the dependence and bonding between human traffickers and victims still present in victims psyche and negative responses of the community and family members to the experience of the victim, the chances are that the victim could still be vulnerable to human traffickers. The human traffickers could be the only centre of

Lifestyle risk model describes the risk of victimisations to be influenced by: personality of the potential victim, absence of a capable guardian, environment with which the potential victim resides and the daily routine activities which occupies the time of the potential victim, (Van den Hoven & Maree, 2005:63). According to Van den Hoven and Maree, (2005:63) the lifestyle activities which a potential victim participates determine the type of victimisation one could experience. For example, substance abuse may fuel the occurrence of interpersonal violence, whereas the use of the internet may expose children to inappropriate social networks, and participation in activities favoured by the deviant groups may pose danger to unsuspecting potential victims, (Van Den Hoven & Maree, 2005:65). Lifestyle activities such as substance abuse, internet use and equivalent groups are key factors explaining human trafficking of young women and girls for involuntary prostitution. It is possible for human traffickers to draw into the human trafficking ring known victims whose lifestyles intersect with theirs instead of selecting girls and young women from unfamiliar places. Such victims could least likely to report the perpetrators to the authorities thus rendering themselves easy prey to

In summary, the victim's vulnerability to human trafficking for involuntary prostitution is created by victim's offender interaction, repeat victimisation and lifestyle pursued by the victim. In this regard, victim vulnerability is the variable selected to construct the integrated framework to explain human trafficking of women and girls for involuntary prostitution.

The central idea of constitutive criminology is that power and equality build socially constructed differences through which harm and deprivation is imposed on the

Three variables can be drawn from the demand theory of prostitution: users, profiteers and publicity gained by prostitution from the public. All three variables point to the situational context of crime commitment. Prostitutes are portraying the victim; users and profiteers are depicting the offender; and publicity is signifying the opportunities available for prostitutes to exist in the public domain.

## **3.3 Victimological framework**

There exist certain concepts within the Victimology paradigm explaining why certain women might be at greater risk of being victimised than others. Victim offender interaction, repeat victimization and lifestyle as a factor in crime victimization are key factors describing the nature of victimisation of human trafficking for involuntary prostitution. Relationships and interactions with traffickers, lifestyles and number of times women have been trafficked form an essential part of the process of human trafficking of women and girls for involuntary prostitution.

## **3.3.1 Victim criminal relationship**

Victim proneness and victim-offender interaction are two factors explaining the vulnerability of young women and girls to human trafficking for involuntary prostitution through maintaining a relationship with a criminal. There are three categories of victims that could be prone to victimisation: innocent, precipitating and provocative victims. By interacting with criminals innocently through no fault of their own or by walking alone in the dark some individuals could be seen as precipitating their own victimisation. In addition, by exhibiting certain behaviours that could be seen as provocative by criminals, some women and girls are prone to victimisation, (Van den Hoven & Maree, 2005:61). The distance between the offender and the victim and the intentions of the offender and the nature of victim-offender interaction may increase the chances of victimization. It is pointed out by Van Den Hoven and Maree, (2005:61) that victims and the offender could have interacted closely before victimization occurred. Victim involvement in the events that led to victimisation could be identified. Either the victim had provoked or precipitated the victimization incident. However, it is a known fact that women and children are more likely to be victimised by a known person than by strangers. It remains to be seen whether young women and girls trafficked by close associates should be blamed or defended for the choices they have made. Victim proneness, precipitation and provocation will be used as the three factors which creates vulnerability of women and girls to human trafficking for involuntary prostitution

#### **3.3.2 Repeat victimization**

Repeat victimisation entails that victims of crimes are likely to be victimised either by different perpetrators or the same assailant during a limited time period, Van den Hoven & Maree, (2005:65). It is pointed out by Van den Hoven and Maree, (2005:66) that repeat victimization is likely to manifest into a cycle of violence. In turn, victims are likely to become abusers by replicating or modelling behaviour and actions perpetrated against them by human traffickers and recruit other women and girls to involuntary prostitution. According to Van den Hoven and Maree (2005:67) there are certain characteristics that make

Three variables can be drawn from the demand theory of prostitution: users, profiteers and publicity gained by prostitution from the public. All three variables point to the situational context of crime commitment. Prostitutes are portraying the victim; users and profiteers are depicting the offender; and publicity is signifying the opportunities available for prostitutes

There exist certain concepts within the Victimology paradigm explaining why certain women might be at greater risk of being victimised than others. Victim offender interaction, repeat victimization and lifestyle as a factor in crime victimization are key factors describing the nature of victimisation of human trafficking for involuntary prostitution. Relationships and interactions with traffickers, lifestyles and number of times women have been trafficked form an essential part of the process of human trafficking of women and girls for

Victim proneness and victim-offender interaction are two factors explaining the vulnerability of young women and girls to human trafficking for involuntary prostitution through maintaining a relationship with a criminal. There are three categories of victims that could be prone to victimisation: innocent, precipitating and provocative victims. By interacting with criminals innocently through no fault of their own or by walking alone in the dark some individuals could be seen as precipitating their own victimisation. In addition, by exhibiting certain behaviours that could be seen as provocative by criminals, some women and girls are prone to victimisation, (Van den Hoven & Maree, 2005:61). The distance between the offender and the victim and the intentions of the offender and the nature of victim-offender interaction may increase the chances of victimization. It is pointed out by Van Den Hoven and Maree, (2005:61) that victims and the offender could have interacted closely before victimization occurred. Victim involvement in the events that led to victimisation could be identified. Either the victim had provoked or precipitated the victimization incident. However, it is a known fact that women and children are more likely to be victimised by a known person than by strangers. It remains to be seen whether young women and girls trafficked by close associates should be blamed or defended for the choices they have made. Victim proneness, precipitation and provocation will be used as the three factors which creates vulnerability of women and girls to human trafficking for involuntary

Repeat victimisation entails that victims of crimes are likely to be victimised either by different perpetrators or the same assailant during a limited time period, Van den Hoven & Maree, (2005:65). It is pointed out by Van den Hoven and Maree, (2005:66) that repeat victimization is likely to manifest into a cycle of violence. In turn, victims are likely to become abusers by replicating or modelling behaviour and actions perpetrated against them by human traffickers and recruit other women and girls to involuntary prostitution. According to Van den Hoven and Maree (2005:67) there are certain characteristics that make

to exist in the public domain.

**3.3 Victimological framework**

involuntary prostitution.

prostitution

**3.3.2 Repeat victimization**

**3.3.1 Victim criminal relationship**

specific categories of people more prone to repeat victimisation than others: target vulnerability, target gratifiability and target antagonism. Target vulnerability is illustrated by victim's physical weakness, and psychological distress; whereas target gratifiability entails attributes that are attractive to the perpetrator. The presence of destructive impulses in one's personality could expose one to the risk of being victimised. With traumatic experiences unaddressed and future plans constrained by the sexual exploitation, and financial gains that could have been generated from prostitution, it is possible for former victims to either work independently as prostitutes or replicate the process by recruiting potential victims for their own benefit. Replication of human trafficking is conceptualised as second-wave trafficking. Repeat victimisation and second wave trafficking correlates. Victim vulnerability is created by repeat victimisation.

If the victim escapes human traffickers, the chances are that she might be re-victimised. The trauma experienced through the process of being victimised at first, may generate feelings of helplessness and could see the victim back with traffickers for involuntary prostitution. With trauma left unresolved, the dependence and bonding between human traffickers and victims still present in victims psyche and negative responses of the community and family members to the experience of the victim, the chances are that the victim could still be vulnerable to human traffickers. The human traffickers could be the only centre of acceptance that the victim could find comforting.

### **3.3.3 Lifestyle as a factor in crime victimization risk**

Lifestyle risk model describes the risk of victimisations to be influenced by: personality of the potential victim, absence of a capable guardian, environment with which the potential victim resides and the daily routine activities which occupies the time of the potential victim, (Van den Hoven & Maree, 2005:63). According to Van den Hoven and Maree, (2005:63) the lifestyle activities which a potential victim participates determine the type of victimisation one could experience. For example, substance abuse may fuel the occurrence of interpersonal violence, whereas the use of the internet may expose children to inappropriate social networks, and participation in activities favoured by the deviant groups may pose danger to unsuspecting potential victims, (Van Den Hoven & Maree, 2005:65). Lifestyle activities such as substance abuse, internet use and equivalent groups are key factors explaining human trafficking of young women and girls for involuntary prostitution. It is possible for human traffickers to draw into the human trafficking ring known victims whose lifestyles intersect with theirs instead of selecting girls and young women from unfamiliar places. Such victims could least likely to report the perpetrators to the authorities thus rendering themselves easy prey to human traffickers, (Van den Hoven, 2005:65).

In summary, the victim's vulnerability to human trafficking for involuntary prostitution is created by victim's offender interaction, repeat victimisation and lifestyle pursued by the victim. In this regard, victim vulnerability is the variable selected to construct the integrated framework to explain human trafficking of women and girls for involuntary prostitution.

#### **3.4 Consitutive theory**

The central idea of constitutive criminology is that power and equality build socially constructed differences through which harm and deprivation is imposed on the

An Integrated Theoretical Framework to

**4. Theory integration**

pain.

**4.1 Variable 1: Decision making**

women and girls for involuntary prostitution.

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 563

justice, crime prevention and criminology conceptualized as Epidemiological Criminology should be considered to prevent, protect victims, and prosecute human traffickers of young

The formal structure for the integrated theory to explain human trafficking for involuntary prostitution takes the form of multiple causality. Human trafficking for involuntary prostitution is an outcome of a combination of multiple factors, (Lanier & Henry, 2010: 383). The concepts integrated for the construction of this framework are done at individual level of theory integration. There exists a mutual relationship between selected variables so that when combined one cannot function without the other. Decision making process will not occur without rational decision making which comprises of rational choice, the demand as well as victim vulnerability. Power and inequality, free will and lifestyle exposure are three concepts creating an opportunity for recruitment to occur. The interconnectedness of the world, victim precipitation as well as severity and certainty of punishment enable human traffickers to move the victims. Exploitation of victims is made easier by the ambivalent attitudes expressed by society towards the victims as well as the costs and benefits generated from prostitution. The investment in crime and profiteers from the involuntary prostitution give effect to the harbouring and transfer of victims. If victims exit the human trafficking process alive, the loss and pain endured from the experience might likely to influence them to either return as recruiters or work independently as prostitutes. To explain the factors contributing to human trafficking of women and girls for sexual exploitation: the variables below have been selected from the theories described above. Each set of variables correlate with each stage of human trafficking from recruitment to loss and

There are three causal or explanatory factors to the decision making process for committing the crime of human trafficking of young women and girls for involuntary prostitution: **Free will, the demand and victim vulnerability.** Decision making process becomes an independent variable because it precedes the free will, demand and victim vulnerability. Dependent variables are drawn from rational choice, victimology and demand theories to explain the decision making process of human traffickers prior the commitment of human trafficking of young women and girls for involuntary prostitution. The assumption in this regard is that human traffickers will not observe the demand, victim vulnerability or free will in the absence of a decision to commit the crime. The demand will not express interest if the promise of their needs to be fulfilled is not relayed by human traffickers. Young women and girls will not be lured into prostitution if traffickers do not rationally create falsehoods that could see one accepting a dubious job in a different location. Essentially, there exists a

mutual relationship between free will, the demand as well as victim's vulnerability.

Certainly, three activities happen before human trafficking for involuntary prostitution occurs. Firstly, human traffickers choose this crime rationally by calculating the costs and benefits to be generated from selling young women and girls as prostitutes to pimps or brothels. Furthermore, the ambivalent social attitudes and approaches towards prostitution