Child trafficking referrals in Portugal (2010–2017).
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"4614",leadTitle:null,fullTitle:"Surface Energy",title:"Surface Energy",subtitle:null,reviewType:"peer-reviewed",abstract:"The words hydro, phobic and philic are derived from Greek and they mean water, fear and adoration respectively. 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We live in a time in which claims proliferate about a multitude of issues regarding social reality and people’s lives. Because some of these issues are understood as adversely affecting a significant part of the population, they create a collective discourse and demands for action. When important societal groups (e.g. politicians, social change groups, the news media and numerous citizens) recognize these claims as legitimate and valid, they become social problems. As such, from a social constructionist perspective, the emergence and recognition of social problems are based on both the empirical evidence of their existence and impact as well as on the perceptions of their implications and need to be solved [1].
As Best [2] mentioned, social progress paradoxically creates social problems for different reasons. On the one hand, it generates a general expectation of perfectibility, which fosters a growing intolerance towards social difficulties and shortcomings. On the other hand, as the biggest challenges of humanity are within our reach (e.g. increased life expectancy, control of diseases), those that once were considered small now seem bigger and more serious (e.g. quality of life, lifelong learning). Moreover, the growing exigence of societies, together with the multiplication of relationships and communication networks, lowers the tolerance threshold of the population. Finally, because social progress improves life expectancy and standards of living, it fosters fears of loss as well as inflates perceived risks and defensive postures [2].
At given times and in relation to certain phenomena, a discrepancy exists not only between social perceptions and the available data on the issues but also among the perceptions of different social groups. For instance, policymakers might be attentive to a certain subject based on their knowledge, and this view might not be shared or valued in the same way by society as a whole. We believe that child trafficking meets this standard worldwide and, specifically, in Portugal.
Regarding Portugal, the following reasons (some general, others country-specific) are put forward to contend that child trafficking is not perceived as a social problem as previously defined: (i) it is relatively unknown among most of the population, (ii) it involves children as victims, (iii) it involves children who are often from disadvantaged backgrounds and/or foreign origins, (iv) it is a police matter and (v) it involves a small group of the population.
Let us discuss each aspect briefly.
Research on the public awareness of trafficking in human beings (THB) is scarce. However, as Sharapov [3] asserts, it is a distant subject for most of the population. Various European countries (e.g. Scotland, Belgium, Czech Republic, Finland and Romania) generally view it as having little relevance to their daily lives. This sense of detachment is not so much due to the lack of information on the subject, as to how this information is framed (i.e. primarily as a legal and criminal issue on the margins of normal everyday life) [4]. Portuguese reports on people’s awareness of human trafficking are in line with this general tendency. In a study conducted by Sani, Nunes and Caridade [5], the authors used a convenience sample to find that most respondents showed a poor understanding of THB and recognized the lack of information concerning this phenomenon in Portugal. Most participants viewed THB as the exploitation of immigrants and socially disadvantaged people in search of work. More than half (58.5%) had not heard any information about it over the last 2 years. Among those who had heard information, social media stood out as the privileged method of communication regarding this phenomenon.
Although the relationships among public opinion, the media and public policies are complex and controversial, the available evidence shows that political and media discourses on human trafficking significantly influence public opinion, and (conversely) public opinion affects media and policymaking [3, 4].
With regard to Portugal, the role the media plays in framing the public discourse on human trafficking has received specific attention. Research examining the written press between 2001 and 2004 [6] substantiated the media representation of human trafficking as infrequent, superficial and stereotyped. News on this topic was poor, barely visible and associated with criminal activity and deviant people from other countries and minorities. In a second study focusing on the news published in a tabloid newspaper in 2008, despite the increased visibility of the phenomenon, Couto, Machado, Martins, and Gonçalves [7] identified similar trends in the coverage: it was framed as a criminal problem, essentially involving deviant groups, and is generally related to illegal immigration. This representation facilitates the adoption of a passive and moralizing attitude of devaluation regarding the phenomena and depreciates the people involved. As has been indicated with regard to child trafficking in other European countries [8], a cross-border problem that affects almost only asylum seekers and immigrants or particular cases is unlikely to affect the general community. This assumption leads to the underestimation of the risks of child trafficking and to the weakening of the social relevance of prevention and protection strategies.
Research on human trafficking and, in particular, child trafficking, is critical. Producing and disseminating knowledge helps sensitize people in general. Moreover, it substantiates more effective processes of identification, prevention, and protection, as well as helps support victims and prosecute criminals [9].
As Clemente [10] stated, the Portuguese investigation concerning human trafficking has developed more slowly and inconsistently than that in other countries (the first publications date back to 2000) [11]. Driven by the increasing attention of the national authorities to the phenomenon, within the framework of international agreements, the academic research made its greatest development beginning in 2007 onwards. As in other European countries, where the empirical literature on child trafficking is scarce [12], the scientific approach to this problem in Portugal since the beginning consisted primarily of secondary research articles on the sexual exploitation of women based on official statistics. For various reasons, this research appears to report only one-third of the referrals per year [11]. Reports on the prevalence of the phenomenon to monitor and evaluate prevention, protection and rehabilitation programmes have been more systematic and frequent than that regarding trafficked victims, the circumstances of their victimization or the trafficking process, its rationale, dynamics and other people involved. Nevertheless, the study of the social representations of human trafficking, in particular those of specific groups including practitioners, has been a significant part of the investigation undertaken in Portugal in this field, yet with sampling limitations. In these types of scholarly papers, child trafficking is often referred to in connection with the characterization of the age of the victims. However, research specifically focusing on child trafficking is scarcer. In this regard, the RCAAP1 portal is a privileged source of access to Portuguese academic production. From 2006 to 2016, 12 papers on human trafficking were registered from Portuguese repositories [13]. However, only eight titles include the keywords “child trafficking” as of 2019: a working paper and seven master’s theses.
In short, the still incipient scientific production and media coverage focusing on criminal cases reinforce the lack of information associated with public opinion and, to that extent, create a distance with regard to this phenomenon.
As has been elaborated elsewhere [14], a widespread social consensus exists regarding child welfare matters. Although these matters are frequently used by politicians and the media as rhetorical devices and emotional assets [15], this discursive intensity is not always consistently translated into policies or practices. On the other hand, this unanimity, even if it arouses ethical shock and emotional indignation, does not induce social pressure or collectively persistent action in relation to children’s issues.
If children whose parents fail to protect their best interest are socially vulnerable, relatively invisible and voiceless, child victims are viewed even as more helpless. This issue is especially relevant because, as Gearon [16] argued, child trafficking narratives are pervaded by the notion of victimhood, conveying representations of helplessness, vulnerability and lack of agency. This convergent negativity (those of children and victims) [14] easily evokes empathic social responses but does not necessarily make the victim a priority.
Furthermore, the formal requirements for eligibility to the protection system, which are understood in light of the social representations of victimhood, create a paradox. On the one hand, the confirmation of the status of a victim is a mandatory requirement for accessing assistance. On the other hand, when victims do not comply with the social expectations of powerlessness and passivity, the question of their responsibility often arises regarding the situation in which they find themselves. Although they are children, if their participation in trafficking is understood as active and voluntary, then their status as child victims gives way to that of the criminal children: those who should be blamed, convicted and punished, rather than protected [16]. Although the victim is viewed as an object of behaviors and situations beyond their control or ability to self-determine, the circumstances of children allegedly involved in criminal activities are dimmed, and their behaviors and condition tend to be abstracted and decontextualized [14]. In short, whether they match the stereotype of a victim or not, children who are victims of trafficking have no voice or do not deserve to be heard. Either case applies to what Clemente [10] called “the deafening silence of trafficked people” (p. 663).
Public opinion is an indication of societal attitudes towards certain phenomena. With regard to human trafficking, if public opinion expresses the culture of society, then it might reflect the social discrimination of women and children as well as a social tolerance towards violence and exploitation [8], which would enable an understanding of the symbolic construction of this phenomenon. On the other hand, because public opinion influences policymaking, if well-formed and informed, it can also help reduce the structural factors that underlie trafficking [3].
Victims of child trafficking and exploitation often come from abroad and the margins of society. According to the final report of the study of groups at high risk for human trafficking in the European Union [8], the risk of child trafficking is significantly higher for children with disabilities or who engage in risky behaviors, from dysfunctional, disadvantaged and/or social excluded families, communities or neighborhoods in areas of conflict or crisis. Generally, they might be viewed as problem children. This label reinforces their inherent negativity [14], social invisibility and exclusion [17]; they are the children of others. As such, instead of a positive approach to the phenomenon based on a human rights perspective, they might evoke attitudes of socially organized denial [18], rejection, disinterest or criticism.
Thus, the genesis of trafficking is essentially sociopolitical, culminating in a legal phenomenon. Experts [16] have criticized the criminal perspective that has dominated child trafficking “as immigration-led and prosecution-focused” (p. 497) and as a threat to human and state security [19]. This simplistic view overshadows the broader dimension of the phenomenon, which as Gearon [16] asserted is not limited to international movements (legal or illegal) or migrant children. In fact, as Palmer [20] claimed, child trafficking is a complex, multidimensional and dynamic process; it is a shape-shifting phenomenon characterized by different patterns across countries. It involves national citizens, migrants (i.e. other EU citizens), immigrants from third world countries, children with their families and unaccompanied asylum-seeking children. It might begin long before it is detected, with or without family involvement, for a variety of purposes, and as part of more or less sophisticated networks. However, according to Crawley’s research in the UK [21], even the intervention of health and welfare professionals is permeated by the logic of immigration control [22], where the concern with the protection of the territory overrides that of children. In the same vein, Clemente [10] characterized the Portuguese support system for victims of trafficking as victim-oriented in theory but as focused on internal security objectives in practice. This feature corresponds to the current trend of protection systems, which are increasingly focused on control rather than care [23].
This partial viewpoint hinders interventions focused on the rights and needs of children and their protection [16]. As experts have argued, the majority of children who eventually become victims of exploitation and/or trafficking have previously been deprived of their rights [24]. In this sense, they contend that the criminal matrix of the definition of child trafficking frequently overshadows its true nature and origin: child trafficking is primarily a matter of rights and protection, and, as such, it reveals the shortcomings of protection and welfare systems [24, 25]. Therefore, the priority or almost exclusive emphasis on legal and procedural aspects and the subsequent production of penal legislation, national action plans and support measures for victims at the expense of action towards the structural conditions that underlie trafficking are criticized. Enforcing the United Nations Convention on the Rights of the Child is the most effective way to prevent the exploitation and trafficking of children and youth as well as safeguard their rights and respond to their needs.
Data available on human trafficking and, specifically, child trafficking provide only an approximation of the reality. In addition to being a hidden phenomenon [19], illegal and clandestine [26], concepts of trafficking differ across countries as various reports have highlighted. Because trafficking is usually closely connected to crimes such as illegal immigration, aid to illegal immigration, forgery and criminal association, the distinction among these phenomena is not clear [24]. Consequently, defining these terms involves a wide range of legislation [27] and a variety of mechanisms to identify phenomena. Furthermore, even at the national level, experts have identified many discrepancies in the data reported across different sources, as in the case of Portugal [11]. These findings support the idea of numerous unreported cases (the dark figures of trafficking). Therefore the low numbers of child trafficking represent the tip of the iceberg [19, 28].
Additionally, the eligibility criteria for acquiring the status of trafficking victim and receiving assistance significantly modify the available data on this phenomenon.
Especially with regard to child trafficking, the criterion used to set the age of the victim, whether at the time of referral or at the beginning of trafficking, remains a sensitive issue. Neves and Pedra [11] drew attention to the fact that many victims have been subjected to exploitation for several years, even though their identification in the system occurred during adulthood. This consideration provides a different basis for calculating the number of child trafficking victims as well as targets and adjusts the interventions made available to people in these conditions within the legal and protection systems. In fact, according to Catch and Sustain [29], trafficked children (especially those with a long history of being exploited) tend to be treated by the legal and the protection systems according to their immigration status or the crimes in which they might have been involved, rather than the crimes that they have suffered along the way. This procedure is contrary to Directive 2011/36/EU, which recommends the development of comprehensive child-sensitive protection systems and the mobilization of recovery processes as soon as children are identified as victims of trafficking.
Another eligibility criterion concerns the distinction between the child trafficking statistics and the risk of child trafficking (i.e. trafficked children and those vulnerable to exploitation and trafficking). In line with this view, researchers have claimed that the groups of children targeted to prevent and combat trafficking (currently unaccompanied asylum-seeking children, child victims of trafficking and child victims of sexual exploitation) should be revised to include accompanied child migrants, undocumented children and homeless children [24]. According to scholars and practitioners, within the logic of prevention and effective interventions, authorities should expand their focus to include children at risk of being trafficked, favoring more comprehensive interventions in addition to focused responses. This option would imply overcoming a segmented view of the intervention, based on children’s status, to adopt an ecological, systemic, multidimensional and dynamic perspective of children’s vulnerability [24].
For the reasons outlined above and given the absence of reliable and disaggregated data [29], comparisons of national data are far from linear [24].
Nevertheless, despite the scarcity of consistent data, according to the United Nations Office on Drugs and Crime [30], human trafficking could likely reach up to 4 million victims. Most are female (72%) and trafficked for sexual exploitation, although significant regional variations are observed [30]. The Organization for Security and Cooperation in Europe (OSCE) estimates that children account for over 30% of the world’s human trafficking [31]. According to the 2018 Global Report on Trafficking in Persons, in 2016, 23% of these children were girls, which is more than double than that identified in 2004 [32]. As the International Labour Organization (ILO) specified, 26% of the 20.9 million people who were victims of forced labour between 2002 and 2011 were children [33].
As noted in the report of Catch and Sustain [29], child trafficking occurs in all European countries, without a clear division among countries of origin, destination or transit. In the European Union (EU) in 2015–2016, approximately 56% of the victims identified were from non-EU countries. The majority were female (68%), and the dominant forms of exploitation were for sexual and labour purposes (56 and 26%, respectively); relevant geographical variations were also observed. Children accounted for 23% of the victims detected and for 23% of all victims of trafficking for sexual exploitation [34]. However, considering the cases reported to/by NGOs and official agencies, experts in this field estimate that the dark figures might be five times higher than official statistics report [35].
The “official data on human trafficking (TSH) in Portugal indicate a residual phenomenon, with approximately 80 cases reported each year on average, with a total of 250 victims in 2009, 2010 and 2011. Of these cases, less than 25% were confirmed (58)” ([11], p. 23). Regarding child trafficking, prior to 2010, national data were subsumed under the general data of human trafficking. Nonetheless, since national data on human trafficking began being collected, reports indicate that few children were victims of this type of crime (e.g. in 2008, the minimum age of the reported cases was 1 year old; in 2009, the minimum age was 12 years old). In accordance with the Report of the Group of Experts on Action against Trafficking in Human Beings [35], between 2008 and 2011, 17 children met this condition, the majority of whom were female (median age = 14 years old). Sexual exploitation, labour exploitation (n = 3) and attempted adoption (n = 3) were the identified purposes of trafficking.
Table 1 details the number of child trafficking referrals considering the total number of human trafficking referrals in Portugal from 2010 to 2017. Data, compiled from different sources, represent cases reported before investigation and substantiation. Absolute figures are relatively low, both in relation to human trafficking in general and to child trafficking specifically; however, notable variations have been found over time. The percentage of child trafficking referrals varied from 8.1% in 2010 to 31.2% in 2012.
According to Neves and Pedra [11], 82.4% of the trafficked children in Portugal are 15 years or older. In addition, those who began to be trafficked in childhood tend to be exploited for longer periods than those who start the process in adulthood. In fact, 44% of trafficked children have been exploited longer than 4 years. According to these authors, if the criterion used to set the age of the victim is the beginning of trafficking, then this number would be approximately 30% of all cases of trafficking.
As Clemente [10] asserted, the introduction of the issue of human trafficking in Portugal was prompted by the need to transpose the international directives issued by the United Nations and the European Commission into national law. When Portugal adopted the United Nations Convention against Transnational Organized Crime and the additional Protocol to Prevent, Suppress and Punish Human Trafficking (especially with regard to women and children) in 2004, all legislative changes that followed have given rise to the definition and development of specific policies and procedures. National Plans against Human Trafficking have played a decisive role in the adoption of an integrated intervention strategy, combining interventions at different levels and multiple actors.
In 2007, the Portuguese authorities developed the first National Plan against Human Trafficking (2007–2010) (I PNCTSH) [31], which had four strategic domains: (1) to understand the phenomenon and disseminate information; (2) to prevent, elucidate and train; (3) to protect, support and integrate; and (4) to conduct criminal investigation and prosecute traffickers [31]. With regard to children, (i) they are recognized as being among the most vulnerable populations to human trafficking (along with women), particularly those living in poverty; (ii) trafficking is considered as a violation of their right to be free and protected; and (iii) victims trafficked for reasons of sexual and/or labour exploitation require special assistance and protection. Considering children’s and youths’ vulnerability, the I PNCTSH considers the following specific areas of intervention: (i) to educate children by promoting creative debates and activities in schools about human rights, children’s rights and human trafficking and (ii) to support trafficked children by providing special measures to promote their rights and protection aiming at their global development.
This Plan led to the creation of the Observatory on Human Trafficking (OTSH) in 2008, which was established by Decree-law no. 229 on November 27, 2008. It is responsible for collecting, producing, processing and analyzing data on human trafficking, including child trafficking.
In 2009, two initiatives stood out in this domain [27]: (a) the certification of documents for foreign children attending Portuguese schools (Immigration and Borders Service [SEF] goes to school) and (b) the creation of the first temporary shelter for 6- to 18-year-old refugee children and (CACR). This centre is expected to provide specialized assistance to children and youth in the asylum process (i.e. legal, social and psychological support).
The second National Plan against Human Trafficking (2011–2013) (II PNCTSH) [42] defined the same areas of intervention as the I PNCTSH. Nonetheless, the special situation of children was not differentiated in this Plan, neither conceptually nor in terms of specific measures.
In 2013, Portugal joined (a) the “European Cross-Actors Exchange Platform for Trafficked Children on Methodology Building for Prevention and Sustainable Inclusion”, which aimed to develop an evidence-based intervention model targeting children who are vulnerable to trafficking and promote knowledge about criminal procedures concerning THB in the EU, and (b) the “Improving and Monitoring Protection Systems against Child Trafficking and Exploitation” (IMPACT) Project, which aimed to improve child protection and welfare policies to prevent and protect children, particularly those vulnerable to trafficking and exploitation [24].
The third National Plan (2014–2017) (III PNCTSH) [43] had five strategic areas: (1) prevent, inform, understand and investigate; (2) educate, train and capacitate; (3) protect, intervene and empower; (4) investigate criminality; and (5) cooperate. Regarding children, it included actions such as the development of education for children, adolescents and adults, as well as the development of protocols for the prevention, detection and protection of child victims of trafficking. The implementation of standardized care protocols for the identification, referral and intervention of victims of trafficking, among others, and for child victims of trafficking, in particular, by the National Health Service (NHS), was particularly important.
The fourth National Plan (2018–2021) (IV PNCTSH) [40] defined three strategic objectives: (i) to develop knowledge and raise awareness on THB, (ii) to improve the quality of interventions for trafficking victims, and (iii) to strengthen the fight against organized crime networks. With regard to children, an emphasis was put on the development of guidelines and protocols for intervening with children across different services as well as on reinforcing networking within different services, including the NHS and the National Network for the Support and Protection of Trafficking Victims.
As the four national plans against human trafficking show, children are included as victims of trafficking and are occasionally specifically targeted. However, none of the plans address the specificity of child trafficking.
The Portuguese Penal Code (Law no. 59/2007) defines child trafficking as enticing, transporting, harboring or housing a child or transferring, offering or accepting the child for the purpose of sexual exploitation, labour exploitation, begging, slavery, the removal of organs or adoption, among other criminal activities (Article 160) [24]. In fact, research shows that, most of the time, children are trafficked for labour exploitation (e.g. domestic servitude, agricultural labour, car washing, factory labour), sexual exploitation (e.g. prostitution, pornography and forced marriage), illegal adoption and criminal exploitation (e.g. cannabis cultivation, robbery, begging) [44].
As detailed, this definition entails the intentional action of the offender to exploit a vulnerable person. In the case of children, the critical elements of the definition of human trafficking do not apply [34]: the means (coercion, fraud or deception, abuse of power or of a position of vulnerability) and the victim’s consent. However, the issue of consent is not exempted from controversy because of the debate concerning the age of consent [19], an issue related to the criterion used to set the age of the victim, as previously discussed.
Associated with age and the corresponding development level are, among others, the issues of: a) capacity to consent to their involvement in certain activities or relationships, especially those that are deviant or criminal; b) the responsibility inherent to this (in)capacity; c) the different developmental needs that children might exhibit depending on their age; d) their plasticity and vulnerability to the external world and the consequent and serious implications of their involvement in harmful relationships and activities; e) longer periods of exploitation than those of trafficked adults; and f) more support needed, given the higher likelihood to develop trauma.
As Greenbaum, Yun and Todres ([45], p. 161) argued, “Given the often multiple vulnerabilities leading to trafficking, the complex trauma experienced during (and sometimes before) the trafficking period, and the myriad adverse effects of exploitation, the needs of the child victim may be extensive and multi-faceted”. In fact, the exploitation and trafficking of children are often associated with adverse experiences of abuse, neglect and other forms of violence that harm their physical and mental health. Empirical evidence indicates that between approximately one-fourth and one-half of all trafficked children are victims of physical or sexual abuse [26, 46]. These forms of maltreatment are associated with psychological disorders such as posttraumatic stress disorder, substance abuse, self-harming behaviour, suicide ideation/attempts, depression and various affective disorders and behavioral difficulties [26].
Thus, interventions must be multidimensional and address different groups and levels of victims’ needs, not only those that result from trafficking but also those that are at its origin. Child trafficking shares with the other forms of human trafficking multiple, complex and systemic causes, especially specific structural features of the life contexts. Family dynamics are especially relevant for children: dysfunctional families, family abuse/neglect and violence are key variables [24]. Social and political factors such as poverty, social and economic exclusion, limited opportunities to pursue education, scarce and precarious employment, gender-based violence and social inequalities between countries and regions are also important enabling factors. Likewise, more distal elements, such as exploitative relationships, organized crime, illegal migration, corruption and armed conflict play key roles in this phenomenon [43].
Child protection systems are the fundamental framework for providing assistance to child victims or those vulnerable to trafficking [20]. In Portugal, a victim of child trafficking is considered as at risk, falling under Protection Law no. 23/2017 and subject to the same assistance as any national child, regardless of nationality or type of risk. Any person identified as a victim of child trafficking should be reported to a public prosecutor who activates a protection measure.
Based on a review of 20 multinational projects funded by the European Commission on child victims of trafficking, including Portugal, Palmer [20] concluded that “trafficked children across Europe are not receiving the state care and protection that they, as children, are entitled to” (p. 7). This study showed the structural flaws in child protection services at three levels: victim detection, support and service coordination. In short, services fail to adjust their level and type of support to the specific needs of these children and youth, either initially, when detecting and referring cases, or in the provision of appropriate assistance. If in some cases a dominant concern exists with the child’s immigration status that overrides the response to their needs, in others the response to these children’s needs is subsumed within the generic provision available to all children at risk. Solutions range from those that compromise children’s freedom to those that do not guarantee their protection or meet their needs, providing overly bureaucratic services. In these circumstances, child protection systems are more harmful than protective and can even facilitate the exploitation and trafficking of these children [47], actively compromising their rights.
Additionally, combating and preventing child trafficking requires a systemic approach in which communication among the health, education, welfare and justice systems is critical [20]. Regarding Portugal, international reports have mentioned the lack of standardized procedures and referral mechanisms [24].
Despite the recognition of the inclusive nature of health, education, welfare and justice sectoral policies, the status of children continues to determine the type of services and rights to which they have access. In accordance with experts, legislation is inclusive, but procedures are not, and the strategic planning and coordination of actions have flaws. However, others argue for the need for comprehensive laws to integrate the different policy domains, procedures and services [24].
Despite the centrality of the child protection system regarding child victims or those at risk of being trafficked, referrals in Portugal are made through two types of entities: criminal agencies (OPC) and NGOs and the Authority for Working Conditions (ACT). Regarding the OPC, the Immigration and Borders Service (SEF) is responsible for detecting unaccompanied asylum-seeking children and for referring them to the Portuguese Refugee Council (CPR) [24] because it is assumed that they are vulnerable to trafficking [19]. The identification of a case triggers its referral for criminal investigation and court proceedings [24]. After referral, the cases proceed through an assessment process during which they can be classified as confirmed, not confirmed or under investigation. This assessment is complex. Usually a panoply of related offenses exist whose legal distinction is challenging, such as aid to illegal immigration, recruitment of illegal labour, kidnapping, slavery, sham marriages/marriages of convenience, counterfeit and false documents, criminal association, domestic violence or violation [36] and smuggling [12]. This procedure confirms, once again, the police and security framing of an essentially sociopolitical phenomenon.
A common reference in the literature on this topic is the need for the specific training of practitioners who, at different levels, work with and for children, especially those with child victims or children at risk of being trafficked to identify and provide the necessary and appropriate assistance. Immigration officers and other police forces are the frontline staff in most of the national referral mechanisms in Europe. Experts contend that the adequate training of these professionals is critical to ensure that victims are correctly identified and receive appropriate support [19], including cooperation with relevant agencies. In addition to these officials [24], from a comprehensive perspective, teachers [32] and healthcare professionals [48] would benefit from training to identify the signs of exploitation and effectively intervene.
Following Pinto et al. [13], child trafficking is not merely a “distant history” taught in school, but it is also geographically and sociologically distant, as portrayed by the media, and a distant interest for research. Law, politics/public administration, research and education are key instruments for fostering the social appreciation of this problem.
The law is a fundamental constituent of society; it is based on justice and is a driver of awareness. Retrospectively, it reflects social and cultural historicity. Looking forward, however, the law sets the standards for behaviour within a culture and promotes psychosocial adjustment. In this sense, legal changes, under international agreements, build an ethical mindset based on human rights that is progressively shared by populations. Education, training and social pedagogy for the community, their organizations and the media must be an ongoing and relentless social task to create a relational culture that is inclusive, rights-based and culturally sensitive.
Child trafficking results from the failure to protect children and safeguard their rights. It is thus a failure towards all children. Protection should be a systemic and ecological feature of the contexts of children’s lives. Additionally, the response to the various needs of each and every child should be the primary concern of children’s services and programmes. For this purpose, instead of a policymaking approach based on a patchwork of scattered and partial measures, we need effective and integrated public policies, particularly child and family policies, informed by rigorous and systematic research. Moreover, the proliferation of plans with goals insufficiently developed and evaluated should give way to a cohesive national anti-child trafficking approach.
The identification of the child victims of trafficking is a critical condition for the provision of the appropriate support. The gaps observed in most EU countries, including Portugal [20], led the experts to recommend the revision of the criteria and thresholds to be eligible for the child protection system. With respect to Portugal, the Protection Law, based on the distinction between risk and danger, excludes from the threshold for referral children in low-risk situations. In these conditions, the probability of not detecting potential victims of trafficking is not negligible [20]. Therefore, within a broader perspective of the concept of child protection, we endorse the revision of these thresholds and the consideration of different levels of intervention according to the level of risk identified.
Another crucial aspect of the intervention is the first service with which the child victims come into contact for the first time because it determines the subsequent provision made available to them. Regarding children at risk, the interaction among the services involved (e.g. health, education, Immigration and Borders Service, criminal justice, labour), should occur, in any situation, under the coordination of the Child Protection System, regardless of the specific status of the child (e.g. immigration status).
These changes will lead to the cultural shift [16] necessary to assign importance to the big and small issues of our time, regardless of the condition of the people affected, their age or number, so that a problem that affects other people is, by definition, a social problem.
This study had the financial support of Research Centre on Child Studies (CIEC), by the Strategic Project UID/CED/00317/2013, through the National Funds through the Foundation for Science and Technology (FCT) and co-financed by European Regional Development Funds (FEDER) through the Competitiveness and Internationalization Operational Program (POCI) with the reference POCI-01-0145-FEDER-007562.
The authors declare no conflict of interest.
Scientific evidence suggests that nutritional status has a great impact on the health and functional status of older people. In addition, during the aging process there are a series of changes that can have a negative impact on nutritional status. These biological, physiological, social, and psychological changes, together with a higher prevalence of morbidities, further increase the susceptibility of the elderly to malnourishment [1].
\nThe etiology of malnutrition is multifactorial in the elderly. The literature indicates that the elderly are at risk of nutritional deficiencies due to changes in body composition, the digestive system, and the regulation of fluids and electrolytes, sensory alterations, increased likelihood of chronic diseases, poly medication, and hospitalization. But also, social changes—such as retirement, less family responsibility, loneliness, widowhood, or lower purchasing power—increase the risk of inadequate nutrition. Although certain autonomy is maintained, the functional capacity is modified, which makes the daily tasks of life—such as shopping, preparing food, or moving from one place to another—difficult. In addition, the coexistence of physical and mental illnesses may increase or decrease nutritional requirements or may limit the individual’s ability to obtain adequate nutrition, thereby increasing the risk of malnutrition [2, 3].
\nThis is why the evaluation of the nutritional risk in this type of population is of the utmost importance.
\nThe assessment of the nutritional status is the step previous to dietary-nutritional treatment [4]. It is a global evaluation that includes the nutritional status of the individual as well as the severity of the underlying disease, due to the relationship between them. It establishes a methodology to obtain information about the current and past situation of the elderly person in relation to their diet, body composition, and functional and health status [5, 6]. In addition, it will help in the detection of nutritional risk or malnutrition. Two steps can be established in this assessment process: a first step of screening the nutritional risk or malnutrition, and a second step of complete nutritional assessment to identify the causes and consequences of malnutrition. The second step would be carried out when a nutritional risk or malnutrition has been detected [4, 5, 7].
\nAs there is no single marker or nutritional tool that is useful for all types of individuals or physiological or pathological situations and is easily reproducible, predictable, and reliable, correct nutritional assessment involves the use of different nutritional parameters in order to perform an evaluation of the nutritional status that is as complete as possible, according to the subject with which we are dealing; in this case, the geriatric population. In addition, the social and cultural aspects of the patient must also be taken into account, because these data provide information on their resources and ability to prepare food, as well as sociocultural, religious, or personal nutritional habits that may affect the intake and nutritional status. Among the different factors or parameters related to malnutrition that can be assessed in the elderly, we find health status, social and clinical conditions, anthropometry, dietary habits and dietary intake, lifestyle, blood biochemistry, etc. [5, 6]. These factors or parameters and their relationship with malnutrition are described below.
\nPerceived health status is one of the most consolidated indicators and is easy to enquire about in health surveys. It is a feasible tool and has been studied in recent years because it is useful as a global indicator of the level of population health. Some of the factors that lead to a poor self-perception of the state of health in the elderly are age, female sex, comorbidity, not receiving treatments, and little accessibility to other health services [8].
\nMany aspects of the individual’s life are covered here. Some of the causes that can lead to an inadequate consumption of food and, therefore, to malnutrition, are isolation, the loss of loved ones in charge of organizing meals, difficulties in buying or cooking, poor pensions, or changes in feeding when moving to a geriatric residence. It is important to know where the individual lives and with whom, the main career’s situation, characteristics of the home, the level of income, their leisure activities, etc. [9].
\nThis is data from the clinical evaluation performed by a medical professional. It will be necessary to know if the individual suffers or has suffered from any disease, as well as the drugs he or she has taken or is taking for said disease(s). Regarding the intake of drugs, it is important to gather information about the dosage and interactions between food and drugs [5].
\nAnthropometric measurements provide information about the morphological dimensions of individuals. It is a non-invasive, low cost, and portable method, when compared to techniques requiring more complex devices. The anthropometric parameters include weight, height, skin folds, diameters, lengths, and girth. Some of these have been related to malnutrition: specifically, weight loss in a short period of time (1–6 months) with respect to usual weight, low percentile of the triceps skin fold, and decrease in body mass index (BMI) [6, 9].
\nFood intake is a process that varies according to the day of the week, month, or season of the year. Other factors that influence food intake are food preferences and aversions, the person preparing the meals, feeling full (before and during meals), and the ease or difficulty of food intake and/or food preparation, among others. Information concerning these factors is relevant to evaluate food intake [6].
\nTo determine the intake of food and liquids, methods that give similar results if they are repeated in the same situation are required; that is, instruments that offer better reproducibility or precision (agreement of results when the same dietary evaluation method is administered more than once, and on different occasions, to the same individual or group). Currently, there are prospective or retrospective methods, such as the dietary diary, 24-hour recall, and food consumption frequency questionnaire (CFCA), among others. The use of two or more methods can give a better and more accurate estimate of the habitual diet of the individual who has been interviewed, since the disadvantages of one method are offset by the advantages of the other. In addition, it is necessary to use a food composition database to obtain information on energy and nutritional intake (macro and micronutrients), thereby allowing comparison with the recommendations for the intake of energy, carbohydrates, proteins, lipids, and micronutrients [5, 6, 10].
\nSome of the blood biochemical parameters are biomarkers related to nutritional status. In spite of the fact that most nutritional risk screenings aimed at the elderly population do not contemplate biochemical parameters, they are included in the screening of hospitalized patients. Decreases in the values of some of these biochemical parameters (albumin, lymphocytes, cholesterol, etc.) are important in the detection and assessment of protein malnutrition [6, 9, 10, 11]. These parameters are described below:
Albumin: this protein is easily determined due to its long half-life (20 days), but has limitations as a nutritional marker. Changes in blood volume, different pathological situations, or any degree of aggression can produce a decrease in its plasma values, although its decrease is related to an increase in the occurrence of complications and mortality [6, 10].
Prealbumin: this is a protein with a half-life of 2 days that decreases in some situations of malnutrition, infection, or liver failure and increases upon renal failure. It should be interpreted with caution if used as a nutritional marker; despite this, it is considered a good indicator for assessing acute nutritional changes [9].
Protein binding retinol: this is a protein with a half-life of 10 hours, whose levels increase with vitamin A intake or renal failure, and are decreased by liver disease, infection, or severe stress. Due to its sensitivity to stress and renal function, it is considered of little clinical use [9].
Lymphocytes: these are related to immunity and nutritional status. Total lymphocytes are related to protein depletion and loss of immune defenses as a result of malnutrition [10, 11].
Total cholesterol: in malnourished patients with renal and kidney failure and malabsorption syndrome, low cholesterol levels are associated with an increase in mortality. A decrease in their values to below 150 mg/dl is related to malnutrition [10, 11].
A wide range of nutritional screening tools have been developed.
\nThe screening tools used most commonly, have been developed in several countries specifically for elderly people, are Australian Nutrition Screening Initiative (ANSI) [12], Ayrshire Nutrition Screening Tool (ANST) [13], Canadian Nutrition Screening Tool (CNST) [14], Chinese Nutrition Screen (CNS) [15], Council of Nutrition Appetite Questionnaire (CNAQ) [16], Simplified Nutritional Appetite Questionnaire (SNAQ) [16], Short Nutritional Assessment Questionnaire (SNAQ) [17], Short Nutritional Assessment Questionnaire for the Residential Care (SNAQ RC) [18], Malaysian Tool (MT) [19], Malnutrition Risk Screening Tool-Hospital (MRSTH) [20], Mini Nutritional Assessment (MNA) [21], Mini Nutritional Assessment Short Form (MNA-SF) [22], Minimal Eating Observation and Nutrition Form Version II (MEONF-II) [23], Nursing Nutrition Screening Assessment (NNSA) [24], Nursing Nutritional Assessment (NNA) [25], Nutrition Screening Initiative (NSI “DETERMINE”) [26], Nutritional Form for the Elderly (NUFFE) [27], Nutritional Risk Assessment Tool (NRAT) [28], Seniors in the Community Version I (SCREEN I) [29], Seniors in the Community Version II (SCREEN II) [30], South African Screening Tool (SAST) [31], The Burton Score (TBS) [32] and Geriatric Nutrition Risk Index (GNRI-NRI) [33] (Table 1). All of them contain several domains, and the parameters included most frequently are those concerning anthropometry, dietary intake, and clinical condition. Among the anthropometric parameters, the most used value is weight change, being the only anthropometric item reported in some of the protocols. Dietary intake comprises information about the quantity and the quality of the food consumed by the patient and, in particular, regarding their appetite and frequency of meals. Some of the instruments also include an item about fluid intake, which is an important aspect to be considered in elderly people. Aspects related to diseases and functional status are the items included most frequently in the clinical condition domain.
\nParameter | \nDefinition | \nRange | \nEquation | \n
---|---|---|---|
% Habitual weight loss | \nWeight variation with respect to the usual weight | \nMild: 85–95% Moderate: 75–84% Severe: <75% | \n% Habitual weight loss = (actual weight (kg)/habitual weight (kg)) × 100 | \n
Body mass index (BMI) | \nRelationship between weight and height | \nMild: 17–18.4 kg/m2 Moderate: 16–16.9 kg/m2 Severe: <16 kg/m2 | \nBMI = weight (kg)/height (m2) | \n
Triceps skinfold | \nVertical skinfold in the middle back of the arm | \nMild: percentile 10–15 Moderate: percentile 5–10 Severe: percentile <5 | \nReview percentiles of the population of origin | \n
Anthropometric parameters related to malnutrition.
Concerning the clinical setting used to develop and/or validate the instrument, the three main contexts found are community, hospital, and long-term care facilities (including nursing homes and residential facilities). Among these settings, the self-administration form is used only in the community or in long-term care facilities. However, in hospitals the administration form used most frequently is filled in by qualified health personnel. The number of items comprising the presented tools ranges from 2 (CNST) to 18 (MNA). Taking into account that the respondents are elderly people, the interviews performed by health professionals seem to be the best option, as well as tools with a low number of items, to minimize the burden of the interviewee.
\nIn order to have the appropriate arguments for using one or other of the screening methods, the main psychometric parameters that should be considered are the sensitivity and specificity of the test. Among the selected tools the sensitivities ranged from 0.32 for the ANSI [34] to 99% for the MNA [22] and the specificities of the tools ranged from 0.38% for the SCREEN I [29] to 0.96% for the MRSTH [20]. Only for five of these instruments Receiver Operating Characteristic (ROC) curves, as a combined measure of sensitivity and specificity, has been informed [16, 17, 22, 29, 30]. The tool which has shown the best values for both, sensitivity and specificity is MNA and its short form (MNA-SF) and, consequently are the nutritional screening tests most commonly used (Table 2).
\nNutrition screening tool | \nParameters | \nSpecific | \nNo. of items | \nSetting | \nAdministration | \nNutritional score | \n
---|---|---|---|---|---|---|
ANSI [12] | \nAnthropometry | \nWeight change | \n12 | \nCommunity | \nSelf-administered Administered by family members or caregivers | \nRange: 0–29 0–3: good 4–5: moderate nutritional risk 6 or more: high nutritional risk | \n
Social condition | \nLoneliness Food access | \n|||||
Clinical condition | \nFunctional status Disease Oral problems Drugs | \n|||||
Dietary intake | \nFrequency of meals and food intake Fluid intake | \n|||||
Life style | \nAlcohol intake | \n|||||
ANST [13] | \nAnthropometry | \nWeight change | \n6 | \nHospital | \nNursing staff | \nRange: 0–18 6 or less: moderate risk 7 or more: high risk | \n
Clinical condition | \nDisease | \n|||||
Dietary intake | \nFrequency of meals Fluid intake Appetite | \n|||||
CNST [14] | \nAnthropometry | \nWeight change | \n2 | \nHospital | \nDietitians | \nRange: 0–2 0–1: no risk 2: nutrition risk | \n
Dietary intake | \nFood frequency intake | \n|||||
CNS [15] | \nAnthropometry | \nWeight change | \n16 | \nHospital Long-term care facilities | \nProfessional not indicated | \nRange: 0–32 ≤16: malnourished 17–19: risk >19: normal | \n
Social condition | \nLoneliness | \n|||||
Clinical condition | \nFunctional status Disease Drugs Skin status | \n|||||
Dietary intake | \nAppetite Food intake Frequency of meals Fluid intake | \n|||||
Emotional status | \nHappiness | \n|||||
Self-assessment | \nHealth status | \n|||||
CNAQ [16] | \nDietary intake | \nFrequency of meals Appetite | \n8 | \nLong-term care facilities Community | \nSelf-administered | \nRange: 8–40 ≤28: significant risk of at least 5% weight loss within 6 months | \n
Emotional status | \nSadness | \n|||||
Eating attitudes | \nFood tastes Feel full, hungry or nauseated | \n|||||
SNAQ [16] | \nDietary intake | \nFrequency of meals Appetite | \n4 | \nLong-term care facilities Community | \nSelf-administered | \nRange: 4–20 ≤14: significant risk of at least 5% weight loss within 6 months | \n
Eating attitudes | \nFood tastes Feeling of fullness | \n|||||
SNAQ [17] | \nAnthropometry | \nWeight change | \n3 | \nHospital | \nNursing staff Dietitians | \nRange: 0–5 ≥2: moderate malnourishment ≥3: severe malnourishment | \n
Dietary intake | \nAppetite Supplemental drinks or tube feeding | \n|||||
SNAQRC [18] | \nAnthropometry | \nWeight change BMI | \n3 + 1 (BMI) | \nLong-term care facilities | \nSelf-administered Administered by family members or care workers Trained care works for anthropometric measures | \nTraffic light system Red score: high risk of undernourishment Orange score: moderate risk of undernourishment Green score: no risk | \n
Clinical condition | \nFunctional status | \n|||||
Dietary intake | \nAppetite | \n|||||
MT [19] | \nAnthropometry | \nWeight change | \n11 | \nRural community | \nInterviewer (professional not indicated) | \nTwo sections: A (range: 0–7): undernutrition: ≥4 high risk of undernutrition B (range: 0–5): dietary inadequacy: ≥2 high risk of consuming an inadequate diet | \n
Social condition | \nFood access | \n|||||
Clinical condition | \nFunctional status Disease Oral problems | \n|||||
Dietary intake | \nFrequency of meals and food intake Appetite | \n|||||
Life style | \nSmoking | \n|||||
MRSTH [20] | \nAnthropometry | \nWeight change Arm circumference Calf circumference | \n5 | \nHospital | \nHealth care professionals | \nRange: 0–8 ≥5: high risk of malnutrition | \n
Social condition | \nFood access | \n|||||
Clinical condition | \nFunctional status | \n|||||
MNA [21] | \nAnthropometry | \nWeight change BMI Arm circumference Calf circumference | \n18 | \nLong-term care facilities Community Hospital | \nHealth care professionals | \nRange: 0–30 ≥24: well nourished 17–23: at risk of malnutrition <17: malnourished | \n
Clinical condition | \nFunctional status Disease | \n|||||
Dietary intake | \nFrequency of meals and food intake Fluid intake Appetite | \n|||||
Self-assessment | \nNutritional problems Health status | \n|||||
MNA-SF [22] | \nAnthropometry | \nWeight change BMI | \n6 | \nLong-term care facilities Community Hospital | \nHealth care professionals | \nRange: 0–14 ≥12: normal-no need for further assessment ≤11: possible malnutrition-continue assessment | \n
Clinical condition | \nFunctional status Disease | \n|||||
Dietary intake | \nAppetite | \n|||||
MEONF-II [23] | \nAnthropometry | \nWeight change BMI (or calf circumference) | \n6 | \nHospital | \nNursing staff | \nRange: 0–8 0–2: low risk of undernutrition 3–4: moderate risk of undernutrition ≥5: high risk of undernutrition | \n
Clinical condition | \nFunctional status Oral problems Clinical signs | \n|||||
Dietary intake | \nAppetite | \n|||||
NNSA [24] | \nAnthropometry | \nWeight change | \n5 | \nHospital | \nNursing staff Dietitians | \nRange: 0–100 <65: high risk 65–79: moderate risk 80–100: minimal risk | \n
Clinical condition | \nFunctional status Disease | \n|||||
Dietary intake | \nFrequency of meals and food intake | \n|||||
NNA [25] | \nAnthropometry | \nWeight change | \n9 | \nHospital | \nNursing staff Dietitians | \nRange: 9–36 <18: low risk 19–27: moderate risk 28–36: high risk | \n
Clinical condition | \nFunctional status Disease | \n|||||
Dietary intake | \nAppetite Frequency of meals | \n|||||
NSI “DETERMINE” [26] | \nAnthropometry | \nWeight change | \n10 | \nCommunity | \nSelf-administered Administered by family members or caregivers | \nRange: 0–21 0–2: good 3–5: moderate nutritional risk 6 or more: high nutritional risk | \n
Social condition | \nLoneliness Food access | \n|||||
Clinical condition | \nFunctional status Disease Oral problems Drugs | \n|||||
Dietary intake | \nFrequency of meals and food intake | \n|||||
Life style | \nAlcohol intake | \n|||||
NUFFE [27] | \nAnthropometry | \nWeight change | \n15 | \nLong-term care facilities | \nNursing staff | \nRange: 0–30 Norwegian version cut-offs: <6: low risk 6–10: medium risk ≥11: high risk | \n
Social condition | \nLoneliness Food access | \n|||||
Clinical condition | \nFunctional status Disease Oral problems Drugs | \n|||||
Dietary intake | \nFrequency of meals and food intake Appetite Dietary intake changes Portion size | \n|||||
Self-assessment | \nHealth status | \n|||||
NRAT [28] | \nAnthropometry | \nWeight change | \n9 | \nCommunity | \nNursing staff Dietitians | \nRange: 0–26 0–6: little or no risk 7–16: probable risk ≥17: malnourished | \n
Clinical condition | \nFunctional status Oral problems | \n|||||
Dietary intake | \nFrequency of meals Appetite | \n|||||
Eating attitudes | \nFeeling of fullness | \n|||||
Self-assessment | \nHealth status Thinness | \n|||||
SCREEN I [29] | \nAnthropometry | \nWeight change | \n15 | \nCommunity | \nSelf-administered Interviewer (professional not indicated) | \nNot specified | \n
Social condition | \nFood access Loneliness | \n|||||
Clinical condition | \nFunctional status Oral problems | \n|||||
Dietary intake | \nFrequency of meals and food intake Fluid intake Appetite Supplemental drinks Dietary intake changes | \n|||||
SCREEN II [30] | \nAnthropometry | \nWeight change | \n17 | \nCommunity | \nSelf-administered Dietitians | \nRange: 0–64 Cut-offs not specified | \n
Social condition | \nFood access Loneliness | \n|||||
Clinical condition | \nFunctional status Oral problems | \n|||||
Dietary intake | \nFrequency of meals and food intake Fluid intake Appetite Supplemental drinks Dietary intake changes Quality of meals | \n|||||
SAST [31] | \nAnthropometry | \nArm circumference | \n10 | \nCommunity Long-term care facilities | \nTrained fieldworkers | \nRange: 0–23 Men <9.5: malnourished 9.5–14.5: risk of malnutrition >14.5: well nourished Women <9.5: malnourished 9.5–16: risk of malnutrition >16: well nourished | \n
Social condition | \nFunctional status | \n|||||
Clinical condition | \nDisease | \n|||||
Dietary intake | \nFrequency of meals and food intake | \n|||||
Self-assessment | \nHealth status | \n|||||
TBS [32] | \nAnthropometry | \nWeight change BMI | \n7 | \nHospital | \nNursing staff Dietitians | \nRange: 6–28 0–5: well nourished 6–10: moderately nourished 11–15: poorly nourished ≥16: very poorly nourished | \n
Social condition | \nAge Sex | \n|||||
Clinical condition | \nFunctional status Symptoms Skin risk areas | \n|||||
Dietary intake | \nAppetite | \n|||||
GNRI-NRI [33] | \nAnthropometry | \nKnee height Usual weight | \nNo items | \nHospital | \nProfessional not indicated | \nGrades of nutrition-related risk: <82: major risk 82 to <92: moderate risk 92 to ≤98: low risk >98: no risk | \n
Social condition | \nAge | \n|||||
Biochemistry | \nAlbumin | \n
Summary of nutritional screening tools.
All the screening tools described here were designed specifically for elderly people; however, there is a set of screenings developed for other populations, mainly adults, which could be used also for aged people. This supposes an advantage if different populations need to be compared. Nevertheless, these instruments could lose content validity in comparison with specific aged-population tools.
\nAmong the different forms of data collection, face to face interview has been demonstrated to be the most suitable form for this age group. A low number of items are also recommended in order to reduce the burden of the respondent [35]. The domains included in each tool can influence the validity of the evaluations. The use of parameters that examine aspects related to the patient’s perception could be less appropriate for elderly patients. The frequent sensorial and cognitive problems of these patients make the collection of accurate data more difficult [36]. The inclusion of objective parameters, such as anthropometric measurements or clinical data, helps to avoid this disadvantage. However, the collection of such data, especially for parameters derived from biochemical analyses, involves a high cost and cannot be achieved in all settings.
\nThe absence of a Gold Standard criterion to validate this kind of instrument supposes a disadvantage. This is a reason for the ongoing development of new, appropriate parameters. Although most of these tools are widely used, none of them has been compared to standard criteria used to evaluate nutritional status.
\nThere is no single nutritional marker that can predict or diagnose malnutrition; rather, the state of health, social and clinical conditions, anthropometry, eating habits, and blood chemistry of the elderly person under consideration—in relation to their specific situation (health, illness, hospitalization, or institutionalization)—must be taken into account. Therefore, the tools described here that include various dimensions are currently the most recommended.
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