As shown in Figure , 216 women survivors of human trafficking returned to Moldova via the IOM APP program during the study period. 178 met the study inclusion criteria, of whom 2 were excluded due to severe ongoing physical illnesses. Of the 176 women, 28 could not be traced by IOM social workers, 9 declined to be approached by the research team following contact with the IOM social worker, and 19 declined to give informed consent upon contact with the research team. 120/176 (68%) women completed interviews at a mean of 6 months post-return (range 2–12 months). IOM provided restricted access to anonymized data to enable broad comparisons to be made between participants and non-participants. No significant differences were observed in respect of age, country trafficked to, duration of trafficking, marital status, or pre-trafficking employment status [16
Figure 1 Recruitment of women into the study from all the women and girls who returned to Moldova through IOM Assistance and Protection services from December 2007 to December 2008. Originally published in Ostrovschi et al.  (reproduced with permission).
Characteristics of women survivors of human trafficking
As shown in Table , the women in our sample ranged from age 18 to 44 years (mean 25.4, SD 6.0). Women had been trafficked to Turkey (39.7%), Russia (27.5%), the European Union (11.6%) and elsewhere (21.2%), including Bosnia and Herzegovina, Croatia, Israel, Kosovo, Serbia, Ukraine, and the United Arab Emirates. 11.7% were married or cohabiting at the time of interview and 51.7% had living children. Only a quarter (25.8%) had completed upper secondary education (from age 16 to 18) or higher. The majority of women (80.8%) had been trafficked for sexual exploitation. The average duration of trafficking was 9.6 months (SD 5.6, range 2–31 months). During the earlier baseline assessments, conducted when women had first returned to Moldova, 85.0% met criteria for mood or anxiety disorder.
Comparison of characteristics of women survivors of human trafficking with and without mental disorder at an average of 6 months post-return: univariable analyses (n=120)*
Women reported an average of 3.8 unmet needs (SD 2.8, range 0–11); the most commonly reported were difficulties with daily activities (51.7%), accommodation (42.5%), employment (40.0%), and lack of money (39.2%). 68.3% of women reported that they had been unemployed prior to trafficking. 36.7% of were currently unemployed. Over three quarters (79.2%) reported abuse in childhood; 30.8% reported sexual abuse, 65.8% physical abuse, and 71.7% emotional abuse.
54.2% of women in the sample were diagnosed with mental disorder (Table ). The most common diagnoses were PTSD, depressive or other anxiety disorder; 35.8% of women had PTSD (alone or co-morbid), 12.5% had depression without PTSD and 5.8% had another anxiety disorder.
Mental disorder among women survivors of human trafficking at an average of 6 months post-return (n=120)
Risk factors for mental disorder
Univariable predictors of mental disorder at an average of 6 months post-return to Moldova included education status; pre-trafficking employment status; pre-trafficking residence (rural or urban) childhood emotional abuse, physical abuse, and sexual abuse; duration of trafficking; post-trafficking marital status; post-trafficking employment status; number of unmet needs; and social support score (Table ). Type of exploitation (sexual versus labour), mental disorder at baseline, and time since returning to Moldova (months) did not show an association with mental disorder in univariable analyses.
As shown in Table , the risk of mental disorder at an average of 6 months post-return was increased by childhood emotional abuse (AOR 3.30; 95% CI 1.36-7.99), physical abuse (AOR 3.82; 95% CI 1.63-8.97) and sexual abuse (AOR 3.66; 95% CI 1.45-9.20) even after adjusting for pre-trafficking socio-economic position.
Association between mental disorder at an average of 6 months post return and (1) childhood emotional abuse, (2) childhood physical abuse, and (3) childhood sexual abuse among women survivors of human trafficking (n=120)
The risk of mental disorder at an average of 6 months post-return was also increased by having more unmet needs (AOR 2.21; 95% CI 1.71-2.84) and decreased by having higher levels of social support (AOR 0.61; 95% CI 0.52-0.71), even after adjusting for baseline mental disorder assessed when women had first returned to Moldova (Table ).
Association between mental disorder at an average of 6 months post-return and (1) social support and (2) unmet needs among women survivors of human trafficking (n=120)
Eleven variables were associated (p<0.1) with mental disorder at an average of 6 months post-return in univariable analyses. A multivariable regression model was created using a backwards stepwise selection procedure which considered ten of these variables; post-trafficking marital status was not included in the backwards stepwise selection procedure because its effects were seen to be driven by very small numbers (see Table ). The subsequent multivariable regression model retained four variables, which remained significant at p<0.1 whilst adjusted for the other retained covariates. Significant independent risk factors for mental disorder at an average of 6 months post-return included: childhood sexual abuse (AOR 4.68, 95% CI 1.04-20.92); social support score (AOR 0.64; 95% CI 0.52-0.79); and number of unmet needs (AOR 1.80; 95% CI 1.28-2.52) (see Table ). Duration of trafficking showed a borderline association with mental disorder (AOR 1.12, 95% CI 0.98-1.29).
Multivariable regression model of risk factors for mental disorder at an average of 6 months post-return among women survivors of human trafficking (n=120)*