Knowledge Gains Following a Child Sexual Abuse Prevention Program Among Urban Students: A Cluster-Randomized Evaluation

摘要

Objectives. We evaluated a school-based child sexual abuse (CSA) prevention program, Safe Touches, in a low–socioeconomic status, racially diverse sample. Methods. Participants were 492 second- and third-grade students at 6 public elementary schools in New York City. The study period spanned fall 2012 through summer 2014. We cluster-randomized classrooms to the Safe Touches intervention or control groups and assessed outcomes with the Children’s Knowledge of Abuse Questionnaire. Hierarchical models tested change in children’s knowledge of inappropriate and appropriate touch. Results. The intervention group showed significantly greater improvement than the control group on knowledge of inappropriate touch. Children in second grade and children in schools with a greater proportion of students in general (vs special) education showed greater gains than other participants in knowledge of inappropriate touch. We observed no significant change in knowledge of appropriate touch among control or intervention groups. Conclusions. Young children benefited from a school-based, 1-time CSA prevention program. Future research should explore the efficacy of CSA prevention programs with children before the second grade to determine optimal age for participation. Child sexual abuse (CSA) is a public health problem of epidemic proportions worldwide. 1 In the United States, approximately 1 in 10 children reports having experienced sexual victimization, 2 and approximately 15% to 32% of women and 5% to 16% of men report being sexually abused as children. 3–5 Among US children, the incidence rate of sexual abuse was 24% in 2009, 6 and in 2012, 62?936 cases of CSA were substantiated nationwide. 7 In addition, authorities suspect that large numbers go unreported. 8 More than 2 decades of research has linked CSA to negative outcomes, such as increased rates of pregnancy, promiscuity, depression, substance abuse, and identifiable permanent changes in brain structure and stress hormone function. 8 CSA is significantly associated with failure to achieve the minimum qualifications to enter high school, graduate from high school, and attend and graduate from college, thus limiting lifetime income. 9 Adult victims of CSA are at increased risk for sexual revictimization and high-risk sexual activity. 10 CSA has been shown to affect mental health through adulthood, with reported evidence of low self-esteem, obesity, anxiety, depression, anger and aggression, posttraumatic stress, dissociation, substance abuse, sexual difficulties, sexually transmitted diseases, and self-injurious behavior. 11–13 CSA prevention efforts have largely consisted of school-based programs. Almost 90% of elementary school districts in the United States offer prevention training, 14 and more than 85% conducted programs in the past year. 15 About two thirds of American children have had some exposure to these programs. Despite the prevalence of these programs, there is a dearth of rigorous research evaluating their efficacy. Although most studies have been limited by a lack of randomization and control groups, the few randomized trials generally found increased knowledge of CSA prevention concepts in children who received interventions 16–18 ; however, most studies included only White, middle-class children. An international meta-analysis of randomized controlled trials and quasi-randomized controlled trials (in which participants were allocated to intervention or control groups by day of the week, alphabetical order, or other sequential allocation such as class or school) found that children who participated in a school-based CSA program were 7 times as likely to show self-protective behavior in simulated situations as children who did not attend a program. 19 Overall, most studies did not adhere to the intent-to-treat principle, failed to account for nonindependence of students within classrooms, and used small samples that were racially homogeneous. We used the Children’s Knowledge of Abuse Questionnaire (CKAQ) 20 to rigorously evaluate the CSA prevention program Safe Touches: Personal Safety Training for Children in a lower-income multiracial population. We hypothesized that the intervention group would show significantly greater changes than the control group on the Inappropriate Touch Scale on the CKAQ from pretest to posttest. We built on previous research by using a large, racially and ethnically diverse, low–socioeconomic status urban sample in the context of a cluster-randomized design.