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Prevention of sexual abuse in preschoolers - teachers’ knowledge and attitudes

Prevenção de abusos sexuais em idade pré-escolar - conhecimentos e atitudes dos educadores

Mafalda Cascais^I, Rui Passadouro^II, Odete Mendes^II, Maria Manuel Zarcos^I

I. Department of Pediatrics, Hospital de Santo André, Centro Hospitalar de Leiria. 2410-197 Leiria, Portugal. mafalda_m_c@hotmail.com; mmanuelzarcos@sapo.pt

II. Public Health Unit, ACES Pinhal Litoral. 2400-137 Leiria, Portugal. ruipfonseca2@gmail.com; momendes@arscentro.min-saude.pt

Endereço para correspondência | Dirección para correspondencia | Correspondence

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ABSTRACT

Introduction: Child sexual abuse (CSA) is a global public health problem across different culture and socioeconomic strata. Teachers have a privileged role in prevention programs and the approach is feasible and effective in preschoolers. The aim of this study was to characterize preschool teachers’ knowledge, attitudes, and training about CSA prevention.

Methods: A non-experimental, exploratory, cross-sectional study was conducted in Leiria, Portugal, comprising 47 preschool teachers. Data was retrieved through a questionnaire developed by study authors.

Results: Most preschool teachers had no CSA prevention training. About half of inquired teachers considered their knowledge about CSA prevention as reasonable. However, 12.8% classified it as poor, mainly teachers with less practice years (50% vs 69.6% of teachers with ≥30 practice years who classified their knowledge as reasonable, p=0.03). Most participants agreed that CSA prevention should be part of preschool curriculum, particularly older teachers (92% vs 77%, p=0.03). Most respondents considered adjusting these concepts to preschoolers challenging for implementation of prevention programs, 72.4% considered that some topics were not suitable for discussion with preschool children, and 82.9% considered that their approach was not well accepted by parents or caregivers.

Discussion: Study results evidenced several difficulties and limited training of preschool teachers in CSA prevention. Encouragingly, most teachers showed a positive attitude towards participating in CSA training education and including this topic in preschool curriculum. This study emphasizes the importance of teachers’ education in this subject through implementation of training programs.

Keywords: child sexual abuse; preschool age; preschool teachers; prevention

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RESUMO

Introdução: O abuso sexual (AS) tem uma distribuição global e é transversal a todas as culturas e estratos socioeconómicos. Os educadores detêm uma posição privilegiada na sua prevenção e a abordagem em idade pré-escolar é viável e eficaz. O objetivo deste estudo foi caracterizar os conhecimentos, atitudes e formação dos educadores de infância face à prevenção de AS em idade pré-escolar.

Métodos: Estudo não experimental, transversal e exploratório, compreendendo 47 educadores de infância do concelho de Leiria, Portugal. Os dados foram recolhidos através da aplicação de um questionário elaborado pelos autores.

Resultados: A maioria dos educadores não teve formação sobre prevenção de AS. Cerca de metade considerou o seu grau de conhecimento sobre prevenção de AS razoável, embora 12,8% − maioritariamente educadores com menor tempo de docência − o tenha considerado fraco (50% vs 69.6% com ≥30 anos de docência que o consideraram razoável, p=0.03). A maioria dos participantes, particularmente educadores de infância mais velhos (92% vs 77%, p=0.03), concordou que a prevenção de AS deve integrar o currículo do ensino pré-escolar. A adaptação de conceitos para crianças nesta faixa etária foi um dos fatores apontados pela maioria dos inquiridos como um dos maiores desafios à implementação de programas de prevenção de AS. No entanto, 72,4% dos participantes considerou que alguns tópicos não são adequados para discutir com crianças em idade pré-escolar e 82,9% que a sua abordagem não é bem aceite pelos pais ou cuidadores.

Discussão: Estes resultados evidenciam várias dificuldades e formação limitada dos educadores de infância no âmbito da prevenção de AS. No entanto, a maioria revelou uma atitude positiva face à formação sobre prevenção de AS e inclusão deste conteúdo no currículo do ensino pré-escolar. Este estudo enfatiza a importância de investir em programas de formação dos educadores de infância nesta área.

Palavras-chave: abuso sexual; educadores de infância; idade pré-escolar; prevenção

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Introduction

Child sexual abuse (CSA) is a prevalent public health problem with negative impact in children’s physical and psychosocial development.^1-5 It is a recognized issue occurring regardless of gender, socioeconomic status, ethnicity, or geographical location.^2,6,7 CSA prevalence in Europe has been estimated in numerous studies, with discrepant results.⁸ It has been reported that one in every five children are victims of some form of sexual violence.^8,9 According to the World Health Organization, 18 million children in Europe suffer from this type of abuse.^10,11 However, statistics account for only a part of CSA cases.¹

The negative CSA consequences and associated costs require primary prevention strategies.² Several professional groups can take part in this approach and school is a privileged environment for implementation of CSA prevention programs.^2,12 Several studies of school-based CSA prevention programs have been conducted, namely in the United States, Canada, United Kingdom, Ireland, Turkey, Spain, Australia, South Korea, Taiwan, and China.^2,9 The aims of school-based CSA prevention programs include helping children recognize potentially abusive situations or potential abusers, providing them with skills to refuse sexual requests by saying “No”, instructing children to resist by trying to get away from the abuser, encouraging children to report abuse, and explaining that secret or inappropriate touching is never the child’s responsibility.^2,13 Various studies have shown that school-based programs have the potential to increase children’s knowledge and skills about CSA prevention.^2,5,7,13,14

Regarding preschoolers, research reveals that CSA prevention programs are feasible and apparently effective, fostering young children’s ability to detect inappropriate touching and increasing behavioral skills about what to do, what to say, who to tell, and how to report if confronted with an inappropriate touching request.^4,5,14,15 Because teachers play an important role in these school-based programs, they should have appropriate knowledge and attitudes regarding CSA.^5,6,9,12 However, teachers often feel inadequately prepared or not having enough knowledge about these topics, with evidence suggesting a critical training need.^5,9,12,16

The aim of this study was to characterize preschool teachers’ knowledge, attitudes, and training about CSA prevention in preschoolers in Leiria, Portugal, as no previous study about this subject has been conducted in Portugal , as far as the authors are aware.

Methods

The current study was approved by the Portuguese General Directorate of Education. It was a non-experimental, exploratory, cross-sectional study. During two months (September-October 2016), preschool teachers of public, semiprivate, and private schools in Leiria, Portugal, were invited to participate. Teachers were asked to anonymously and voluntarily complete a survey provided through an online platform. Survey aims and instructions were provided in the front page.

The original, non-validated survey was based on research objectives and literature review findings. It comprised 17 main questions (four with sub-questions) divided in four sections: teacher’s general demographics (three items), professional data (three items), curricular information and training education (three items), and CSA prevention knowledge and attitudes (eight items). Response options were simple binomial (“yes” or “no”) or based on a Likert score with five options defined as “poor”, “not reasonable”, “reasonable”, “very reasonable”, “excellent” or “totally disagree”, “partially disagree”, “indifferent”, “partially agree”, and “totally agree”.

Data was analysed using the statistical program SPSS, version 23.0. A descriptive analysis was performed for sociodemographic variables. Measures of central tendency, dispersion, and position were estimated for quantitative variables, and absolute and relative frequencies for qualitative variables. Chi-Square test was used for comparing categorical variables, adopting p <0.05 significance level.

Results

A total of 47 preschool teachers participated in the survey, 100% female. Participants’ age ranged between 31 and 60 years (mean 50.4, standard deviation [SD] 7.96 years) and 81% (n=38) were older than 45 years. Regarding education, 66% (n=31) had a licence degree, 19.1% (n=9) a master’s degree, and 14.9% (n=7) a bachelor’s degree.

According to professional data, 78.7% (n=37) of preschool teachers worked at a public school, 19.1% (n=9) at a private school, and 2.1% (n=1) at a semiprivate school. Schools were located in rural area in 59.6% (n=28) of cases and in urban area in 40.4% (n=19) of cases. Participants had an average of 27.2 teaching experience years (SD 8.38, range 5−39 years), with 48.9% (n=23) working for 30 or more years.

Concerning teacher’s training about CSA prevention, 14.9% (n=7) of respondents acknowledged having received specific training, while 85.1% (n=40) said having never received training. Only one teacher acknowledged having received CSA prevention information during preschool teaching training in an extracurricular course, and six teachers after finishing teaching training (five in training actions and one during master’s degree). However, all respondents agreed that it is important for teachers to have access to that information. Still, 12.8% (n=6) of teachers admitted that their knowledge about CSA prevention was very reasonable, 51.1% (n=24) reasonable, 23.4% (n=11) not reasonable, and 12.8% (n=6) poor. Most teachers with ≥30 practice years (69.6%, n=16) classified their knowledge as reasonable and 50% (n=2) of those with <10 practice years as poor, with this difference being statistically significant (p=0.03). Teacher’s educational level, school setting (urban/rural), and school type (private/public) had no statistically significant association with CSA prevention knowledge. When asked whether feeling confident to carry out activities on this topic with preschoolers, 61.7% (n=29) answered favorably, but no statistically significant difference was found regarding teacher’s age, teaching experience years, or CSA prevention training.

Regarding preschool teachers’ knowledge and attitudes towards CSA prevention, 85.1% (n=40) of participants agreed that teaching preschoolers about CSA prevention is important, and the same proportion acknowledged keeping up to date on the subject through the internet (n=26), books/magazines/articles (n=25), or information sharing with colleagues (n=22).

Concerning available teaching techniques and materials adjusted to this age group, more than half of participants acknowledged books (63.8%, n=30), stories (68.1%, n=32), and videos (55.3%, n=26) and 23.4% (n=11) acknowledged role-playing, 19.1% (n=9) songs, and 8.5% (n=4) board games. Only three teachers recognized all methods. Among participants, 38.3% (n=18) had previously addressed this issue with classroom children, mostly through books (n=13) and stories (n=12), and 14.9% (n=7) knew other schools where this issue had been addressed with preschoolers.

As shown in Table 1, 89.4% of participants agreed that CSA prevention should be included in preschool curriculum, with statistically significant results when comparing older (>45 years) with younger teachers (92% vs 77%, p=0.03). In addition, more than 90% agreed that CSA education has the potential to prevent CSA. However, approximately 31.9% of respondents worried that CSA education could make the child know too much about sex.

 

 

Addressing concepts like “private parts”, “safe and unsafe touching”, “healthy sexual development”, “correct designation of private parts”, “not keeping secret”, “identification of trusted adults”, and “not blame the child in case of abuse” was accepted by most respondents. However, less than 50% of teachers agreed with teaching children that a person who they know and trust can hurt them. Statistically significant differences were also found in these answers, with teachers with over 20 years of experience being more receptive to approach healthy sexual development (p=0.04), older teachers agreeing with children learning correct names of private parts (p=0.02), and teachers in rural areas being more conscious of the importance of topics like “safe and unsafe touching” (p=0.04) and “identification of trusted adults” (p=0.03).

Concerning challenges to implementation of CSA prevention programs, most teachers indicated paucity of materials on the subject (85,1%) and difficulties in adapting concepts to preschool children (91,5%), 72.4% considered some topics not suitable for discussion with children this age, and 82.9% considered that CSA prevention education is not well accepted by parents or caregivers. Additionally, 23.4% said that children forget knowledge acquired on the subject in the long-term. The same percentage agreed that addressing this topic increases children’s stress and fear; these were mostly younger teachers (<45 years) and those working in public schools, with statistically significant differences (p=0.04).

Discussion

Findings from this study disclosed considerable difficulties and lack of teacher knowledge about CSA prevention in preschoolers. However, although not having the accurate number of preschool teachers with access to this survey and considering the controversial nature of the topic, a reasonable participant adhesion was achieved in a short period of time. Overall, this study shows that preschool teachers with more teaching practice years and older teachers seem to be better informed and alert to this topic compared with younger teachers with less practice time.

Similarly to previous studies, most preschool teachers (85.1%) had never received formal training about CSA prevention. In a Chinese study, 71.8% of 245 preschool teachers had never attended training programs including CSA prevention information, and in a Spanish survey including 450 teachers, 65.3% had never received any type of CSA education training.^5,9 In another study, preschool teachers’ knowledge and attitudes regarding CSA prevention were significantly associated with their training education: teachers attending training programs including CSA prevention information were more knowledgeable and positive towards CSA prevention, with other authors sharing the same results.^5,6 Additionally, a U.S. study reported increased knowledge of undergraduate teachers about child maltreatment after training, and an Irish study assessed training needs of undergraduate teachers and concluded that there is an urgent need for inclusion of pre-service child protection training programs.^17,18 Accordingly, 36.2% of teachers in this study classified their knowledge about CSA prevention as not reasonable or poor, leading us to assume that lack of education may play an important role in these findings.

Several studies suggest that preschool teachers’ education should include more information regarding CSA and that CSA prevention education should be an important part of routine teacher training.^5,16 Thus, there is a need to provide educational materials and techniques that promote teachers’ training on CSA prevention. These may include formal lecture presentations, small group and individual tutorials, or workshop sessions.⁵ Receptively, all preschool teachers in this study found it useful to receive training on CSA prevention and 85.1% mentioned trying to keep up to date on the issue, revealing a positive attitude towards this topic.

Available literature generally supports that school-based prevention can contribute to CSA prevention and that starting primary CSA prevention in preschool-aged children is important and feasible, although current data regarding program evaluation is insufficient to make strong statements about its overall efficacy.^5,14 Yet, in the current study 85.1% of participants agreed that teaching preschoolers about CSA prevention is important, 89.4% that CSA prevention should be included in preschool curriculum, and more than 90% that CSA education will prevent CSA. These findings are similar to those from a Spanish survey reporting that 96.6% of participants agreed that application of prevention programs is effective, and more encouraging than those from a Chinese study reporting that only 30% of teachers had confidence in the effectiveness of prevention education programs for children and that approximately 30% of preschool teachers disagreed or were indecisive on whether to develop CSA prevention in preschool.^5,9

A significant percentage of teachers (31.9%) in this study were afraid that CSA prevention education could make children know too much about sex. Still, this is a lower percentage than previously reported, including in the referred Chinese study, in which more than 70% of preschool teachers had this concern.5 According to the literature, CSA prevention programs seem to have no adverse effects, like fear and anxiety increase in preschoolers, and no negative consequences on children sexual development.^9,14

CSA prevention programs are associated with a number of challenges, such as difficulties in conveying prevention concepts to young children in an understandable way, concerns that some topics are not appropriate for discussion with children, feelings that parents should be responsible for teaching their children about CSA , lack of knowledge about CSA, and also money and time constraints.¹³ In the present study, some of these limitations were mentioned by respondents: 72.4% considered that some topics are not suitable for discussion with children in this age group and referred difficulties in adapting concepts to preschool children, 82.9% considered that CSA prevention education is not well accepted by parents or caregivers, and 85.1% emphasized the paucity of materials on the subject. However, some studies report that prevention programs for preschoolers are well received by parents and preschool teachers.¹⁴ Different preschool options in different languages are available regarding CSA prevention programs and didactic materials, including comic books, children books, videos, figures, songs, and board games.^12,13 Skill practice, rehearsal or role-play, modelling, group discussion, and lectures are also valid techniques.¹³

Another challenge with CSA prevention programs, pointed out by 23.4% of teachers in this study, is that children forget acquired knowledge in the long term. However, evidence suggests that, in general, knowledge gains among preschool-aged children are maintained over time, usually last for several months, and may last as long as one year.^13,14 Yet, in order to maintain knowledge gains, children need follow-up training.^12,13

This study has several limitations worth mentioning, starting with topic sensitivity and the complexity that is usually involved in addressing aspects related to sexuality. Second, study participant selection was based on a convenience sample and limited to one geographical area (Leiria), hindering data generalization due to lack of a representative sample and reduced sample size. Finally, as the survey was designed to be simple and succinct, CSA knowledge and training education assessment was somehow superficial and did not allow to retrieve specific data.

Despite these challenges and limitations, preliminary results from this study may represent a first step towards development of further studies, allowing to recognize teachers’ main difficulties and training needs on the topic and educate them for prevention of sexual abuse.

Conclusion

Overall, findings from this study reveal that preschool teachers lack training and face difficulties in CSA prevention in preschoolers. This is particularly true for young teachers and for those with less practice years. Encouragingly, most preschool teachers showed a positive attitude towards participating in CSA training education, adopting prevention measures, and including this topic in preschool curriculum. The study also highlights the need for teacher’s education in the area, through implementation of training programs that can contribute to improve teacher’s knowledge and attitudes about CSA prevention in this age range. However, more methodologically rigorous studies using large, culturally diverse samples of preschool teachers are required before robust conclusions can be taken.

 

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Endereço para correspondência | Dirección para correspondencia | Correspondence

Mafalda Cascais
Department of Pediatrics
Hospital de Santo André
Centro Hospitalar de Leiria
R. de Santo André
2410-197 Leiria
Email: mafalda_m_c@hotmail.com

 

Acknowledgements

We thank Dr. Sónia Guerra from research centre of Centro Hospitalar de Leiria for statistical analysis assistance.

 

Received for publication: 16.01.2019. Accepted in revised form: 11.03.2020