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Walsh, Kerryann, Zwi, Karen, Woolfenden, Susan, & Shlonsky, Aron(2018)School-based education programs for the prevention of child sexual abuse:a Cochrane systematic review and meta-analysis.Research on Social Work Practice, 28(1), pp. 33-55.

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https://doi.org/10.1177/1049731515619705

https://eprints.qut.edu.au/view/person/Walsh,_Kerryann.html

https://eprints.qut.edu.au/103893/

https://doi.org/10.1177/1049731515619705

1 Running head: SCHOOL-BASED EDUCATION PROGRAMS FOR PREVENTION OF CHILD SEXUAL ABUSE

Title page

Title of the article

School-based education programs for the prevention of child sexual abuse: A Cochrane systematic

review and meta-analysis.

Corresponding author

Kerryann Walsh Associate Professor Children and Youth Research Centre, Queensland University of Technology Victoria Park Road Kelvin Grove QLD 4059 Australia Phone: 07 3138 3174 Email: [email protected]

Co-authors

Kerryann Walsh, Children and Youth Research Centre, Queensland University of Technology

Karen Zwi, School of Women’s and Children’s Health, University of New South Wales & Sydney

Children’s Hospital Network

Susan Woolfenden, School of Women’s and Children’s Health, University of New South Wales &

Sydney Children’s Hospital Network

Aron Shlonsky, School of Health Sciences, University of Melbourne

Keywords

Child sexual abuse, child sexual assault, primary prevention, systematic review, meta-analysis


Abstract

Objective: To assess evidence of the effectiveness of school-based education programs for the

prevention of child sexual abuse. The programs deliver information about child sexual abuse and

strategies to help children avoid it, and encourage help seeking.

Methods: Systematic review including meta-analysis, of randomised controlled trials, cluster

randomised controlled trials, and quasi-randomised controlled trials.

Results: Twenty-four studies with 5802 participants were included. Child self-protective skills

[(OR=5.71 (CI 1.98, 16.51)], factual [SMD=0.61 (0.45, 0.78)] and applied knowledge [SMD=0.45 (0.24,

0.65)] increased in the intervention group, and knowledge gains were retained at 6-months [SMD

0.69 (0.51, 0.87)]. There were no differences in anxiety or fear [(SMD -0.08 (0.22, 0.07)], and findings

regarding disclosure of abuse were inconclusive.

Conclusions: Children’s self-protective skills and knowledge can be increased by participation in

school-based sexual abuse prevention programs. However, it is unknown whether gains in skills and

knowledge actually decrease the likelihood of child sexual abuse.


Introduction

The World Health Organization (WHO) defines child sexual abuse as “the involvement of a

child in sexual activity that he or she does not fully comprehend, is unable to give informed consent

to, or for which the child is not developmentally prepared and cannot give consent, or that violates

the laws or social taboos of society” (WHO, 1999, p 15). Child sexual abuse is a problem of

considerable magnitude with short- and long-term repercussions for those victimised. Recent meta-

analyses of data collected from retrospective studies of adults in countries and cultures worldwide

estimate that 10% to 20% of female children, and 5% to 10% of male children, have experienced

child sexual abuse on a spectrum from exposure through unwanted touching to penetrative assault

before the age of 18 years (Barth, Bermetz, Heim, Trelle, & Tonia, 2003; Pered, Guilera, Forns, &

Gómez-Benito, 2009; Stoltenborgh, Van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). These

data are likely to underestimate its true prevalence because two-thirds of individuals never disclose

their victimisation (London, Bruck, Ceci, & Shuman, 2005) and most cases go unreported to

authorities (Wyatt, Loeb, Solis, & Carmona, 1999). Sexual abuse has been reported across all

socioeconomic and ethnic groups, in both males and females, and perpetrators can include adults or

other young people outside the family as well as within it (Finkelhor, 1993; Turner, Finkelhor,

Hamby, Shattuck, & Ormrod, 2011). The WHO estimates that child sexual abuse contributes to seven

to eight per cent of the global burden of disease for females, and four to five per cent for males

(Andrews, Corry, Slade, Issakidis, & Swantson, 2004).

Child sexual abuse is associated with adverse psychosocial outcomes such as depression (Roosa,

Reinholtz, & Angelini, 1999), post-traumatic stress disorder (Widom, 1999), antisocial and suicidal

behaviours (Bensley, Van Eenwyk, Spieker, & Schoder, 1999), eating disorders (Perkins & Luster,

1999), alcohol and substance abuse (Spak, Spak, & Allebeck, 1998), post-partum depression and

parenting difficulties (Buist, 1998), sexual re-victimisation, and sexual dysfunction (Fleming, Mullen,

Sibthorpe, & Bammer, 1999). A recent meta-analysis found child sexual abuse was also associated

with higher rates of physical health conditions, including gastrointestinal, gynaecological, and


cardiovascular problems, and obesity (Irish, Kobayashi, & Delahanty, 2010). A longitudinal analysis of

the association between childhood sexual abuse and educational achievement found a linear

relationship between increasing severity of child sexual abuse and poorer educational achievement,

however the relationship was confounded by sociodemographic characteristics (e.g. lower maternal

age and qualifications) and family functioning variables (e.g. inter-parental violence) known to be

associated with child maltreatment (Boden, Horwood, & Fergusson, 2007). These consequences are

far-reaching into families and communities, with significant costs for institutions in terms of primary

and rehabilitative health care, education and welfare assistance, child protection, and justice system

costs (Fang, Brown, Florence, & Mercy, 2012). The time of greatest vulnerability for child sexual

abuse appears to be during the pre-pubescent and early pubescent periods, for example in the USA,

between 7 and 12 years of age (Finkelhor & Baron, 1986), in Ireland 5-12 years (McGee, Garavan, de

Barra, Byrne, & Conroy, 2002), and in China 4-15 years (Chen, Dunne, & Han, 2004). These risk

periods fall predominantly into the elementary (primary) school years.

School-Based Education Programs for Prevention of Child Sexual Abuse

School-based education programs for prevention of child sexual abuse were first developed

by women’s sexual assault prevention collectives in the United States of America (USA) in the 1970s

(Berrick & Gilbert, 1991). Programs were rapidly and widely adopted across the USA, assisted in

some states by policy mandates, and by the mid-1990s it was estimated that two-thirds of 10- to 16-

year olds in the USA had participated in programs (Finkelhor, Asidigian, & Dziuba-Leatherman,

1995a). School-based programs have since emerged as an important primary prevention strategy in

many countries. From a public health perspective (Rosenberg & Mercy, 1991) schools are

appropriate systems for program delivery because programs can be implemented universally at

comparatively little cost without stigmatising those at greater risk (Wurtele & Kenny, 2010); program

content aligns with school health curricula (Sexuality Information and Education Council of the

United States [SIECUS], 2004; Walsh, Berthelsen, Nicholson, Brandon, Stevens, & Rachele, 2013); and


schools provide a direct conduit to other prevention targets such as school personnel, parents,

extended families, and communities (Duane & Carr, 2002).

School-based education programs for prevention of child sexual abuse are typically presented to

groups of students (e.g., in classes) and are tailored to ages and cognitive levels. They seek to

prevent child sexual abuse by providing students with knowledge and skills to recognise and avoid

potentially sexually abusive situations, and with strategies to physically and verbally repel sexual

approaches by offenders. They endeavour to minimise harm by disseminating messages about

appropriate help seeking in the event of abuse or attempted abuse, and equip adults with strategies

for responding quickly and effectively to disclosures to protect children from further abuse.

Interventions aim to transfer the knowledge and skills learned by the child or adolescent in the

classroom to real life situations. Interventions work by capitalising on effective pedagogical

principles used by classroom teachers and program facilitators, most notably those based on social

cognitive learning theories (Bandura, 1986; Vygotsky, 1986), which stress the social context of

learning via the use of instruction, modelling, rehearsal, reinforcement, and feedback (Wurtele,

Marrs, & Miller-Perrin, 1987a).

There is some evidence from cross-sectional community-based studies conducted in the USA, that

participation in school-based child sexual abuse prevention programs may decrease the occurrence

of child sexual abuse. A study of 2000 10- to 16-year olds found that those exposed to more

comprehensive prevention education were more knowledgeable about sexual abuse, more likely to

report using self-protection strategies, more likely to report protective efficacy, more likely to have

disclosed their victimisation, and less likely to engage in self-blame (Finkelhor, Asidigian, & Dziuba-

Leatherman, 1995a). In a follow-up study, the same individuals were more likely to use the

protective strategies they had been taught when confronted with threats and assaults (Finkelhor,

Asdigian, &, Dziuba-Leatherman, 1995b). Two further studies with high-school (Ko & Cosden, 2001)

and college students (Gibson & Leitenberg, 2000) showed programs were associated with reduced


incidence of child sexual abuse. However these studies harbour the limitations of retrospective recall

and have not been replicated with larger and more diverse samples. Research with sexual offenders

on their perceptions of the efficacy of children’s self-protection strategies in actual abuse situations

found that the most effective strategy, reported by three-quarters of offenders, was to tell the

offender they did not want to participate in sexual activities. Girls under the age of 12 years

effectively used six such strategies to avoid abuse: demanding to be left alone, saying they would tell

someone, crying, saying they were scared, saying the they did not want to, and saying “no” (Leclerc,

Wortley, & Smallbone, 2011). These same verbal strategies are commonly taught in school-based

education programs for prevention of child sexual abuse (Duane & Carr, 2002).

Prior Reviews

Several prior reviews have synthesised literature on school-based education programs for

prevention of child sexual abuse. Our searches identified 21 reviews published up to August 2014.

Over half were published in the 1990s with the most recent appearing in 2009. Most were

traditional narrative reviews summarising the findings of existing intervention studies, however

these were not systematic; they did not have defined objectives, specific search strategies, explicit

inclusion and exclusion criteria, or a method by which to appraise study quality. Four previous

studies using meta-analysis were identified (Berrick & Barth, 1992; Heidotting, Keiffer, & Soled,

1994; Rispens, Aleman, & Goudena, 1997; and Davis & Gidyz, 2000). These reviews were limited by

methodological flaws such as pooling randomised and nonrandomised studies; aggregating diverse

outcomes; and the use of suboptimal statistical methods. Prior reviews have differed in their scope,

are now outdated, and none have been replicated.

Prior reviews were also limited by theoretical flaws. For example, the classification of programs as

primarily active or passive (also termed behavioural or instructional) (see for example, Davis & Gidyz,

2000). This theoretical dichotomy is unsound from an educational perspective because most

programs are, in practice, multifaceted, involving a much broader range of integrated teaching


methods used to deliver program content (MacMillan, MacMillan, Offord, Griffith, & MacMillan,

1994). Classifying programs as either active or passive may therefore lead to erroneous conclusions

about program effects; more needs to be known about specific program characteristics that

contribute to program effectiveness.

This systematic review and meta-analysis improves upon prior reviews by offering an objective,

rigorous, comprehensive, and contemporary assessment of all the evaluation studies in the area,

and presenting this in a format that is transparent and replicable. Advancing upon prior work, this

review applies a comprehensive search strategy using the most advanced databases across multiple

disciplines, capitalises upon advances in the availability of electronic documents, narrows inclusion

criteria to programs focused specifically on child sexual abuse prevention, focuses only on gold

standard evaluations using experimental methods, assesses risk of bias in included studies (Higgins,

Altman, Gøtzsche, Jüni, Moher, Oxman, et al., 2011), and uses newly introduced synthesis methods

for meta-analysis (e.g., Borenstein, Hedges, Higgins, & Rothstein, 2009). The original review was

published in 2007 (Zwi et al., 2007). This paper details the substantive review update undertaken

with research published up to September 2014.

Objectives

The objective of this review is to systematically assess evidence of the effectiveness of

school-based education programs for the prevention of child sexual abuse. Specifically, to assess

whether: programs were effective in improving students’ protective behaviours (i.e. self-protective

skills), and knowledge about sexual abuse prevention; skills and knowledge were retained over time;

and program participation resulted in a greater likelihood of disclosure of sexual abuse, and/or

produced harmful effects.

Methods


We used the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green,

2011) for guidance on all aspects of the review including question development, eligibility criteria,

searching, screening, data extraction, assessment of risk of bias, data analysis, and presenting and

interpreting results (see http://community.cochrane.org/handbook ). We used meta-analysis to

quantitatively synthesise effects of school-based interventions (Borenstein et al., 2009; Higgins &

Green, 2011).

Types of Studies

We included studies if they were randomised controlled trials (RCTs), cluster-RCTs, or quasi-

RCTs where participants were randomly allocated to the intervention or control group or were

allocated using a quasi-random method such as day of the week, alphabetical order, or other

sequential allocation such as class or school.

Types of Participants

The study population comprised children (aged 5 to 12 years) and adolescents (aged 13 to

18 years) attending primary (elementary) or secondary (high) schools.

Types of Interventions

Included interventions were school-based education programs focusing on knowledge of

sexual abuse and sexual abuse prevention concepts, or skill acquisition in protective behaviours, or

both, compared with no intervention or the standard school curriculum. We excluded: interventions

for preventing relationship and dating violence, and sexually coercive peer relationships, as these

were reviewed elsewhere (Fellmeth, Heffernan, Nurse, Habibula, & Sethi, 2013); interventions for

abduction prevention, the aims of which did not clearly refer to prevention of child sexual abuse;

interventions aimed broadly at child protection or personal safety in which it was not possible to

isolate the effects of the sexual abuse component; and interventions set entirely in before- and after

school programs, and early childhood programs that were not in schools (e.g. day-care settings).

http://community.cochrane.org/handbook


Types of Outcome Measures

Child outcome measures were:

1. Protective behaviours (i.e. self-protective skills, as measured by an independently scored

simulation test);

2. Knowledge of sexual abuse or knowledge of sexual abuse prevention concepts, or both (as

measured by questionnaires or vignettes);

3. Retention of protective behaviours over time;

4. Retention of knowledge over time;

5. Harm, manifest as parental or child anxiety or fear (as measured by questionnaires); and

6. Disclosure of sexual abuse by a child or adolescent during or after programs (as measured by

official records of student self-reports to school staff, child protective services, or police).

Outcomes measured did not form criteria for inclusion in the review. We included studies meeting

the inclusion criteria for types of study, participants, and interventions only.

Search Strategy

A comprehensive search strategy was devised with the aim of identifying and retrieving all

relevant studies in the field, published and unpublished. Searches for the original review were

conducted in August 2006. We updated these extensively to September 2014 incorporating new

search terms to describe recent concepts, and adding new databases. We searched the following 15

databases:

Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 8);

Ovid MEDLINE(R), 1946 to August Week 4, 2014;

EMBASE (OVID), 1980 to 2014 Week 36;


PsycINFO (OVID),1967 to September Week 1 2014;

CINAHL (EBSCOhost), 1937 to current;

Social Science Citation Index (SSCI), 1970 to 29 August 2014;

ERIC (EBSCOhost), 1966 to current;

Sociological Abstracts (ProQuest), 1952 to current;

Conference Proceedings Citation Index - Science (CPCI-S), 1990 to 29 August 2014;

Conference Proceedings Citation Index - Social Sciences & Humanities (CPCI-SSH), 1990 to 29

August 2014;

Database of Abstracts of Reviews of Effects (DARE) 2014, Issue 3, part of theCochrane

Library;

ClinicalTrials.gov (clinicaltrials.gov/);

ICTRP (apps.who.int/trialsearch/);

Australasian Theses (via TROVE) (trove.nla.gov.au/);

Networked Digital Library of Theses and Dissertations (NDLTD) (via SCIRUS)

(ndltd.org/serviceproviders/scirus-etdsearch); last searched September 2013, not available

in September 2014.

Search terms and strategies were modified slightly according to the conventions for individual

databases. There were no restrictions on language or publication date. We also hand searched

reference lists of previous systematic and narrative reviews, and reference lists of included studies.

We searched program evaluation databases such as the Promising Practices Network (RAND

Corporation 2013), and Blueprints for Healthy Youth Development (Center for the Study and


Prevention of Violence, 2013). To identify unpublished studies, we circulated requests via email to

relevant listservs (e.g. Child-Maltreatment-Research-Listerv). Details of the search strategy are

available from the full review (Walsh, Zwi, Woolfenden, & Shlonsky, 2015) in the Cochrane Library at

http://www.cochranelibrary.com/.

Data Collection and Analysis

Screening and selection of studies.

We screened and selected studies in three phases. In phase one, we imported titles and

abstracts of articles identified in the searches into reference management software and two review

authors independently screened them. We excluded papers if they clearly did not meet the inclusion

criteria (i.e. study design, participants, type of intervention, types of comparisons). In phase two,

two review authors independently screened the titles, abstracts, and methodology sections of

papers appearing to meet inclusion criteria. In cases where agreement could not be reached during

screening, we asked a third and fourth review author to independently assess the study against the

inclusion criteria, and resolved these cases via discussion and consensus. In phase three, we

retrieved the full text of studies meeting all inclusion criteria for data extraction and we linked

together multiple reports of the same study (e.g. Blumberg, 1991). One study was translated into

English (Del Campo Sanchez & Sanchez, 2006).

Data extraction and management.

We used an electronic data extraction form adapted from the checklist of items specified in

the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011, Table 7.3a).

Two review authors independently performed data extraction in the original review. In the review

update, one new review author performed data extraction for all studies, and a second review

author who was involved in data extraction in the original review performed data extraction only for

new studies. Data were entered into the Cochrane Collaboration’s software, Review Manager

http://www.cochranelibrary.com/


(RevMan) 5.2 (2012) and checked for accuracy by a research assistant, working independently, and

who was not a review author. All discrepancies were resolved via discussion.

Via email, we contacted authors of studies in which methods of sequence generation, allocation

concealment, or blinding were unclear, asking for additional information. We also contacted

corresponding authors of studies with insufficient information to allow inclusion in meta-analyses

and studies that used cluster-randomisation with a request to provide additional detail.

Assessment of Risk of Bias.

Problems with the design, conduct, and reporting of studies of interventions can produce

misleading results in which there is risk that studies may over- or under-estimate the true effects of

the interventions (Higgins & Green, 2011). We assessed risk of bias in each study using the seven

domains on the Cochrane revised ‘Risk of bias’ assessment tool (Higgins & Green, 2011, Table 8.5a):

(i) random sequence generation; (ii) allocation concealment; (iii) blinding of participants and

personnel; (iv) blinding of outcome assessment; (v) incomplete outcome data; (vi) selective

reporting; and (vii) other sources of bias. We assessed included studies on each domain as ‘low risk’,

‘high risk’, or ‘unclear risk’ with the latter indicating lack of information or uncertainty. We entered

this information into RevMan and summarised it in a ‘Risk of bias’ table for each included study.

Further details about this process can be found in the full review.

Calculating Effect Sizes.

Effect sizes were calculated using methods and formulae recommended in the Cochrane

Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011). We reported the

summary of effect for dichotomous outcomes as an odds ratio (OR) with 95% CI. Continuous

outcomes were reported as the standardised mean difference (SMD) with 95% CI. Standardised

mean differences are appropriate for data synthesis where different outcome measures are used

across studies.


The allocation of participants to study conditions in groups rather than as individuals (known as

cluster-randomisation) alters the type of statistical methods required in data analysis to calculate

effect sizes and their standard errors. Studies having this design feature should adjust results with

appropriate statistical methods, and publish intra-class correlation coefficients (ICCs) (Campbell,

Elbourne, & Altman, 2004). However, we found ICCs were not reported in included studies, nor were

they available from study authors, and no ICC for school-based child sexual abuse prevention

interventions had been published, hitherto, in the literature. We noted that estimates of 0.1 and 0.2

had been used in a review of school-based violence prevention programs (Mytton, DiGuiseppi,

Gough, Taylor, & Logan, 2006), based on the rationale for a published ICC of 0.15 for similar trials

(CPPRG, 1999b in Mytton et al., 2006), and this was considered a plausible yet conservative estimate

for the impact of clustering at the classroom level (Schochet, 2008). We reasoned that a suitably

conservative approach would be to use the extremes of ICC 0.1 and 0.2 to calculate a design effect

for each cluster-RCT according to the formula given in the Cochrane Handbook for Systematic

Reviews of Interventions (Higgins & Green, 2011, Section 16.3.4). We weighted these using the

generic inverse variance function and used random-effect models.

Assessing Heterogeneity.

Assessing heterogeneity involves considering between study diversity and determining

whether the degree of variability is at an acceptable level for statistically combining studies (Higgins,

2008). We assessed heterogeneity using visual inspection of forest plots and two statistical measures

(Tau² and the I² statistic), in order to describe and measure variability in the data (Borenstein et al.,

2009). The I² statistic and its CIs describe the proportion of variability in effect size estimates

resulting from heterogeneity rather than chance (Higgins, 2008; Higgins & Green, 2011).

Data Synthesis.

We synthesised the data using tools provided in Review Manger (RevMan) 5.2 (RevMan

2012) and assessed the appropriateness of combining studies based on sufficient comparability with


respect to: the type of intervention, the type of outcome measures, and the nominated data

collection points pre- and post-intervention. We then calculated summary statistics (OR for

dichotomous data and SMD for continuous data) with 95% CIs for each study. We used a random

effects model to combine data. In all cases, we generated pooled estimates for those studies for

which complete statistical data were available or could be derived (i.e. counts and proportions for

dichotomous data; means and SDs for continuous data). Forest plots were presented for each of the

pooled estimates. In all cases, we corrected for small sample size bias by using Hedges’ g, which is

the default in RevMan.

Results

Results of the Searches

The original review identified 15 studies (Zwi et al., 2007). In the new searches, we identified

a total of 12,969 records through database searching and a further 58 records from other sources

(see study flow diagram in Figure 1). After duplicates were removed, we screened the titles and

abstracts of 10,218 records and, in addition to grey literature and citation searches, located an

additional 10 papers. The original included studies were reassessed and one (Pacifici, 2001) was

excluded due to its focus on sexual violence prevention in the context of dating relationships for

adolescents (see Fellmeth et al., 2013). In total, this current review included 24 unique trials

reported in 29 papers. A comprehensive list of excluded studies with reasons for exclusion can be

found in the full review (Walsh, et al., 2015, pp.87-90).

<Insert Figure 1 about here>

Characteristics of Included Studies

Table 1 summarises the characteristics of included studies. Of the 24 included studies, seven

were randomised controlled trials (RCTs), 11 were cluster-RCTs, and six were quasi-RCTs. Of the


quasi-RCTs, all but Del Campo Sanchez et al., 2006 used a Solomon four-group design (Campbell &

Stanley, 1963; Solomon, 1949). The unit of randomisation in 14 studies was clusters (classrooms,

schools, or districts). Of these, 11 were cluster-RCTs (as above) and three were quasi-RCTs. In 10

trials the unit of randomisation was individual school students. Of these, seven were RCTs and three

were quasi-RCTs.

Studies were conducted in a number of different countries. Sixteen studies were conducted in the

USA. Three studies were conducted in Canada (Daigneault, Hébert, McDuff, & Frappier, 2012;

Hébert, Lavoi, Piche, & Poitras, 2001; Tutty, 1997). Single studies were conducted in China (Lee &

Tang, 1998), Germany (Krahé & Knappert, 2009), Spain (Del Campo Sanchez et al., 2006), Taiwan

(Chen, Fortson, & Tseng, 2012), and Turkey (Ҫeҫen-Eroğul & Kaf Hasirci, 2013).

The total number of participants randomised in cluster-RCTs ranged from 74 (Poche, Yoder, &

Miltenberger, 1988) to 1269 (Oldfield, Hays, & Megal, 1996). Eleven studies each included more than

200 participants.

All studies were conducted in school settings: 23 in primary (elementary) schools and one in a

special school for adolescents with intellectual disabilities (Lee & Tang, 1998). The studies were

conducted with children of varying ages, sometimes grouped together. Ten studies were conducted

with younger participants from kindergarten to grade three; eight studies with older participants

from grade four upwards; and six studies combined younger and older participants together. None

of the included studies were conducted in secondary (high) school settings.

<Insert Table 1 about here>

Participants.

A total of 5802 school-aged participants were included in the 24 trials. Study participants’

mean ages at baseline ranged from 5.8 years (Harvey et al., 1988) to 13.44 years (Lee & Tang, 1998).

The proportion of females in the included studies ranged from 45% (Poche et al., 1988; Ҫeҫen-Eroğul


& Kaf Hasirci, 2013) to 55% (Crowley, 1989). Ethnicity data were reported in 13 studies. Two studies

reported 100% Chinese participants (Chen et al., 2012; Lee & Tang, 1998); in five studies the

predominant ethnicity reported was White or Caucasian comprising 74% to 97%of participants

(Grendel, 1991; Oldfield et al., 1996; Poche et al., 1988; Snyder, 1986; Tutty, 1997); and six studies

reported diverse samples in which the proportion of non-White participants ranged from 32%

(Hazzard et al., 1991) to 66% (Dake et al., 2003).

Parental socioeconomic position, religious background, and participants’ school achievement data

(e.g. grades) at baseline were not reported in any study. In one study, the Peabody Picture

Vocabulary Test (PPVT) (Dunn & Dunn, 1981) was used to assess children’s receptive and expressive

language ability at baseline (Fryer et al., 1987a), and, in another study, Raven’s Standard Progressive

Matrices (RSPM) (Raven, 1960) was used as a measure of general intellectual ability at baseline (Lee

& Tang, 1998). In the latter study, participants were adolescent Chinese females with mild

intellectual disabilities from four special needs schools in Hong Kong, China. None of the studies

enrolled participants on the basis of previously reported abuse.

Interventions

Table 2 provides a summary of key features of the interventions. In all 24 trials,

interventions focused specifically on child sexual abuse prevention. The targets of the interventions

were school-aged children who were taught knowledge of sexual abuse, sexual abuse prevention

concepts, and/or protective behaviours (i.e. self-protective skills). A wide range of previously

published, modified, and new prevention programs were used in the trials. Fifteen discrete

programs were identified. Contents of or topics covered in the intervention programs included

safety rules, body ownership, private parts, distinguishing appropriate and inappropriate touches,

distinguishing types of secrets, and whom to tell. Four studies also included abduction prevention

content (Chen et al., 2012; Fryer et al., 1987a; Kraizer, 1991; Poche et al., 1988).


Teaching methods included rehearsal, practice, or role-play reported in 12 studies, discussion in 10

studies, and modelling in six studies. The teaching method, review, which involved revisiting

previous content and summarising new content, was nominated in one study (Grendel, 1991). A

specific suite of teaching strategies was designated in four studies, including instruction, modelling,

rehearsal, social reinforcement, shaping, feedback, and group mastery (Chen et al.,, 2012; Lee &

Tang, 1998; Saslawsky & Wurtele, 1986; Wurtele, Saslawsky, Miller, Marrs, & Britcher, 1986).

Program delivery formats were reported in the majority of studies. These included film, video, and

DVD formats in 12 studies, theatrical plays in three studies, and multimedia presentations in two

studies. Additional resources used by program facilitators included songs, puppets, comics, a

colouring book, a storybook, and games. No programs were delivered electronically in interactive

web- or computer-based formats.

The duration of the intervention programs in the included trials ranged from a single 45-minute

session (Oldfield et al., 1996) to eight 20-minute sessions on consecutive days (Fryer et al., 1987a).

Fourteen interventions were brief (i.e. less than 90 minutes total duration), and the remainder were

longer, lasting from 90 to 180 minutes in total duration.

In 17 trials, the effectiveness of prevention programs was compared to that of a wait-listed control

group. In the seven remaining studies, the control group interventions were as follows: discussion

about self concept (Saslawsky & Wurtele, 1986; Wurtele et al., 1986); multimedia presentation with

no child abuse content (Harvey et al., 1988); fire safety (Blumberg, 1991); fire or water safety

(Hazzard et al., 1991); attention control program (Lee & Tang, 1998); and a game of hangman

(Snyder, 1986). All programs were delivered on school premises and during school hours, apart from

one study in which the program was delivered in the morning, before school classes began (Chen et

al., 2012).

<Insert Table 2 about here>


Effects of Interventions

We present the main findings on the effects of the interventions for the six outcomes: (i)

protective behaviours (self-protective skills); (ii) knowledge (questionnaire-based knowledge and

vignette-based knowledge); (iii) retention of protective behaviours over time; (iv) retention of

knowledge over time; (v) harm (parental or child anxiety or fear); and (vi) disclosures.

Protective behaviours.

Of the 24 included studies, three studies reported collecting data on protective behaviours

(i.e. demonstration of self-protective skills) (Fryer 1987a;Kraizer 1991; Poche 1988). All used a

version of a stranger simulation test involving the staging of a simulated abuse or grooming situation

with each individual child where a research assistant, posing as a stranger, requested the child’s help

with a task that required them to go with the stranger (e.g. accompany the stranger to the stranger’s

car to do a special task). Children’s responses were recorded by independent assessors using

contemporaneous video monitoring (Fryer et al., 1987a; Kraizer, 1991), or by the research assistant

(Poche et al., 1988). Scoring was pass or fail. All three studies were conducted with children in lower

primary school (kindergarten to grade three).

Only the Fryer 1987a (n = 48; randomised controlled trial (RCT)) and Poche 1988 (n = 74; cluster-RCT)

studies could be included in the meta-analysis for protective behaviours, as Kraizer 1991 (n = 670;

cluster-RCT) did not report a breakdown of pass or fail scores for intervention and control groups. In

the analysis, heterogeneity approached the moderate range (I² = 27%; Tau² = 0.16) and was non-

significant (P value = 0.24). Protective behaviours were greatly enhanced in intervention groups

compared to control groups immediately post-intervention (odds ratio (OR) 5.71, 95% confidence

interval (CI) 1.98 to 16.51; two studies; n = 102) (Figure 2). The results did not change when we

made adjustments using intraclass correlation coefficients (ICCs) to correct errors made in studies

where data were analysed without accounting for the clustering of students in classes or schools

(ICC: 0.1 OR of 5.43, 95% CI 1.88 to 15.65; ICC: 0.2 OR of 5.16, 95% CI 1.81 to 14.70).



Knowledge (questionnaire-based knowledge).

Of the 24 included studies, 21 reported questionnaire-based knowledge using a range of

different measures. Eighteen studies were included in the meta-analysis comprising a total of 4657

participants. In the meta-analysis, there was evidence of substantial heterogeneity (I² = 84%; Tau² =

0.10). The high Chi² statistic (104.76; df = 17) and low P value (< 0.00001) indicated variation of

effect estimates beyond chance. The SMD was 0.61 (95% CI 0.45 to 0.78), reflecting an average 0.61

standard deviation (SD) increase in factual knowledge, across various measures, for the intervention

group. These results suggest that children exposed to the interventions tend to display increased

factual knowledge about sexual abuse and its prevention, when measured immediately after

completion of the program, and the effect is of a moderate size (Figure 3). The results did not

change when adjusted for clustering (ICC: 0.1 SMD 0.66, 95% CI 0.51 to 0.81; ICC: 0.2 SMD 0.63, 95%

CI 0.50 to 0.77).

When studies at high risk of bias were excluded, the SMD was reduced to 0.47 (95% CI 0.29 to 0.66),

indicating that knowledge scores may be influenced by assessor bias or contamination from group

assessment, or both, such that better controlled studies may generate lower effect sizes for this

knowledge outcome. We also examined studies in two age-based subgroups: studies with only

younger participants from kindergarten to grade three; and studies with only older participants from

grade four upwards. The SMD was 0.42 (95% CI 0.08 to 0.77) for the younger group and 0.89 (95% CI

0.59 to 1.19) for the older group. The test for subgroup differences was just below the statistically

significant cut-off of 0.05 (Chi² = 4.04, df = 1; P value = 0.04). These results indicate that knowledge

may be better gained immediately after the intervention by older children.



Knowledge (vignette-based knowledge).

Twelve studies used vignette-based measures in various formats, including verbal, picture,

and video vignettes. Eleven studies were included in the meta-analysis with a total of 1688

participants. There was evidence of substantial heterogeneity (I² = 71%; Tau² = 0.08) in the meta-

analysis. The high Chi² statistic (34.25, df = 10) and low P value (< 0.0002) provide further evidence

of variation in effect estimates beyond chance. The SMD was 0.45 (95% CI 0.24 to 0.65), indicating

that those receiving treatment had an average 0.45 SD increase in applied knowledge as reflected in

their responses to vignettes administered post-intervention, a gain of moderate effect size (Figure

4). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.53, 95% CI 0.32 to 0.74;

ICC: 0.2 SMD 0.60, 95% CI 0.31 to 0.89).

When studies at high risk of bias on the blinding of outcome assessment domain were excluded, the

SMD was reduced to 0.36 (95% CI 0.17 to 0.56), indicating a slight testing effect. We again conducted

subgroup analyses to assess the effects of participant age as above. The SMD was 0.39 (95% CI 0.09

to 0.69) for the younger group and 0.56 (95%CI 0.03 to 1.08) for the older group. The test for

subgroup differences was not significant (Chi² = 0.29, df = 1; P value = 0.59).


Retention of protective behaviours over time.

Three of the 24 included studies measured retention of protective behaviours over time.

Complete data were not available for any of these studies. Meta-analysis could not be conducted.

Retention of knowledge over time.

Questionnaire-based measures were used in 21 of the 24 included studies. Ten of these

studies reported on retention of knowledge over time, from one to six months post intervention.

Complete data were available for four studies (956 participants). The effect of intervention seemed

to persist beyond the immediate assessment (SMD 0.78, 95% CI 0.38 to 1.17; I² = 84%, Tau² = 0.13, P


value = 0.0003; n = 956) to six months (SMD 0.69, 95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value

= 0.26; n = 929) (Figure 5).The results did not change when adjustments were made using ICCs.

Vignette-based measures were used in 12 of the 24 included studies. Nine of these studies reported

on retention of knowledge over time. None could be included in a meta-analysis because either the

study did not provide data in a form useable in meta-analysis, or the study’s wait-listed control

group had already received the intervention.


Harm.

A total of six studies measured harm in relation to children’s participation in school-based

sexual abuse prevention programs. We included three studies (795 participants) in the meta-

analysis. In these studies, harm was measured via child self report using anxiety or fear scales, with

all studies using unique measures: Dawson (1987) used the State-Trait Anxiety Inventory for Children

(STAIC), Lee & Tang (1998) used the Fear Assessment Thermometer Scale (FATS), and Blumberg

(1991) used a custom-made scale. There was no heterogeneity (I² = 0%, P value = 0.79). The SMD

was -0.08 (95% CI -0.22 to 0.07) suggesting evidence of no increases or decreases in anxiety or fear

in intervention participants (Figure 6). The results did not change substantially when adjustments

were made using ICCs (ICC: 0.1 SMD -0.04, 95% CI - 0.42 to 0.33; ICC: 0.2, SMD -0.03, 95% CI -0.46

to 0.40).

Narrative synthesis of included studies revealed that a small proportion of program participants

experienced anxiety or fear but these (anxieties or fears) were mild rather than severe, and short-

rather than long-term. Although parent satisfaction data were collected in some studies, parental

anxiety or fear was not measured in any study.



Disclosure.

We included three studies (1788 participants) in the meta-analysis for disclosures of

previous or current sexual abuse during or after program participation. There was no heterogeneity

(I² = 0%, P value = 0.84). Disclosures occurred more often in the intervention groups (OR 3.56, 95% CI

1.13 to 11.24). Adjusting for the effect of clustering in the Kolko et al., (1989) and Oldfield et al.,

(1996) studies, however, had the effect of widening the confidence intervals around the OR (ICC: 0.1

OR 3.04, 95% CI 0.75 to 12.33; ICC: 0.2 OR 2.95, 95% CI 0.69 to 12.61) making the result less certain,

and indicating the effect of intervention programs on disclosure was sensitive to different

assumptions regarding the effect of clustering on the results (Figure 7 shows results with correction

for clustering using ICC 0.1).


Subgroup analyses

Insufficient information was provided in the included studies to conduct planned subgroup

analyses and there were insufficient studies for this to be meaningful. The problem here was that

the included studies provided insufficient information about issues that were hypothesised as being

relevant for subgroup analysis such as gender, program type, and setting. We did not conduct

subgroup analyses for active or passive involvement as it was not possible to categorise programs in

this way; most were multifaceted, involving combinations of approaches (see Table 2).

Discussion and Application to Practice

This review reported on the effects of 24 trials (published in 29 reports) examining the

effectiveness of school-based programs for the prevention of child sexual abuse including 5802 child

participants of whom approximately 98.8% were from primary (elementary) schools. Studies were

conducted in countries with high and upper-middle income economies according to the World

Bank’s analytical income categories (The World Bank, 2013). Most (16 of 24) were conducted in

North America, the remainder in Europe, East Asia, and Central Asia. Ethnicity data were poorly


reported or not reported in 10 of the 24 studies. Where data were reported, participants were from

a diverse range of ethnicities, increasing the generalisability of the evidence, and also suggesting

that there is widespread concern about child sexual abuse and its prevention.

We assessed program effectiveness according to six outcomes: (i) protective behaviours (self-

protective skills); (ii) knowledge (questionnaire-based knowledge and vignette-based knowledge);

(iii) retention of protective behaviours over time; (iv) retention of knowledge over time; (v) harm

manifesting as parental or child anxiety or fear; and (vi) disclosures of past or current child sexual

abuse. Our overall interpretation is that there is moderate quality evidence that school-based

education programs for the prevention of child sexual abuse, of the types described in this review,

are effective in increasing knowledge about a range of behaviours that may help primary

(elementary) school-aged children avoid potentially dangerous circumstances. In addition, when

measured in the context of vignettes or other experimental approaches, children provided with this

type of intervention more often act on this knowledge (i.e., behave in ways that are more

protective) than children who do not receive the intervention. Results are best immediately post-

intervention, but there is more limited evidence that some effects are maintained over time.

Caution in the interpretation of these results is in order. Protective behaviours, also known as self-

protective skills, were studied in simulated situations. These were a form of in vivo assessment,

which exposed children to an invitation to go with an unknown adult (Fryer et al., 1987a; Kraizer,

1991; Poche et al., 1988). The use of these simulation techniques is designed to assess children’s

skills in responding to actual threats, however, the approach is difficult to justify and raises

important ethical questions about balancing risks to participants against potential benefits for

research. Assessing children’s skills where there is active concealment via role-playing also presents

significant challenges to the principle of voluntary consent. Although this is arguably as close as

researchers can get to testing whether participants’ learned skills can be translated into appropriate

behaviour, several salient issues must be considered. First, it is not known if skills tested in the


context of approaches from strangers are the same as those required for children to deal with

threats from familiar adults, who are the most common perpetrators of child sexual abuse. Second,

although the generalisation of responses from simulated to actual settings has been demonstrated

in some educational contexts (see for example Vogel, Vogel, Cannon-Bowers, Bowers, Muse, &

Wright, 2006), it cannot be assumed that this applies in the specific context of an approach from an

unknown adult towards a child in a school hallway or playgound. Third, there is the possibility that

this type of outcome assessment may desensitise children to similar occurrences in the future.

Outcome assessment of this type, therefore, must be rigorously conducted and monitored.

Knowledge acquisition was the most frequently tested study outcome, either via questionnaires

designed to capture factual knowledge, or via vignettes which attempt to ascertain applied

knowledge. Tests of knowledge acquisition are used routinely in classroom assessment of students’

learning. Children exposed to the interventions displayed increased factual and applied knowledge

about child sexual abuse and its prevention, when measured immediately after completion of the

program, and scores were maintained for intervention participants one to six months after program

participation. Older children appeared to make greater knowledge gains than younger children when

tested using questionnaire-based measures, but not with vignette-based measures, indicating a

further need for caution when selecting outcome measures and interpreting study findings. In this

review it was not possible to quantify the magnitude of knowledge improvement required to

produce clinically important protective effects. For example, it is not clear what a 0.61 SD increase in

factual knowledge or a 0.45 SD increase in applied knowledge translates to in practical knowledge

terms. Are these findings sufficient to offer protective effects under threats of sexual abuse? Further

research is required to answer these vexing questions regarding the magnitude of skill or knowledge

improvement (or both) that can (if at all) translate to clinically-important protective effects. Such

evidence will be a necessary precursor to assessing programs’ cost-effectiveness.


On balance of evidence, programs do not appear to cause harm. That is, they do not appear to

increase or decrease children’s fear or anxiety. This is important because the historical controversy

over school-based child sexual abuse prevention programs is concentrated on two outcomes:

programs’ actual effectiveness in preventing child sexual abuse, and concerns over negative program

effects (Finkelhor, 2007). In examining individual studies, it appears that when children do report

concerns, these manifest as moderate initially, and then decline on program completion. Future

research should monitor a wider range of children’s and parents’ reactions to programs and assess

the transient and/or persistent nature of potential harms associated with program exposure.

The only direct measure of program effects was participants’ disclosures of past or current sexual

abuse that were made following interventions. Programs may result in greater odds of disclosures of

past or current sexual abuse from children who have been program participants. However, we could

not be certain of this result because children’s disclosures were poorly and inconsistently reported,

or not reported at all. Studies that did report disclosures did not use correct analytic techniques.

Future studies must make advances in assessing this direct program outcome by designing more

consistent and reliable strategies for recording disclosures; considering data linkage to child

protection, hospital, or police records, or both (Blumberg, 1991; MacIntyre & Carr, 1999; Oldfield et

al., 1996); and/or interviewing or surveying participants at repeated follow-up intervals to enable

greater detection and referral for secondary prevention. If the ultimate goals of school-based

education programs for prevention of child sexual abuse are to prevent children from ever

experiencing abuse, and in cases where children have already experienced abuse, to stop the abuse

and limit the harm caused, higher levels of evidence are required to demonstrate effectiveness in

relation to these primary outcomes. This will require large cohort studies with repeated follow-up

into adulthood. However, even large cohort studies may not provide definitive evidence for changes

in child sexual abuse incidence, as it is under-identified and difficult to prove.


Five previous meta-analyses of sexual abuse prevention programs exist, including the original

version of this review (Zwi et al., 2007). Our review differs from previous reviews in that it assesses a

broader range of outcomes, applies more rigorous inclusion criteria to select high quality studies. All

prior reviews found medium to large effects for knowledge outcomes in favour of intervention

groups. These effect sizes ranged from 0.57 (Heidotting, Keiffer, & Soled, 1994, 18 studies), through

0.71 (Rispens, Aleman, & Goudena, 1997, 16 studies) and 0.90 (Berrick & Barth, 1992, 13 studies) to

1.07 (Davis & Gidycz 2000, 27 studies). Our original review (Zwi et al., 2007) found a SMD of 0.59

(95%confidence interval (CI) 0.44 to 0.74; nine studies, n = 3022) for the questionnaire-based

knowledge outcome, which is the outcome most comparable to the outcomes reported in previous

reviews. The current review found a SMD of 0.61 (95% CI 0.45 to 0.78; 18 studies, n = 4657).

The full systematic review (Walsh et al., 2015) also includes a detailed discussion of the

methodological limitations and reporting shortcomings of the included studies. While the use of

randomized and quasi-randomized designs is laudable, their presence is no guarantee that the

studies were carried out in ways that avoid substantial bias or that they are reported in ways that

support high quality synthesis. On the whole, the translation of research into practice in this area is

limited by lack of rigour in study methods and failure to report the full range of child, intervention,

and study design characteristics that could possibly account for variations in program effects. In the

period since the original review was conducted (Zwi et al., 2007), Cochrane Reviews have become

more rigorous in identifying methodological limitations in trials via risk of bias analyses, and the

CONSORT statement has been developed to provide guidance on the reporting of randomised

controlled trials (Shulz, Altman, & Moher, 2010). Nevertheless, our review suggests that the

methodological quality of trials in this area has not improved substantially. At the time of this

review, no study in this area had yet published a study protocol, and we found only one clinical trials

register record for a school-based education program for prevention of child sexual abuse (see

https://clinicaltrials.gov/ct2/show/NCT02181647). This observation is sobering given that our review

also showed that the number of gold-standard program evaluations of school-based CSA prevention

https://clinicaltrials.gov/ct2/show/NCT02181647


studies worldwide has declined each decade since the 1980s (see Table 1). Researchers must

continue testing these interventions, but use study design methodology, data collection tools, trial

registration, and reporting guidelines that enable rigorous scientific evaluation and synthesis.

Conclusions

Children’s self-protective skills and factual and applied knowledge can be increased by

participation in school-based sexual abuse prevention programs. Fifteen programs representing 24

unique studies were evaluated in our review. Currently, schools implement a variety of child-focused

interventions aimed at preventing child sexual abuse, many of which were not included in this

review. Our findings apply only to the types of programs included in this review and do not apply to

those programs with substantially different content and methods. We still need to know a great deal

more about school-based programs for prevention of child sexual abuse, such as their acceptability

to parents and teachers, their effectiveness with particular groups of children at greater risk, which

specific program components offer the strongest effects, the long-term outcomes (including a better

look at disclosure of past, current and future abuse, and possible adverse events) and their costs.

A public health approach for prevention of child sexual abuse proposes that multiple types of

interventions are necessary, targeting: (i) offenders and potential offenders, (ii) children and

adolescents, (iii) situations in which child sexual abuse is known to occur, and (iv) communities

(Smallbone, Marshall, & Wortley, 2008). School-based education programs fit within this approach,

by directly targeting potential victims, and providing a conduit to other important prevention targets

in communities such as teachers, parents, and extended families.

While we found few or no adverse outcomes in our review, concerns that these programs introduce

complex concepts to children that they may not understand and cause children to be wary of adults

should continue to be explored and taken seriously. More importantly, the results from this review

should not be misconstrued to imply that children are responsible for protecting themselves from

sexual abuse, nor that they can even do so even with the types of knowledge and skills imparted by


these programs. Adults who sexually abuse children are clearly responsible for taking advantage of

the most vulnerable among us. Equipping children with increased protective skills and knowledge

does not replace society’s responsibility to ensure child safety via myriad other means (Finkelhor,

2007). Nonetheless, the overall prevalence of child sexual abuse suggests that, even if successful in

only a small proportion of situations, it is possible that the skills and knowledge learned in

prevention programs may be of assistance to a considerable number of children.


Acknowledgements

For expert guidance during the preparation of the review, we sincerely thank Professor

Geraldine MacDonald (Coordinating Editor), Dr Joanne Wilson (Managing Editor), Gemma O'Loughlin

(Assistant Managing Editor), and Laura MacDonald (former Managing Editor) at the Cochrane

Developmental, Psychosocial and Learning Problems Group’s editorial base. We are grateful to

Margaret Anderson, Trials Search Coordinator for the Cochrane Developmental, Psychosocial and

Learning Problems Group for developing and conducting searches for the review. We are especially

appreciative of statistical advice and support provided by Dr Toby Lasserson and Dr Kerry Dwan at

the Cochrane Editorial Unit. Leisa Brandon and Pauline Mulligan provided much valued research

assistance. The Australasian Cochrane Centre provided training and review completion workshops.

Finally, we thank external Cochrane reviewers and statisticians for their comments on earlier

versions of the review.

Author Note

This article is based on a Cochrane review first published in the Cochrane Library 2007 Issue

3, and updated in the Cochrane Library 2015 Issue 4. Cochrane reviews are “living reviews” and are

updated regularly as new evidence emerges and in response to feedback. The most up to date

version is available, freely, at the Cochrane Library at http://www.cochranelibrary.com/. The first

author acknowledges and thanks the original 2007 review team: Karen Zwi, Susan Woolfenden,

Danielle M Wheeler, Tracey O’Brien, Paul Tait, and Katrina J. Williams.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research,

authorship and/or publication of this article.

http://www.cochranelibrary.com/


Funding

The authors disclosed receipt of the following financial support: in-kind support was

provided by the authors’ respective institutions; an Australian Research Council Discovery Project

grant (DP1093717), and a QUT Vice-Chancellor’s Research Fellowship to the first author. The

manuscript content represents the views of the authors and does not embody the views or policies

of the funding agencies or institutions.


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Figures & Tables

Figure 1. Study screening and selection process (study flow diagram).


Figure 2. Effects of interventions on protective behaviours (events), no correction for clustering.


Figure 3. Effects of interventions on questionnaire-based knowledge scores, no correction for

clustering.


Figure 4. Effects of interventions on vignette-based knowledge scores, no correction for clustering.


Figure 5. Effects of interventions on retention of questionnaire-based knowledge over time, no

correction for clustering.


Figure 6. Effects of interventions on anxiety or fear, no correction for clustering.


Figure 7. Effects of interventions on disclosures, correction made for clustering using ICC: 0.1.


Table 1. Characteristics of included studies.

Characteristic Number of studies

Publication Year 1980 – 1989 1990 – 2000 2001 – 2009 2009 – 2015

10 7 4 3

Publication Type Journal Dissertation or thesis

20 4

Study design RCT Cluster-RCT Quasi-RCT

7

11 6

Location USA Canada China Germany Spain Taiwan Turkey

16 3 1 1 1 1 1

Setting Primary (elementary) school Special school

23 1

Sample size 1 – 200 200 +

13 11

Participants Total number of participants: 5802 students Mean age range: 5.5-13.44 years Gender proportion range (female): 45-55%


Table 2. Summary of the 24 Included Studies Author (Year) Intervention Intervention content Intervention methods N Study Design Outcomes Measured

Blumberg (1991)a Stop, Tell

someone, Own your body, Protect Yourself (STOP)

Body ownership/body rights; body openings needing protection (eyes, ears, private places); appropriate and inappropriate touches; safety rules (Stop, Go, Tell, tell, tell and keep telling until somebody listens); perpetrators are usually someone known to the child; sexual abuse is not the child’s fault; appropriate and inappropriate secrets.

Role-play, modelling, rehearsal, and discussion

264 Cluster-RCT Protective behaviours (simulation) Knowledge (questionnaire-based knowledge) Knowledge (vignette-based knowledge) Disclosures

Child Abuse Primary Prevention Program (CAPP)

Discriminating types of touches based on feelings; they have the right to say no; safety rules “Say No,” “Go,” and “Tell”; no one should touch private areas unless you need help; “touching secrets” or “secrets that hurt” should never be kept; sexual abuse is never the child’s fault.

Modelling, film and discussion

Ҫeҫen-Eroğul & Kaf Hasirci (2013)

Preventing child sexual abuse psycho-educational training program based on the Good Touch/ Bad Touch program (Childhelp, 2011) adapted for the Turkish culture

My body belongs to me; discriminating good touch/bad touch; promises; body safety rules; saying “No”; secrets; talking with adults; and abuse is never a child’s fault.

Video, lecture, role-play, modelling, and rehearsal.

36 RCT Knowledge (questionnaire-based knowledge)

Chen et al. (2012) Based on Red Flag/Green Flag People (Rape and Abuse Crisis Center, 2008) and Red Flag/Green

Body ownership; distinguishing appropriate from inappropriate touches and requests; distinguishing types of secrets; and abduction prevention training based on the book “Who Is a Stranger and What Should I Do?” (Girard 1985)

Instruction; modelling, role-play, rehearsal, practice, feedback, and reinforcement.

46 RCT Knowledge (questionnaire-based knowledge) Knowledge (vignette-based knowledge)


Flag People II (Grimm, 1994)

Crowley (1989) Good Touches/Bad Touches: A Program to Prevent Child Sexual Abuse (MHAWC, 1984)

Individuals are unique and special; feelings are special and important; different kinds of touches; body ownership; touching; saying no; distinguishing types of secrets; identifying trusted adults; how to tell.

Discussion; structured activities, including active participation and rehearsal; film; review.

293 Quasi-RCT Knowledge (questionnaire-based knowledge)

Daigeneault et al. (2012)

ESPACE child sexual abuse prevention program, French adaptation of the CAPP workshop (Cooper, 1991)

Awareness of personal rights; (safe, strong, secure), self-assertion skills (self-defence yell), and appropriate responses to instances of abuse (seeking out peer support, confiding in a trusted adult). Also, prevention of verbal and physical violence.

Role-playing, guided discussions, behaviour modelling, and rehearsals.

160 Quasi-RCT Knowledge (questionnaire-based knowledge) Knowledge (vignette-based knowledge) Harm

Dake et al. (2003) Child abuse prevention curriculum modified from an existing curriculum (title not reported)

Abuse problems children may encounter; people in family and community support systems that children can turn to; 3 types of touches; personal safety rules; child abuse is never a child’s fault; child abuse should never be kept secret; empathy for others who find themselves in abusive situations.

Role-play, video, discussion.

450 Cluster-RCT Knowledge (questionnaire-based knowledge)

Dawson (1987) Child sexual abuse prevention programme presentation + film from the series Child Sexual Abuse: A Solution (Adams, 1984)

Definitions; session standards; purpose of session; discriminating appropriate and inappropriate touches; trusting feelings; talking with a trusted adult; offender characteristics and approaches; offenders are likely to be someone they know; personal safety rules; distinguishing appropriate and inappropriate secrets; child sexual abuse is against the law; children are not to blame; skills for resisting or avoiding abuse; identifying support systems.

Role-play; modelling; problem-solving activities (“what if ” situations); questions and answers.


Del Campo Sanchez et al.

Prevention of child sexual abuse

Details not reported Details not reported. 382 Quasi-RCT Knowledge (questionnaire-based knowledge)


(2006) programme (Lopez, 1997)

Disclosures Harm

Fryer et al. (1987)

b

Children Need to Know Personal Safety Training Program (Kraizer, 1981)

4 safety rules to follow when they are not with care-taking adults: stay an arm’s reach away from strangers; don’t talk to them; don’t take anything from them; don’t go anywhere with them.

Role-play. 48 RCT Protective behaviours (simulation) Knowledge (questionnaire-based knowledge)

Grendel (1991) Child Sexual Abuse Prevention Program (Women Helping Women, Ohio, no citation)

What is a stranger?; public versus private parts of the body; happy versus sad touches; trusting your feelings or inner voices; 3 body safety rules (say no, get away, tell someone); what if situations/concrete examples; who could you trust to tell?

Film, discussion, and review.

100 Cluster-RCT Knowledge (Questionnaire-based knowledge): Knowledge (vignette-based knowledge)

Harvey et al. (1988)

Good Touch-Bad Touch programme (no citation)

Defining sexual abuse; differentiating between good, bad, and sexually abusive touches; identifying who can sexually abuse children; 5 body safety rules (I can decide with whom I want to share my body; recognising when “something wrong” is happening to me; learning to say “no” and get away; learning to tell someone what happened; and recognising that, if abuse occurs, it is never my fault).

Story, game, film, song, and role-plays utilising modelling, rehearsal, and social reinforcement.

90 RCT Knowledge (Questionnaire-based knowledge): Knowledge (vignette-based knowledge)

Hazzard et al. (1991)

Adaptation of Feeling Yes, Feeling No (National Film Board of Canada, 1985) + sexual abuse prevention curriculum for children + homework handouts

Touches can give children positive or negative feelings; children can say “no”, leave, and tell a trusted adult; defining child sexual abuse; children can problem-solve (use “3 stranger questions”) to avoid dangerous situations with strangers; sometimes children are sexually abused by someone they know; there are many adults who can help so keep telling if the first adult does not believe you; sexual abuse is never the child’s fault.

Video tape, discussion, and role-play, plus Spiderman and Power Pack comic book (Marvel Comics, 1984) and homework handouts.

399 Cluster-RCT Knowledge (Questionnaire-based knowledge): Knowledge (vignette-based knowledge) Disclosures


Hébert et al. (2001)

ESPACE child sexual abuse prevention program, adapted from Child Assault Prevention Program [CAPP] (Cooper, 1991)

Enhance children’s awareness of their personal rights; basic prevention concepts and skills; self-assertion skills; self-defence yell; children are encouraged to ask friends for help and to tell a trusted adult if abuse occurs; verbal and physical abuse and bullying; workshops for parents and teachers.

Role-play, guided discussions, behaviour modelling, and rehearsal.

133 Quasi-RCT Knowledge (Questionnaire-based knowledge): Knowledge (vignette-based knowledge) Harm

Kolko et al. (1989) Red Flag/Green Flag programme (Williams, 1980)

Defining sexual abuse; differences between good and bad touching from strangers, familiar people, and family members; prevention rules; potentially helpful adults; discussion of personal experiences, and training in prevention skills (say no, get away quickly, tell adult immediately); parent orientation session; in-service training for teachers and volunteers.

Film + colouring book. 337 Cluster-RCT Knowledge (questionnaire-based knowledge) Disclosure

Krahé & Knappert (2009)

LIVE: a live performance of a theatre play entitled (No) Child’s Play

Promoting children’s skills in handling uncomfortable interactions with adults, such as being asked to keep a secret when they feel uneasy; promoting confidence in their ability to seek help.

Theatrical performance. 148 Cluster-RCT Knowledge (vignette-based knowledge) Harm

Kraizer (1991)c The Safe Child

Program (Kraizer, 1991)

Your body belongs to you; you have a right to say who touches you and how; if someone touches you in a way that you do not like, in a way that makes you feel funny or uncomfortable, or in a way that you think is wrong, it’s okay to say no; if the person does not stop, say “I’m going to tell”; if you have a problem, or if something like this is happening to you, tell and keep telling until someone helps you; adults cannot read your mind, you need to communicate clearly and fully; touch should never have to be a

Video, role-play, classroom activities.

670 Cluster-RCT Protective behaviours (simulation) Knowledge (questionnaire-based knowledge)


secret. Also includes: prevention of abuse and abduction by strangers; prevention of physical and emotional abuse; safety in self-care.

Lee & Tang (1998) Behavioral Skills Training Program (Wurtele, 1990)

We are the bosses of our bodies; the locations of private parts; touching your own private parts is acceptable when done in private; it is appropriate for doctors, nurses, or parents to touch children’s private parts for health or hygiene reasons; otherwise, it is not okay to have private parts touched or looked at by a bigger person; it is wrong to be forced to touch a bigger person’s private parts; a bigger person’s inappropriate touching of a child’s private parts is never the child’s fault; personal body safety rule “It’s not okay for a bigger person to touch or look at my private parts” (unless they need help as in situations when their private parts get hurt).

Instruction, modelling, behavioral rehearsal (practice), shaping, social reinforcement, and feedback.

77 RCT Knowledge (Questionnaire-based knowledge): Knowledge (vignette-based knowledge)

Oldfield et al. (1996)

Project TRUST (Anderson, 1990)

The touch continuum (nurturing, confusing, exploitative); the right to question or refuse exploitative touch; the way to say “no” to uncomfortable situations; the fact that perpetrators can be either people you know or strangers.

Discussion, theatrical play, question/response period.

1269 Cluster-RCT Knowledge (questionnaire-based knowledge) Disclosure

Poche et al. (1988)

Videotape intervention (no citation)

Several child abduction scenes in which adults approach children in a friendly manner and entice them; child actors demonstrate 2 safety rules (no further detail reported).

Video, questioning, articulation of strategies, feedback, guiding of attention, praise, and using the child’s viewpoint.

74 Cluster-RCT


Videotape intervention + behavioural rehearsal (no citation)

Several child abduction scenes in which adults approach children in a friendly manner and entice them; child actors demonstrate 2 safety rules (no further detail reported).

As above with the addition of behavioural rehearsal in a role-play.

Saslawsky & Wurtele (1986)

Film: Touch (Illusion Theater Company, 1984)

Portrayal of abusive incidents with modelling of 4 prevention skills (say no; yell for help; get away; tell someone and keep telling until someone believes you).


67 Quasi-RCT Knowledge (questionnaire-based knowledge) Knowledge (vignette-based knowledge)

Snyder (1986) Good Secrets, Bad Secrets (citation not reported)

General safety; distinguishing appropriate and inappropriate touching; assertiveness; help seeking and action planning.

Role-play, discussions, story-like situations.

177 Quasi-RCT Knowledge (questionnaire-based knowledge)

Tutty (1997)d Who Do You Tell

programme (Calgary Sexual Assault Centre, 1983)

Prevention concepts; giving information; permission to say no to unwanted touch; whether children should be suspicious of all touches or adults; a parent information evening; teacher in-service workshop.

Discussion, pictures, short videos, and role-plays.

231 RCT Knowledge (questionnaire-based knowledge) Harm

Wolfe et al. (1986)

Theatrical plays performed by volunteer medical students (title not reported)

5 themes: abuse can be perpetrated by someone you love and trust; feelings generated in such circumstances; importance of telling someone, even if unsure of what is happening; abuse is not your fault; and getting help right away is the best way to respond.

Theatrical skits and discussion.


Wurtele et al. (1986)

Film: “Touch“ (Illusion Theater Company, 1984)

Body safety rules (saying “No”; yelling for help; getting away; telling someone and keep telling until someone believes you).


71 RCT Knowledge (questionnaire-based knowledge) Knowledge (vignette-based knowledge)


Body Safety Training (BST) (Wurtele, 1986a)

3 specific self-protective skills (being able to identify the location of one’s ”private parts; knowing when it is “okay” or “not okay” to have their private parts touched; developing verbal responses (e.g. saying “No!” in a big voice) and motor responses (e.g. getting away, telling someone) in potential abuse situations.

Instruction, modelling, rehearsal, social reinforcement, shaping and feedback + group mastery of skills

a also includes Blumberg, Chadwick, Fogarty, Speth, & Chadwick (1991) and Chadwick (1989). b also includes Fryer, Kraiser, & Miyoshi (1987). c also includes Kraizer, Witte, & Fryer (1989). d also includes Tutty (2000).


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