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.

<sup># 1.96</sup> 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.

<sup>\*</sup>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.

(Glasgow et al., 1991).

the real world.

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

Arias E, Anderson RN, Kung H, Murphy SL, Kochanek KD. (2003). Deaths: final data 2001.

Asher MI, Montefort S, Björkstén B, Lai CK, Strachan DP, Weiland SK, Williams H. (2006).

Berry T, Prosser T, Wilson K, Castro M. (2011). Asthma friendly pharmacies: A model to

Centers for Disease Control and Prevention. (1997). Asthma hospitalizations and

Centers for Disease Control and Prevention. (2001). Adapted from "A Public Health Response to Asthma," PHTN Satellite Broadcast, Course Materials 2001. Centers for Disease Control and Prevention. (2010a). Logic Model, Accessed on 25 Feb 2010,

Centers for Disease Control and Prevention. (2010b). Guide for state health agencies in the

Centers for Disease Control and Prevention. (2010c). Behavioral Risk Factor Surveillance

Cheadle A, Beery W, Greenwald H, Nelson GD, Pearson D, Senter S. (2003). Evaluating the

Coffman JM, Cabana MD, Halpin HA, Yelin EH. (2008). Effects of asthma education on

Cohen L, Swift S. (1999). The spectrum of prevention: developing a comprehensive approach to injury prevention. *Inj Prev*. 5, 3, (September 1999), pp. 203-207. Davis A, Kreutzer R, Lipsett M, King G, Shaikh N. (2006). Asthma prevalence in Hispanic

model. *Ann Behav Med.* 18, 4, (Fall 1996), pp. 290-304.

(May 2009), pp. 24.

31, (August 1997), pp. 726-9.

*National Vital Statistics Reports*. 52, 3, (September 2003), pp. 111.

*RespirCrit Care Med*. 168, 9, (November 2003), pp. 1095-1099.

Available from: <http://www.cdc.gov/eval/resources.htm>

<http://www.cdc.gov/asthma/pdfs/asthma\_guide.pdf>

approach. *Health PromotPract*. 4, 2, (April 2003), pp. 146-56.

<http://www.pediatrics.org/cgi/content/full/121/3/575>

Survey. *Pediatrics*. 118, 2, (August 2006), pp. 363-370.

System, Accessed on January 30, 2010, Available from

<http://www.cdc.gov/asthma/survey/brfss.html>

online March 4, 2008], Available from:

dependence under managed health care: A combined stepped care and matching

Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross-sectional surveys.*Lancet*. 368, 9537, (August 2006), pp. 733-743. Bahadori K, Doyle-Waters MM, Marra C, Lynd L, Alasaly K, Swiston J, FitzGerald JM.

(2009).Economic burden of asthma: a systematic review. *BMC Pulm Med*. 19, 9,

improve communication and collaboration among pharmacists, patients, and health care providers. *Journal of Urban Health*.88, 1, (February 2011), pp. 113-125. CAACP site directors or investigators personal communication, February–September 2008. Castro M, Zimmerman NA, Crocker S, Bradley J, Leven C, Schechtman KB. (2003). Asthma

intervention program prevents readmissions in high healthcare utilizers. *Am J* 

readmissions among children and young adults—Wisconsin 1991-1995.*MMWR*. 46,

development of asthma programs, Accessed on 25 Feb 2010, Available from:

California Wellness Foundation's Health Improvement Initiative: a logic model

children's use of acute care services: meta-analysis, In: *Pediatrics* 121:575-586 [serial

and Asian American ethnic subgroups: results from the California Healthy Kids

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**

Abrams DB, Orleans CT, Niaura RS, Goldstein MG, Prochaska JO, Velicer W. (1996). Integrating individual and public health perspectives for treatment of tobacco

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

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

Abrams DB, Orleans CT, Niaura RS, Goldstein MG, Prochaska JO, Velicer W. (1996).

Integrating individual and public health perspectives for treatment of tobacco

projects aiming to reduce the burden of asthma at a population level.

provider and by extension, by state and country.

children's asthma.

**5. Conclusion** 

**6. References** 

health disparities is the goal.

dependence under managed health care: A combined stepped care and matching model. *Ann Behav Med.* 18, 4, (Fall 1996), pp. 290-304.


<http://www.pediatrics.org/cgi/content/full/121/3/575>


Addressing Asthma from a Public Health Perspective 553

Magid DJ, Houry D, Ellis J, Lyons E, Rumsfeld JS. (2004). Health-related quality of life

Mathiowetz NA, Dipko SM. (2000). A comparison of response error by adolescents and

McNairm J, Ramos C, Portnoy J. (2007). Outcome measures for asthma disease management.*CurrOpin Allergy ClinImmunol*. 7, (June 2007), pp. 231-235. Moorman JE, Rudd RA, Johnson CA, King M, Minor P, Bailey C, Scalia MR, Akinbami LJ;

National Heart Lung and Blood Institute. Expert Panel. *Report 3 (EPR 3): Guidelines for the* 

Smith DH, Malone DC, Lawson KA, Okamoto LJ, Battista C, Saunders WB. (1997). A

Sorensen G, Emmons KM, Dobson AJ. (1998). The implications of the results of community

Starfield B. (1998). Quality of care research: internal elegance and external relevance

Teach SJ, Crain EF, Quint DM, Hylan MI, Joseph JG. (2006). Improved asthma outcomes in a

U.S Census Bureau. (2010). Geographic Mobility Between 2004 and 2005, In: *Population* 

United States Environmental Protection Agency. (2008a). *2008 National Asthma Forum Change* 

United States Environmental Protection Agency. (2008b) *Communities in Action for Asthma-*

Vogt TM, Hollis JF, Lichtenstein E, Stevens VJ, Glasgow RE, Whitlock E. (1998). The medical

Vollmer WM, Markson LE, O'Connor E, Frazier EA, Berger M, Buist AS. (2002). Association

intervention trials.*Annu Rev Public Health*.19, (1998), pp.379-416.

[commentary]. *JAMA*. 208, 11, (September 1998), pp. 1006-1008.

better? *American J Mang Care*. 10, 12, (December 2004), pp. 948-54.

<http://www.census.gov/population/www/pop-

United Sates Environmental Protection Agency; 2008.

*RespirCrit Care Med*. 165, 2, (January 2002), pp. 195-199.

profile/files/dynamic/Mobility.pdf>

Protection Agency.

(March 1998), pp. 5-13.

*Med*. 43, 5, (May 2004), pp. 551-557.

(September 1997), pp. 787-793.

pp.1-54.

2007.

predicts emergency department utilization for patients with asthma. *Ann Emerg* 

adults: findings from a health care study. *Med Care*. 38, 4, (April 2000), pp. 374-382.

Centers for Disease Control and Prevention (CDC). (2007). National surveillance for asthma—United States,1980-2004. *MMWR SurveillSumm*. 56, 8, (October 2007),

*Diagnosis and Management of Asthma*. Bethesda, MD: National Institutes of Health;

national estimate of the economic costs of asthma.*Am J RespirCrit Care Med*. 156,

high-morbidity pediatric population: results of an emergency department-based randomized clinical trial. *Arch PediatrAdolesc Med*. 160, 5, (May 2006), pp. 535-541. Tinkelman D, Wilson S. (2004). Asthma disease management: regression to the mean or

*Profile of the United States: Dynamic Version*, Accessed on 25 Feb 2010, Available from

*Package: The System for Delivering High Quality Asthma Care*. Washington, DC:

*Friendly Environments: A Systems-Based Approach for Creating and Sustaining Effective Community Asthma Programs*. Washington, DC: United States Environmental

care system and prevention: The need for a new paradigm. *HMO Practice*. 12, 1,

of asthma control with health care utilization: a prospective evaluation. *Am J* 


Davis SQ, Krishnan JA, Lee K, Persky V, Naureckas ET. (2011) Effect of a community-wide

Eisner MD, Ackerson LM, Chi F, Kalkbrenner A, Buchner D, Mendoza G, Lieu T. (2002).

Glasgow RE, Hollis JF, McRae SG, Lando HA, LaChance P. (1991). Providing an integrated

Glasgow R, Vogt T, Boles S. (1999). Evaluating the public health impact of health promotion

Hatziandrew EJ, Sacks JJ, Brown R, Taylor WR, Rosenberg ML, Grahan JD. (1995). The cost

Herman E. (2011). Conceptual framework of the Controlling Asthma in American Cities

Holgate S. (1999). Difficult asthma: the unanswered questions. *Difficult Asthma*. London:

Hoppin P, Jacobs M, Stillman L. (2007).Investing in Best Practices for Asthma: A Business

Institute of Medicine. (1988). *The Future of Public Health*. Washington, DC: National Academy

Johnston SL, Pattemore PK, Sanderson G, Smith S, Campbell MJ, Josephs LK, Cunningham

Li D, German D, Lulla S, Thomas RG, Wilson SR. (1995). Prospective study of

Liu AH, Zeiger R, Sorkness C, Mahr T, Ostrom N, Burgess S, Rosenzweig JC, Manjunath R.

Love D, Rudolph B, Shah G. (2008). Lessons learned in using hospital discharge data for

Macias CG, Caviness AC, Sockrider M, Brooks E, Kronfol R, Bartholomew LK, Abramson S,

emergency department utilization.*Pediatrics*. 117, 4, (April 2006), pp. S86-95

Kantor A. (2007). Breathing easier. *AHIP Cover*. 48, 3, (May-June 2007), pp. 50-2,54,56.

Control Test. *J Allergy ClinImmunol*. 119, 4, (April 2007), pp. 817-25.

*Health*.88, 1, (February 2011), pp. 144-155.

(September 1999), pp. 1322-1327.

Martin Dunitz Ltd. 1999.

*Med*. 151, (March 1995), pp. 647-55.

(Nov-Dec 2008), pp. 533-542.

Press; 1988.

654–660.

*Allergy Asthma Immunol*.89, 1, (July 2002), pp. 46-55.

organization. *Health Educ Res*. 6, 1, (March 1991), pp. 87-99.

children.*Public Health Rep.* 110, 3, (May-June 1995), pp.251-259.

Project.*Journal of Urban Health*. 88, 1, (February 2011), pp. 7-15.

*New England Health Resources in Action.* (July 2007), pp. 1-21.

asthma intervention on appropriate use of inhaled corticosteroids. *Journal of Urban* 

Health-related quality of life and future health care utilization for asthma. *Ann* 

program of low intensity tobacco cessation services in a health maintenance

interventions: The RE-AIM Framework. *American Journal of Public Health*. 89, 9,

effectiveness of three programs to increase use of bicycle helmets among

Case for Education and Environmental Interventions. Ast*hma Regional Council of* 

A, Robinson BS, Myint SH, Ward ME, Tyrrell DA, Holgate ST. (1996) The relationship between upper respiratory infections and hospital admissions for asthma: a time-trend analysis. *Am J RespirCrit Care Med*. 154, (September 1996), pp.

hospitalization for asthma: a preliminary risk factor model. *Am J RespirCrit Care* 

(2007). Development and cross-sectional validation of the Childhood Asthma

state and national public health surveillance: Implications for Centers for Disease Control and Prevention Tracking Program. *J Pub Health Management Practice*. 14, 6,

Shearer W. (2006). The effect of acute and chronic asthma severity on pediatric


**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. Therefore prostitution, which is a voluntary sex work performance, is not equated with sexual exploitation. 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. Therefore prostitution, which is a voluntary sex work performance, is not equated with sexual exploitation. 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.

An Integrated Theoretical Framework to

from a caged person.

**3.2.2 Profiteers of prostitution** 

**3.2.3 Publicity of prostitution** 

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 559

is pointed out by Hughes (2004:3) that users of prostitutes do not distinguish between a prostitute who is a victim of human trafficking and a commercial sex worker. 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. It is pointed out by Coy et al, (2007: 19) as well as Macleod, et al. (2008) that the prostitute user's perception generally equates men, sexual aggression, and entitlement as cultural values defining superior manhood. According to the authors it is possible that the users of prostitute, who hold such beliefs adhere to rape myths, are mentally programmed to dominate women, have the desire to use prostitutes to revenge towards women who had wronged them in the past. 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 is pointed out by Hughes (2004:3) that users of prostitutes do not distinguish between a prostitute who is a victim of human trafficking and a commercial sex worker. 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. It is pointed out by Coy et al, (2007: 19) as well as Macleod, et al. (2008) that the prostitute user's perception generally equates men, sexual aggression, and entitlement as cultural values defining superior manhood. According to the authors it is possible that the users of prostitute, who hold such beliefs adhere to rape myths, are mentally programmed to dominate women, have the desire to use prostitutes to revenge towards women who had wronged them in the past. 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

subordinated group. The interconnectedness of societies which cannot be seen outside of cultural and structural contexts, determines the types of crimes that are likely to be perpetrated in specific geographical communities, (Lanier & Henry, 2004:321). Constitutive criminologists perceives criminals as excessive investors in crime who could use any means necessary to achieve the desired outcomes whereas a victim is often the disabled party who experiences pain, loss and denied humanity, (Lanier & Henry, 2004:323). As intercontinental trade agreements become a profitable way of conducting business, relations between countries expand. Business executives and non-governmental organizations travel frequently inter- and intra-continentally. With the world connecting on global scale immigration, traveling and tourism opportunities are now more accessible. Power and inequality, interconnectedness, investment in crime and loss and pain experienced by victims during the perpetration of human trafficking are identifiable variables important to build an integrated theoretical framework to explain human trafficking of young women and girls for involuntary prostitution. The constitutive cultural and structural contexts within which potential victims emanate are important to describe victim vulnerability to human traffickers.

#### **3.5 Economic theory**

Economic theory can be used to explain crimes, actions and behaviours which calculate the gains and benefits accrued from participating in a certain task. Economic theory of crime suggests that people make decisions to offend in ways that resemble their decisions made about other non-criminal activities, (Witt & Witte 2000:4, 6). The criminal might commit crime if the expected gains from legal work are less than the ones that are to arise from illegal work. The underlying principle of the economic theory is that, criminals commit crime because they have perceived the benefits from the crime to outweigh the possibility of being prosecuted and incurring costs, (Eagle & Betters, 2007:166; Persson & Siven, 2007:213). It is pointed out by Pratt (2008:44) as well as Witte & Witt (2002:2, 5) that individuals apply legal or illegal actions because of the expected utility from those acts and are influenced by the fact that the possibility of the expected gains from crime relative to earnings from legal work accentuates trafficking endeavours. Another component of this theory is that the lesser the punishment the more human trafficking progresses. The probability of being apprehended prosecuted and sentenced and the value of the expected punishment will determine the extent of the crime. That brings another economic dimension in human trafficking that is presented by McCray, (2006) in which he argues that certainty is more important than severity. Furthermore, McCray observes that the criminal in this regard would act like an economist and apply the image of a self-maximizing decision maker, carefully calculating his or her advantage, which might be different from an opportunist whose ill considered and reckless nature might get him into trouble. Certainty and severity of punishment are the two variables that are considered important for the formulation of an integrated theory.

In summary, once rational decisions have been made, vulnerability of potential victims ascertained and requirements of the demand considered the human trafficking process resumes. The human traffickers could by then have studied the legal response to human trafficking to ascertain the sanctions confronting them should they get caught by the criminal justice authorities. Hence, it is vital that a combination of public health, criminal justice, crime prevention and criminology conceptualized as Epidemiological Criminology should be considered to prevent, protect victims, and prosecute human traffickers of young women and girls for involuntary prostitution.

## **4. Theory integration**

562 Public Health – Social and Behavioral Health

subordinated group. The interconnectedness of societies which cannot be seen outside of cultural and structural contexts, determines the types of crimes that are likely to be perpetrated in specific geographical communities, (Lanier & Henry, 2004:321). Constitutive criminologists perceives criminals as excessive investors in crime who could use any means necessary to achieve the desired outcomes whereas a victim is often the disabled party who experiences pain, loss and denied humanity, (Lanier & Henry, 2004:323). As intercontinental trade agreements become a profitable way of conducting business, relations between countries expand. Business executives and non-governmental organizations travel frequently inter- and intra-continentally. With the world connecting on global scale immigration, traveling and tourism opportunities are now more accessible. Power and inequality, interconnectedness, investment in crime and loss and pain experienced by victims during the perpetration of human trafficking are identifiable variables important to build an integrated theoretical framework to explain human trafficking of young women and girls for involuntary prostitution. The constitutive cultural and structural contexts within which potential victims emanate are important to describe victim vulnerability to

Economic theory can be used to explain crimes, actions and behaviours which calculate the gains and benefits accrued from participating in a certain task. Economic theory of crime suggests that people make decisions to offend in ways that resemble their decisions made about other non-criminal activities, (Witt & Witte 2000:4, 6). The criminal might commit crime if the expected gains from legal work are less than the ones that are to arise from illegal work. The underlying principle of the economic theory is that, criminals commit crime because they have perceived the benefits from the crime to outweigh the possibility of being prosecuted and incurring costs, (Eagle & Betters, 2007:166; Persson & Siven, 2007:213). It is pointed out by Pratt (2008:44) as well as Witte & Witt (2002:2, 5) that individuals apply legal or illegal actions because of the expected utility from those acts and are influenced by the fact that the possibility of the expected gains from crime relative to earnings from legal work accentuates trafficking endeavours. Another component of this theory is that the lesser the punishment the more human trafficking progresses. The probability of being apprehended prosecuted and sentenced and the value of the expected punishment will determine the extent of the crime. That brings another economic dimension in human trafficking that is presented by McCray, (2006) in which he argues that certainty is more important than severity. Furthermore, McCray observes that the criminal in this regard would act like an economist and apply the image of a self-maximizing decision maker, carefully calculating his or her advantage, which might be different from an opportunist whose ill considered and reckless nature might get him into trouble. Certainty and severity of punishment are the two variables that are considered important for the formulation of an

In summary, once rational decisions have been made, vulnerability of potential victims ascertained and requirements of the demand considered the human trafficking process resumes. The human traffickers could by then have studied the legal response to human trafficking to ascertain the sanctions confronting them should they get caught by the criminal justice authorities. Hence, it is vital that a combination of public health, criminal

human traffickers.

integrated theory.

**3.5 Economic theory** 

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 pain.

## **4.1 Variable 1: Decision making**

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

An Integrated Theoretical Framework to

**4.4 Variable 4: Exploitation** 

ease with which human traffickers conduct their business.

victims makes them least likely to avoid exploitation.

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 565

victims from one location to the other occurs because of the global interconnectedness, victim precipitation as well as certainty and severity of punishment. Human trafficking for involuntary prostitution is an outcome of interactions between human beings across the world, made possible by the interconnectedness of human beings, social and organisational structures, (Lanier & Henry, 2010). The mobility of people from one country to the other, accessibility of the victim to the traffickers as well as the ineffectiveness of the criminal justice system in arresting, prosecuting and convicting human traffickers, could explain the transportation stage of the trafficking process. The same modes of transportation used to transport non-victims of human trafficking are used by human traffickers to move victims. A correlation exists between transportation and interconnectedness. These two variables occur simultaneously. Interconnectedness may appear to take the place of an independent variable. If the world were a closed entity exempt from intercontinental trade agreements, foreign investment and technological advancements, human traffickers would not transport victims in abundance in the manner that they are currently moving. However, the primary intention to be achieved in this regard is the transportation of human trafficking victims. Transportation takes precedence over interconnectedness. The global connection just creates

Victim precipitation as well as severity and certainty of punishment become third variables which strengthens the relationship between interconnectedness and transportation. The acceptance of employment opportunities as well as travelling to another location may seem to create an impression that the victim agrees with the plans of the human trafficker. However, the intended outcome should not benefit the victim but the traffickers. The weak response of the criminal justice system to the crime reinforces the transportation of victims.

Exploitation of victims of human trafficking for involuntary prostitution would occur despite the publicity created by the demand, victims' proneness and costs and benefits. It is pointed out by Fick, (2005); Gould and Fick, (2007) as well as SWEAT, (n.d) that exploitation of prostitutes is prevalent: clients, police officers and the public prone to victimise prostitutes. Exploitation becomes an independent variable which occurs alongside the bad and good publicity received by the industry, victim proneness to violence as well as the monies that are generated by the pimps and traffickers from prostitution. The assumption is that victims of human trafficking for involuntary prostitution are exploited because: Firstly, by being in the industry they are prone to victimisation. Secondly human traffickers intend to generate huge returns from the business of prostitution. Lastly, the space occupied by

The demand theory, victimology and rational choice theory concepts explain the manner in which human traffickers, users and profiteers of prostitution exploit sex workers. The publicity that media advertisements, academic debates and representations by human rights organisations give to the sex work industry creates an impression that prostitutes are bodies to be exploited. A client, who purchase sex services for the purpose of displacing anger, may have psychologically and biologically perceived prostitutes as provocative bodies expecting to be violated. The manner in which the prostitutes dress, the precipitative words they use to solicit clients and the media images glamorizing the sex business could provoke a violent

clear the path for human traffickers to commit the crime. Secondly, they could establish the financial capabilities of the demand and the type of girls preferred by the potential users of victims. Lastly, by ascertaining vulnerability, they determine the easiness with which they could assess the specific type of girls preferred by the demand. For example, within an organised crime context, human traffickers could decide on human trafficking once they have ascertained the leeway paving the way for the commitment of drug dealing such as a drug courier, officials to corrupt and the demand for the drugs.

On the contrary, Joubert (2008:112), Lanier & Henry (2010:81) as well as Brown et al. (2007:219) cautions against contending that rational decision making might be preceded by other variables prior the commitment of crime for the reason that some crimes could be committed impulsively. However, human trafficking for involuntary prostitution involves not only the victim, opportunity and the perpetrator. It involves different locations, spaces, participants and routes; namely victim's country of origin, country of transit or destination from where victimisation might occur and potential users of victims. Nevertheless, rational choice theories are not enough to explain the decision making process involved prior the commitment of human trafficking for involuntary prostitution. The crime involves the situational context which puts victims in the position of vulnerability, better explained by the victimological theories and the demand theories that provide insights into the factors behind the use of prostitutes, ambivalent attitudes towards prostitution as well as the purchasing of young girls and women by brothel owners. Once the human traffickers have decided on the crime, identified victims, analysed the situational factors that could lure victims by measuring the distance between themselves and potential victims, recruitment phase resumes.

## **4.2 Variable 2: Recruitment**

A casual relationship exists between **power and inequality, free will and lifestyle exposure**  creating opportunities for the recruitment process to occur. Recruitment becomes an independent variable and power and inequality, free will and lifestyle exposure are dependent variables. The dependent variables to describe the manner in which human traffickers recruit victims for involuntary prostitution are derived from the constitutive criminology, rational choice and lifestyle exposure model. For the recruitment phase to occur, there ought to exist unequal power differences between the trafficker and the victim. The victim should need to access opportunities for economic advancement. The traffickers may come up with a strategy that could help advance the victim. Social position, psychological well-being, self-realization and actualisation, (Lanier & Henry 2010) of victims should condition them to accept the offers made by human traffickers. In addition the victim should pursue a lifestyle that positions her closer to the traffickers. Essentially power and inequality influences the free will to recruit potential victims based on the lifestyle personality of the victim. With little or no knowledge of victims' lifestyle, gender, socio-economic status, ethnicity and race per preference of the demand, the traffickers will not recruit victims.

#### **4.3 Variable 3: Transportation**

Constitutive criminology, victimology and economic crime explain the easiness in which human traffickers move victims from one location to the other. The process of transporting victims from one location to the other occurs because of the global interconnectedness, victim precipitation as well as certainty and severity of punishment. Human trafficking for involuntary prostitution is an outcome of interactions between human beings across the world, made possible by the interconnectedness of human beings, social and organisational structures, (Lanier & Henry, 2010). The mobility of people from one country to the other, accessibility of the victim to the traffickers as well as the ineffectiveness of the criminal justice system in arresting, prosecuting and convicting human traffickers, could explain the transportation stage of the trafficking process. The same modes of transportation used to transport non-victims of human trafficking are used by human traffickers to move victims.

A correlation exists between transportation and interconnectedness. These two variables occur simultaneously. Interconnectedness may appear to take the place of an independent variable. If the world were a closed entity exempt from intercontinental trade agreements, foreign investment and technological advancements, human traffickers would not transport victims in abundance in the manner that they are currently moving. However, the primary intention to be achieved in this regard is the transportation of human trafficking victims. Transportation takes precedence over interconnectedness. The global connection just creates ease with which human traffickers conduct their business.

Victim precipitation as well as severity and certainty of punishment become third variables which strengthens the relationship between interconnectedness and transportation. The acceptance of employment opportunities as well as travelling to another location may seem to create an impression that the victim agrees with the plans of the human trafficker. However, the intended outcome should not benefit the victim but the traffickers. The weak response of the criminal justice system to the crime reinforces the transportation of victims.

## **4.4 Variable 4: Exploitation**

564 Public Health – Social and Behavioral Health

clear the path for human traffickers to commit the crime. Secondly, they could establish the financial capabilities of the demand and the type of girls preferred by the potential users of victims. Lastly, by ascertaining vulnerability, they determine the easiness with which they could assess the specific type of girls preferred by the demand. For example, within an organised crime context, human traffickers could decide on human trafficking once they have ascertained the leeway paving the way for the commitment of drug dealing such as a

On the contrary, Joubert (2008:112), Lanier & Henry (2010:81) as well as Brown et al. (2007:219) cautions against contending that rational decision making might be preceded by other variables prior the commitment of crime for the reason that some crimes could be committed impulsively. However, human trafficking for involuntary prostitution involves not only the victim, opportunity and the perpetrator. It involves different locations, spaces, participants and routes; namely victim's country of origin, country of transit or destination from where victimisation might occur and potential users of victims. Nevertheless, rational choice theories are not enough to explain the decision making process involved prior the commitment of human trafficking for involuntary prostitution. The crime involves the situational context which puts victims in the position of vulnerability, better explained by the victimological theories and the demand theories that provide insights into the factors behind the use of prostitutes, ambivalent attitudes towards prostitution as well as the purchasing of young girls and women by brothel owners. Once the human traffickers have decided on the crime, identified victims, analysed the situational factors that could lure victims by measuring the distance between themselves and potential victims, recruitment

A casual relationship exists between **power and inequality, free will and lifestyle exposure**  creating opportunities for the recruitment process to occur. Recruitment becomes an independent variable and power and inequality, free will and lifestyle exposure are dependent variables. The dependent variables to describe the manner in which human traffickers recruit victims for involuntary prostitution are derived from the constitutive criminology, rational choice and lifestyle exposure model. For the recruitment phase to occur, there ought to exist unequal power differences between the trafficker and the victim. The victim should need to access opportunities for economic advancement. The traffickers may come up with a strategy that could help advance the victim. Social position, psychological well-being, self-realization and actualisation, (Lanier & Henry 2010) of victims should condition them to accept the offers made by human traffickers. In addition the victim should pursue a lifestyle that positions her closer to the traffickers. Essentially power and inequality influences the free will to recruit potential victims based on the lifestyle personality of the victim. With little or no knowledge of victims' lifestyle, gender, socio-economic status, ethnicity and race per preference of the

Constitutive criminology, victimology and economic crime explain the easiness in which human traffickers move victims from one location to the other. The process of transporting

drug courier, officials to corrupt and the demand for the drugs.

phase resumes.

**4.2 Variable 2: Recruitment** 

demand, the traffickers will not recruit victims.

**4.3 Variable 3: Transportation** 

Exploitation of victims of human trafficking for involuntary prostitution would occur despite the publicity created by the demand, victims' proneness and costs and benefits. It is pointed out by Fick, (2005); Gould and Fick, (2007) as well as SWEAT, (n.d) that exploitation of prostitutes is prevalent: clients, police officers and the public prone to victimise prostitutes. Exploitation becomes an independent variable which occurs alongside the bad and good publicity received by the industry, victim proneness to violence as well as the monies that are generated by the pimps and traffickers from prostitution. The assumption is that victims of human trafficking for involuntary prostitution are exploited because: Firstly, by being in the industry they are prone to victimisation. Secondly human traffickers intend to generate huge returns from the business of prostitution. Lastly, the space occupied by victims makes them least likely to avoid exploitation.

The demand theory, victimology and rational choice theory concepts explain the manner in which human traffickers, users and profiteers of prostitution exploit sex workers. The publicity that media advertisements, academic debates and representations by human rights organisations give to the sex work industry creates an impression that prostitutes are bodies to be exploited. A client, who purchase sex services for the purpose of displacing anger, may have psychologically and biologically perceived prostitutes as provocative bodies expecting to be violated. The manner in which the prostitutes dress, the precipitative words they use to solicit clients and the media images glamorizing the sex business could provoke a violent

An Integrated Theoretical Framework to

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 567

from different disciplines to explain the occurrence of human trafficking. To synthesize, human traffickers and the demand, each play an instrumental role in the victimization of trafficked women. Identified are unguarded victims - seen as attractive targets who are innocent or facilitating the process, cooperative even and whose countries may be experiencing some structural constraints - to supply the needs of the demand. Traffickers follow an economic approach to perform human trafficking by calculating the strength of punishment against the financial incentives likely to be drawn from the process of human trafficking. By taking advantage of globalization issues, they commit the crime. Human trafficking is a constitutive crime that involves role players from diverse populations and professional backgrounds. As the world becomes more interconnected human trafficking is increasing rapidly. In addition, constitutive criminology points out that, victims are always at the receiving end of the human trafficking process. They experience, emotional loss,

There are currently many varied approaches applied by academics and researchers' to explain and respond successfully to the challenges faced by victims and potential victims of human trafficking for involuntary prostitution. The expanding area of Epidemiological Criminology or "EpiCrim" might be useful to devise strategies to respond effectively to human trafficking of young women and girls for involuntary prostitution (Lanier, Pack & Akers 2009). EpiCrim emphasizes the need to provide public health, justice, victim support and investigation to victims of human trafficking (Akers & Lanier, 2009). Public awareness on human trafficking for potential victims is a focus of concern for EpiCrim adherents. The purpose of this approach is to ensure that the cycle of violence is not repeated. By providing

There are few chances of getting caught and convicted for the crime of human trafficking in South Africa (SA). Human Trafficking is not even a legally defined crime in SA as the country is still in the final stages of approving the Human Trafficking Bill. In the meantime, some sections of legislations such as Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007), Children's Act (38 of 2005), Prevention of Organized Crime Act, (121 of 1998) and Immigration Act, (13 of 2002) are used to respond to the crime. Human trafficking accused have been appearing in court to defend allegations of sexual offences, child maltreatment and participation in organized activities, with most being sentenced under the Prevention of Organized Crime Act (121 of 1998). Dryden et al. (2001:6) are of the opinion that the inevitability of crime commission might be obvious in a situation where the legal sanctions are not available to respond to crime or if the sentencing procedures is not consistent. As a consequence of the lack of an approved legislation to respond and combat human trafficking for all purposes, South Africa has been put on tier two by the United Nations Convention against Transnational Crime: meaning that whilst contingency measures are underway to respond promptly to this crime, the process is slow. Non-governmental organizations and some research institutions perform prevention and

protection duties especially for victims and potential victims of human trafficking.

Negative consequences outweigh positive consequences of human trafficking for trafficked victims. Human rights violations and deterioration of mental and physical health are

suffering and dislocation during and after the trafficking process.

justice and services to victims, redress for the crime suffered is conducted.

**5.1 Policy suggestions: The South African experience** 

**5.2 Consequences of human trafficking for victims** 

client to use violence towards sex workers. Whilst the cost and benefit analysis calculated by human traffickers prior commitment of crime allows exploitation of trafficked victims to occur. Human traffickers may not risk getting caught, or share financial gains or the skills needed to successfully commit the crime with the victims for the reason that they will not obtain the goals set prior crime perpetration.

## **4.5 Variable 5: Harbouring and transfer**

Harbouring and transfer are vital activities causing brothel owners, clients as well pimps to profit and invest in the human trafficking of young women and girls for involuntary prostitution. The extent to which they are willing to keep victims and use them to generate income is one of the factors driving the human trafficking process. However, they vary in the manner in which they retain victims for victimisation. Harbouring and transfer are the concepts derived from demand and constitutive theories to comprehend the motives behind the confinement and selling of victims by human traffickers. The victims are sold because the crime in which the traffickers have invested generates profits. In essence, harbouring and transfer become an independent variable: taking precedents over profits and investment in crime. Harbouring and transfer causes profiteers and investment in crime. Profiteers and investment in crime become dependent variables. Brothel owners buy victims because they are available by means of confinement by traffickers. In turn, participating in crime for prolonged time becomes an investment in crime.

The longer the traffickers keep victims confined and performing involuntary sex work, the more profits they generate from the crime. The investment in the human trafficking of young women and girls for involuntary prostitution persuade traffickers to apply every means necessary to keep control of the victims. Profits are a necessary prerequisite for the harbouring and transfer of the victims. The greater the profits traffickers generate, the more creative traffickers' become in the methods they use to invest in the crime.

#### **4.6 Variable 6: Loss and pain**

The economic, physical, sexual and psychological losses and pains encountered during the process of human trafficking for involuntary prostitution could create second wave trafficking. Derived from constitutive criminology the concept of loss and pain resonate with the occurrence of second wave trafficking. Constitutive criminology postulates that crime is "power to deny others their ability to make a difference", (Lanier & Henry, 2010). According to Lanier and Henry (2010) victimisation is a sign of disrespect to the victims – when victimised victims are prevented from interacting with others, transform themselves and better their economic situation. Victims do not only lose income and integrity but their sense of self-worth and value. By being forced involuntarily to perform sex work, victims could be severely traumatised and physically damaged. In turn, if the trauma of loss and pain is left unresolved they might likely recruit other girls into human trafficking for involuntary prostitution. Thus, the cycle of violence and victimisation is displaced upon a second group of victims.

## **5. Theory synthesis**

An integrated framework to explain and describe the process of human trafficking was described in this paper. To construct an integrated framework this paper coalesced variables

client to use violence towards sex workers. Whilst the cost and benefit analysis calculated by human traffickers prior commitment of crime allows exploitation of trafficked victims to occur. Human traffickers may not risk getting caught, or share financial gains or the skills needed to successfully commit the crime with the victims for the reason that they will not

Harbouring and transfer are vital activities causing brothel owners, clients as well pimps to profit and invest in the human trafficking of young women and girls for involuntary prostitution. The extent to which they are willing to keep victims and use them to generate income is one of the factors driving the human trafficking process. However, they vary in the manner in which they retain victims for victimisation. Harbouring and transfer are the concepts derived from demand and constitutive theories to comprehend the motives behind the confinement and selling of victims by human traffickers. The victims are sold because the crime in which the traffickers have invested generates profits. In essence, harbouring and transfer become an independent variable: taking precedents over profits and investment in crime. Harbouring and transfer causes profiteers and investment in crime. Profiteers and investment in crime become dependent variables. Brothel owners buy victims because they are available by means of confinement by traffickers. In turn, participating in

The longer the traffickers keep victims confined and performing involuntary sex work, the more profits they generate from the crime. The investment in the human trafficking of young women and girls for involuntary prostitution persuade traffickers to apply every means necessary to keep control of the victims. Profits are a necessary prerequisite for the harbouring and transfer of the victims. The greater the profits traffickers generate, the more

The economic, physical, sexual and psychological losses and pains encountered during the process of human trafficking for involuntary prostitution could create second wave trafficking. Derived from constitutive criminology the concept of loss and pain resonate with the occurrence of second wave trafficking. Constitutive criminology postulates that crime is "power to deny others their ability to make a difference", (Lanier & Henry, 2010). According to Lanier and Henry (2010) victimisation is a sign of disrespect to the victims – when victimised victims are prevented from interacting with others, transform themselves and better their economic situation. Victims do not only lose income and integrity but their sense of self-worth and value. By being forced involuntarily to perform sex work, victims could be severely traumatised and physically damaged. In turn, if the trauma of loss and pain is left unresolved they might likely recruit other girls into human trafficking for involuntary prostitution. Thus,

obtain the goals set prior crime perpetration.

crime for prolonged time becomes an investment in crime.

creative traffickers' become in the methods they use to invest in the crime.

the cycle of violence and victimisation is displaced upon a second group of victims.

An integrated framework to explain and describe the process of human trafficking was described in this paper. To construct an integrated framework this paper coalesced variables

**4.5 Variable 5: Harbouring and transfer** 

**4.6 Variable 6: Loss and pain** 

**5. Theory synthesis** 

from different disciplines to explain the occurrence of human trafficking. To synthesize, human traffickers and the demand, each play an instrumental role in the victimization of trafficked women. Identified are unguarded victims - seen as attractive targets who are innocent or facilitating the process, cooperative even and whose countries may be experiencing some structural constraints - to supply the needs of the demand. Traffickers follow an economic approach to perform human trafficking by calculating the strength of punishment against the financial incentives likely to be drawn from the process of human trafficking. By taking advantage of globalization issues, they commit the crime. Human trafficking is a constitutive crime that involves role players from diverse populations and professional backgrounds. As the world becomes more interconnected human trafficking is increasing rapidly. In addition, constitutive criminology points out that, victims are always at the receiving end of the human trafficking process. They experience, emotional loss, suffering and dislocation during and after the trafficking process.

There are currently many varied approaches applied by academics and researchers' to explain and respond successfully to the challenges faced by victims and potential victims of human trafficking for involuntary prostitution. The expanding area of Epidemiological Criminology or "EpiCrim" might be useful to devise strategies to respond effectively to human trafficking of young women and girls for involuntary prostitution (Lanier, Pack & Akers 2009). EpiCrim emphasizes the need to provide public health, justice, victim support and investigation to victims of human trafficking (Akers & Lanier, 2009). Public awareness on human trafficking for potential victims is a focus of concern for EpiCrim adherents. The purpose of this approach is to ensure that the cycle of violence is not repeated. By providing justice and services to victims, redress for the crime suffered is conducted.

## **5.1 Policy suggestions: The South African experience**

There are few chances of getting caught and convicted for the crime of human trafficking in South Africa (SA). Human Trafficking is not even a legally defined crime in SA as the country is still in the final stages of approving the Human Trafficking Bill. In the meantime, some sections of legislations such as Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007), Children's Act (38 of 2005), Prevention of Organized Crime Act, (121 of 1998) and Immigration Act, (13 of 2002) are used to respond to the crime. Human trafficking accused have been appearing in court to defend allegations of sexual offences, child maltreatment and participation in organized activities, with most being sentenced under the Prevention of Organized Crime Act (121 of 1998). Dryden et al. (2001:6) are of the opinion that the inevitability of crime commission might be obvious in a situation where the legal sanctions are not available to respond to crime or if the sentencing procedures is not consistent. As a consequence of the lack of an approved legislation to respond and combat human trafficking for all purposes, South Africa has been put on tier two by the United Nations Convention against Transnational Crime: meaning that whilst contingency measures are underway to respond promptly to this crime, the process is slow. Non-governmental organizations and some research institutions perform prevention and protection duties especially for victims and potential victims of human trafficking.

## **5.2 Consequences of human trafficking for victims**

Negative consequences outweigh positive consequences of human trafficking for trafficked victims. Human rights violations and deterioration of mental and physical health are

An Integrated Theoretical Framework to

(1998), 165-171.

Sage Publications.

*experiences.* Cape Town: SWEAT.

*prostitution.* Cape Town: SWEAT.

University of Rhode Island.

Oxford: Oxfam Publishers.

Westview Publishers.

Westview Publishers.

m Assessed 25/03/2008.

Relevance. *Journal unknown*, 7(1), 43-52.

Describe Human Trafficking of Young Women and Girls for Involuntary Prostitution 569

Davis, L. (2005). Theoretical approaches and perspectives in Victimology. In Davis, L. & Snyman, R. *Victimology in South Africa*. Pretoria: Van Schaik Publishers (pp 35-52). Dryden Witte, A., & Witt, R. (2001). What we spend and what we get: Public and private provision of crime prevention and criminal justice. *Fiscal Studies*, 22 (1), 1-40. Eagle, J.G., & Betters, D.R. (1998). The endangered species act and economic values: A

Fick, N. (2005). *Coping with stigma, discrimination and violence: Sex workers talk about their* 

Groom, T.M., & Nandwani, R. (2006). Characteristics of men who pay for sex: A UK sexual

Gould, C., & Fick, N. (2007). *Report to the South African Law Commission: Preliminary research* 

Henry, S., & Milovanovic, D. (1998). *Constitutive Criminology: Beyond Postmodernism*. London:

Hughes, M. D. (2004). *Best practices to address the demand side of sex trafficking*. Rhode Island:

Joubert, S. (2008). Contemporary theoretical explanations for youth misbehaviour. In

Kinnu, G. (2006). *From Bondage to Freedom: An analysis of International Legal Regime on Human* 

Lanier, M., & Henry, S. (2004). *Essential Criminology.* 2nd edition. United States of America:

Lanier, M., & Henry, S. (2010). *Essential Criminology.* 3rd edition. United States of America:

Lanier, M., Pack. R. P. & Akers. T. (2009). Epidemiological Criminology: Drug use among African American gang members. *Journal of Correctional Health Care*, x:xx-xx. Macleod, J., Farley, M., Anderson, L., & & Golding, J. (2008). *Challenging men's demand for* 

McCray, J. (2006). *Dynamics and the economic theory of crime. Criminology and Economics* 

Persson, M. Siven, C-H. (2007). The Becker Paradox and type I versus type II Errors in the

Phinney, A. (2006). *Trafficking of women and children for sexual exploitation in the America's*. [O] Available:http://www.planetwire.org/wrap/files.fcgi/2369\_trafficking\_paper.ht

Pratt, T.C. (2008). Rational Choice Theory, Crime Control Policy, and Criminological

Economics of crime. *International Economic Review*, 48 (1), 211-233.

*prostitution in Scotland: A research report based on interviews with 110 men who bought* 

Immigration Act 13 of 2002. *Government Gazette*, (26901). Pretoria: Government Printer. Jordan, A. (2002). Human rights or wrongs? The struggle for a human rights-based response

*holistic approach.* (pp 108-122) Pretoria: Van Schaik Publishers.

*women in prostitution*. Glasgow: Women's Support Project. Mansson, S.A. (2006). Men's demand for prostitutes. *Sexologies*, 15 (2006): 87-92.

*Summer Workshop.* University of Michigan: June 5.

*Trafficking*. [O] Available:http://www.nhrc.nic.in

health clinic survey. *Sexually Transmitted Infections*, 82, 364-367.

comparison of fines and contingent valuation studies. *Ecological Economics*, 26

*findings or relevance to combat trafficking in persons and legislation pertaining adult* 

to trafficking in human beings. In Masika, R. (Ed). *Gender, Trafficking and Slavery*.

Bezuidenhout, C. & Joubert, S. *Child and Youth Misbehaviour in South Africa: A* 

impairments experienced by victims of human trafficking during and after the process of trafficking. Free will, human dignity and an ability to make decisions are some of the human rights violations experienced by victims at the hands of human traffickers (Hughes, 2004; Kinnu, 2006:24; Phinney, 2006:4; Timoshkina & MacDonald, n.d:17 ). Trafficked young women and girls often have traveling documents confiscated by human traffickers, which render them incapable of seeking assistance from the authorities at the host country (Jordan, 2002:35; Simic, 2004:25; Timoshkina & MacDonald, nd: 17). They are often deprived of basic medical and mental health care; shelter that is not a form of prison or detention; protection from traffickers; access to information on legal rights and to attorneys or advocates; financial or other assistance, for example food, clothing and telephone calls as well as a means to return home safely. Having proof of identity, traveling documents or a work permit, would provide the victim permission, short stay or employment, at the host county.

The often confining process of human trafficking does not leave victims unscathed; trafficked victims could experience nightmares, depression, anxiety, sexually transmitted infections, back aches and other mental health related ailments. Epi-criminological framework is recommended to respond to victim experiences, rehabilitate human traffickers and assist other persons that could indirectly be affected by human trafficking such as families and relatives of victims.

## **6. Summary**

The purpose of this paper was to construct an integrated framework for explaining and describing human trafficking of women and girls for involuntary prostitution. Variables from existing theories were drawn to formulate a comprehensive view of the process followed during the commitment of this crime. The basic argument is that, since human trafficking involves a high contingent of role players from a variety of backgrounds, a single explanation for its cause cannot exist. Essentially, human trafficking responses should consider the importance of an integrated framework in order to effectively, prevent, prosecute suspects and protect victims of human trafficking of women and girls for involuntary prostitution.

## **7. References**


impairments experienced by victims of human trafficking during and after the process of trafficking. Free will, human dignity and an ability to make decisions are some of the human rights violations experienced by victims at the hands of human traffickers (Hughes, 2004; Kinnu, 2006:24; Phinney, 2006:4; Timoshkina & MacDonald, n.d:17 ). Trafficked young women and girls often have traveling documents confiscated by human traffickers, which render them incapable of seeking assistance from the authorities at the host country (Jordan, 2002:35; Simic, 2004:25; Timoshkina & MacDonald, nd: 17). They are often deprived of basic medical and mental health care; shelter that is not a form of prison or detention; protection from traffickers; access to information on legal rights and to attorneys or advocates; financial or other assistance, for example food, clothing and telephone calls as well as a means to return home safely. Having proof of identity, traveling documents or a work permit, would

The often confining process of human trafficking does not leave victims unscathed; trafficked victims could experience nightmares, depression, anxiety, sexually transmitted infections, back aches and other mental health related ailments. Epi-criminological framework is recommended to respond to victim experiences, rehabilitate human traffickers and assist other persons that could indirectly be affected by human trafficking such as

The purpose of this paper was to construct an integrated framework for explaining and describing human trafficking of women and girls for involuntary prostitution. Variables from existing theories were drawn to formulate a comprehensive view of the process followed during the commitment of this crime. The basic argument is that, since human trafficking involves a high contingent of role players from a variety of backgrounds, a single explanation for its cause cannot exist. Essentially, human trafficking responses should consider the importance of an integrated framework in order to effectively, prevent, prosecute suspects and protect victims of human trafficking of women and girls for

Akers. T., & Lanier, M. (2009). Epidemiological Criminology: Coming Full Circle. *American* 

Bruckett, C., & Parent, C. (2002). *Trafficking in human beings and organized crime: A literature* 

Brown, S.E., Esbensen, F., & Geis, G. (2007). *Criminology: Explaining crime and its context*.

Coy, M., Horvath, M., & Kelly, L. (2007).*'Its just like going to the supermarket': Men buying sex in East London. Report for safe exit*. London: London Metropolitan University. Criminal (Sexual Offences and Related Matters) Amendment Act 32 of 2007. *Government* 

*Review*. Ottawa, ON, Canada: RCMP. [O] Avaialble:http://www.rcmp-grc.gc.ca

Bales, K. (2009) Presentation at the University of Central Florida, January 15, 2009.

Children's Act 38 of 2005. *Government Gazette*, (28944). Pretoria: Government Printer.

provide the victim permission, short stay or employment, at the host county.

families and relatives of victims.

involuntary prostitution.

*Journal of Public Health*, 99 (2), 1-6.

Sixth Edition. Cincinnati: Anderson Publishing.

*Gazette*. Pretoria: Government Printer.

Assessed 14/03/2008.

**7. References** 

**6. Summary** 


 http://www.umn.edu/humanrts/svaw/trafficking/explore/3factors.htm Assessed 25/03/2008.

SWEAT. [Sa]. *Policing sex workers: A violation of human rights*. Cape Town: SWEAT.


Prevention of Organized Crime Act 121 of 1998. *Government Gazette*, (19553). Pretoria:

Simic, O. (2004).*Victims of trafficking for forced prostitution: Protection mechanisms and the right* 

Snyman, R. (2005). Overview of and concepts in Victimology. In Davis, L & Snyman, R.

South African Law Reform Commission (SALRC). (2009). Discussion Paper 0001/2009,

Stop Violence Against Women. (SVAW). (2008). *Factors that contribute to trafficking in women*.

Truang, T.D. (2006). *Poverty, gender and human trafficking in Sub-Saharan Africa: Rethinking best* 

Truong, T. (2001). *Human Trafficking and Organized Crime. Institute of Social Studies Working Papers Series no.339.* [O] Avaialable:http://www.iss.nl. Assessed 25/03/2008 United Nations. (2000). *Protocol to prevent, suppress and punish trafficking in persons, especially* 

*organized crime.* [O] Available:http://www.un.org.za Assessed 26/02/2008. Van den Hoven, A., & Maree, A. (2005). Victimization risk factors, repeat victimization and

Van Impe, K. (2000). 'People for sale': The need for a multi-disciplinary approach towards human trafficking. *International Migration, Special Issue*, 2000 (1):113-131. Witte, A.D., & Witt, R. (2002). Crime Causation: Economic Theories. In *Encyclopaedia of Crime* 

*practices in migration management* [O] Available:http://www.popline.org/docs

*women and children, supplementing the United Nations convention against transnational* 

victim profiling. In Davis, L. & Snyman, R. *Victimology in South Africa* (pp55-71).

(Eds.) *Victimology in South Africa.* Pretoria: Van Schaik Publishers.

Project 107: Sexual Offences Adult Prostitution. Pretoria: SALRC.

http://www.umn.edu/humanrts/svaw/trafficking/explore/3factors.htm

SWEAT. [Sa]. *Policing sex workers: A violation of human rights*. Cape Town: SWEAT. Timoshkina, N., & MacDonald, L. [Sa]. Defining Trafficking in Women. [S1:sn).

*to remain in the destination countries*. Switzerland: Global Commission on

Government Printer.

International Migration.

[O] Avaialable:

Assessed 25/03/2008.

Assessed 14/03/2008.

Pretoria: Van Schaik Publishers.

*and Justice*, 1 (302-308) New York: Macmillan.

## *Edited by Jay Maddock*

Human behavior accounts for the majority of morbidity and premature mortality throughout the world. This book explores several areas of human behavior including physical activity, nutrition and food, addictive substances, gun violence, sexual transmitted diseases and more. Several cutting edge methods are also examined including empowering nurses, community based participatory research and nature therapy. Less well known public health topics including human trafficking, tuberculosis control in prisons and public health issues in the deaf community are also covered. The authors come from around the world to describe issues that are both of local and worldwide importance to protect and preserve the health of populations. This book demonstrates the scope and some of the solutions to addressing today's most pressing public health issues.

Photo by agsandrew / iStock

Public Health - Social and Behavioral Health

Public Health

Social and Behavioral Health

*Edited by Jay Maddock*