Knowledge,Skills,and Self-Disclosure Following a Sexual Abuse Prevention Program Among Iranian Preschoolers: A Cluster Quasi-Experimental Controlled Study

Abstract

Standard empirical studies are needed despite three decades of research on child sexual abuse prevention programs (CSAPPs). This study aimed to investigate the effects of CSAPP on the child’s sexual safety. A multicenter, random cluster, quasi-experimental controlled survey was conducted in a 1:1 ratio in Tehran, Iran, from May to December 2019 in seventy 5- to 6-years-old children from 10 kindergartens. In groups of 7 to 8, the intervention group participated in four sessions of 45 minutes of face-to-face sexual self-care training, 3 to 4 days apart. The control groups received one session on accident safety. Knowledge, self-protective skills, fear, and self-disclosure were assessed respectively by the “Personal Safety Questionnaire (PSQ),” “What If Situation Test (WIST),” “Fear Assessment Thermometer Scale (FATS),” and researcher-made questions before and 8 weeks after the intervention. At the baseline, children obtained 70% of knowledge and 45% of protective skills scores. After the intervention, knowledge, protective skills, and detection of “appropriate requests” were significantly promoted (p < .001). Detecting “inappropriate requests” did not differ; however, all quadruple skills (Say, Do, Tell, and Report) improved significantly. “Girl sex” and “parents’ education” were related factors promoting children’s protective skills. Sexual abuse self-disclosure was 4.2% (n = 3), and one child reported child sexual abuse (CSA) only after the intervention. Despite the lack of formal education, children's basic knowledge reflects the importance of parents in preventing CSA. However, the CSAPP significantly improved children’s skills and revealed one CSA case. CSAPP should not focus solely on risky scenarios because if children cannot distinguish between safe and unsafe situations, they will experience unnecessary anxiety. Even after recognizing the dangerous conditions, CSA prevention will practically fail without appropriate reactions such as escaping and reporting. CSAPP should emphasize individual rights such as body ownership and assertiveness skills and explain the “danger of known people” with detailed scenarios, especially in collectivistic and traditional societies.

Keywords

knowledge protective skills child sexual abuse prevention quasi-experimental preschooler Iran

Introduction

Child sexual abuse (CSA) is a widespread public health issue (Finkelhor & Dunne, 2013). Investigations across various countries and cultures have revealed a 7% to 36% prevalence rate among girls and 3% to 29% among boys (Stoltenborgh et al., 2011). A CSA global survey, in a review of 38 prevalence studies, reported a rate of 20% for women and 10% for men (Beier, 2018). Few population-based surveys have been conducted on CSA prevalence in developing countries (Russell et al., 2020). Some research in Islamic countries such as Saudi Arabia and Egypt reported a prevalence of 22% and 29.8%. In Asian countries such as India, this rate was 4% to 41% among girls and 10% to 55% among boys (Aboul-Hagag & Hamed, 2012; Choudhry et al., 2018; Finkelhor, 1994; Omar & Alkhateeb, 2019).

CSA victims are at increased risk of various short- and long-term physical, psychological, social, and sexual impairments. Cardiovascular, digestive, and gynecological diseases, obesity, and sexually transmitted infections are among the CSA victims’ experiences (Bensley et al., 2000; Hornor, 2010; Irish et al., 2009; Leserman, 2005; Pérez-Fuentes et al., 2013). CSA is associated with psychological outcomes such as depression, anxiety, dissatisfaction, sexual problems, suicide, posttraumatic stress disorder, eating disorders, borderline personality disorder, and postpartum depression (Izdebska, 2021; Maniglio, 2009; Wondie et al., 2011). Moreover, CSA exposes individuals to an increased risk of further sexual abuse in adolescence and adulthood (Filipas & Ullman, 2006; Hornor, 2010), unwanted pregnancy, and prostitution (Noll et al., 2009; Wilson & Widom, 2010), or sexual criminal behaviors (Levenson et al., 2015), divorce, smoking, drug use, antisocial behaviors, and poor educational outcomes (Gauthier-Duchesne et al., 2021; Walsh et al., 2015).

Due to the high prevalence of CSA and its catastrophic consequences, the prevention of CSA should be a social priority. Preventive strategies such as school-based programs indicated a significant decrease in CSA (Fryda & Hulme, 2015; Knack et al., 2019; Manheim et al., 2019). However, many aspects of CSA prevention program (CSAPP) interventions remain questioned. After nearly three decades of research, few standard quasi-experimental or experimental studies have been done in this field (Russell et al., 2020; Walsh et al., 2015). A systematic review in 2020 stated that only eight surveys were eligible for final analysis, even without considering any publication time restriction (Russell et al., 2020). Some of the reported common problems were insufficient information about methods such as randomization, concealment, blinding; lack of assessment self-disclosure and possible fear after the intervention; and absence of trial registration (Walsh et al., 2018).

Another crucial shortcoming in the CSA field is the dearth of knowledge about the effect of CSAPP in developing countries (Russell et al., 2020). Many Asian countries, particularly Islamic ones, do not have a CSAPP. The first step to convincing politicians and decision-makers to add these programs to the school’s curriculum is discovering the child’s sexual self-protective situation.

We tried to cover many concerns about methodology transparency and mentioned problems in designing this survey. This study also aimed to assess CSAPP efficacy in countries with different cultures. To the best of our knowledge, it is among the first experimental studies in Iran, the Middle East, and Islamic countries on CSAPP.

The main goal of this survey was to evaluate the effectiveness of a CSAPP on children’s knowledge, personal safety skills, and self-disclosure. We assessed the children’s fear after CSAPP as possible side effects based on expert recommendations.

Setting

This study was conducted in the metropolis of Tehran, the capital of Iran, with a heterogeneous population of 12 million people and an area of 720 square kilometers.

In Iran, CSAPP training is not officially planned. Sexual self-protection education is not taught formally in schools. Like other sexual issues, there is a social silence, and talking about sexual abuse is taboo; even adults don’t report sexual abuse cases. For most parents, discussing sexual matters is accompanied by embarrassment and shame. Although new generation parents have understood the necessity of this training, their educational resources are limited to satellite transmissions and unofficial sites (Farnam et al., 2008).

Despite much research on various sexual topics in Iran, entering the area of CSA has faced many challenges, and surveys in this field are scarce. In many cases, studies are not allowed, or the process is too complex and lengthy that researchers practically ignore it. The few studies in this field have only focused on parents and teachers without evaluating any outcomes in the main target group, students (Alavi-Arjas et al., 2018). Consequently, we do not have enough data about CSA. In some studies, CSA has been mentioned as a secondary variable, with a reported prevalence of 2.3% to 32.5% (Fakhari et al., 2012; Namdari, 2003; Pirdehghan et al., 2015).

Methods

A multicenter, random cluster, quasi-experimental controlled survey was conducted in a 1:1 ratio in Tehran from May to December 2019. The whole process followed the principles of Helsinki. The scientific requisites and ethical approval were obtained from the Tehran University of Medical Sciences (TUMS) (IR.TUMS.FNM.REC.1398.021). Then, the survey was registered on the Iranian Registry of Clinical Trials (IRCT) under the identity number (IRCT190713044192N1). Finally, permission to work in kindergartens was obtained from the Iran Welfare Organization, and only this final process took about 9 months.

Randomization and Blinding

Tehran was divided into five clusters; north, south, east, west, and center, each having some differences in socioeconomic variables. The list of all kindergartens in each cluster was placed in a separate box. To determine the kindergartens in the intervention group, FF (research supervisor) pulled out the name of a center from each box by simple random sampling. Since selecting one kindergarten for both the control and intervention group would cause data contamination (Zwi et al., 2007), a quasi-experimental controlled study was employed, and five kindergartens were assigned to the intervention and five to the control group. After identifying the intervention kindergarten in each cluster, the nearest kindergarten was considered as the control group (selected by FF and from the prepared list of kindergartens) to achieve a highly homogeneous control group with similar socioeconomic status. The maximum distance between the two centers was 500 to 1000 meters in each cluster. An opaque sealed envelope containing the names of selected kindergartens was sent to ZM (a research team member) for concealed allocation. Following that, 76 eligible 5- to 6-years-old children were assigned to the intervention or control groups from the ten kindergartens. Due to the children’s age, the research team had to complete most questionnaires themselves. ZM has completed only the pretest data and presented the interventions to avoid data-gathering bias, and FF has filled out the post-test questionnaire. Consequently, the researcher who presented the intervention did not conduct the post-test. Blinding has been done for participants and the data analyzer, but due to the educational nature of the intervention, complete blinding was not possible for the research team.

Participants

The researcher held a meeting for the parents in each center and provided a complete explanation about the purposes of the study, voluntary participation, confidentiality of the findings, and the training content. 90 out of 110 families who were invited to the research agreed to their children’s participation and signed the written consent. Our inclusion criteria were met by 76 male and female children who were randomly divided into two groups (Figure 1).

Figure 1.

Flow diagram of participant’s selection process.

The inclusion criteria entailed falling into the 5 to 6 years age group, absence of physical or mental disabilities, and no record of prior participation in sexual self-care training. Exclusion criteria were: parents’ disagreement with the child’s involvement in the research process, the child’s absence in more than one session, and the occurrence of any psychological or physical illness during the study.

Intervention

After the pretest, the intervention group participated in four face-to-face training sessions, in groups, for 45 minutes, at intervals of 3 to 4 days. Each group consisted of 7 to 8 children, and training was provided at the relevant kindergarten. The training method included pictures, games, role-playing, and puppeteering, considering the target group’s age. The content of the intervention is explained in Table 1. Post-test was conducted 8 weeks after the training sessions. The control group received one face-to-face training session with the same lecturer on “accident safety” subjects. After completing the post-test, the control group received CSAPP in one session as a matter of ethical considerations.

Table 1.

Content Presented in the Class About Sexual Self-Care.

Session	Content	Educational Method
First Session	Body ownership	- Using objects, pictures and animations, reading story-book
	Concept of privacy	- Brainstorming, telling the story
	Private parts of the body	- Showing pictures with highlighted private parts, drawing or coloring private parts
Second Session	Safe and unsafe touches/safe and unsafe requests	- Showing animations, role-playing, singing song
	Different types of secrets and keeping secrets	- Telling stories and involving children to guess the type of secret
	Difference between appropriate and inappropriate touches/requests	- Playing different games, flashcards
	Characteristics of perpetrators	- Bringing up different scenarios and storytelling
Third Session	Circle of trusted people	- Making hand-craft, drawing picture, singing song
	Reaction to unsafe touches/inappropriate requests	- Simulating different abusive situations for children to train the appropriate reactions, puppet show, animation
	Protective skills (Say, Do, Tell, Report)	- Role-playing
Fourth Session	Practicing four skills through different scenarios	- Flashcards and role-playing
Fourth Session	Reassuring the child that he or she is not guilty of abuse	- Storytelling

Outcome Measurements

For collecting data, we employed a checklist of demographic questions for assessing independent variables and four standard questionnaires for dependent variables (primary outcomes).

Demographic characteristics

This part included eight questions related to a child’s sex and age, number of children, adequacy of the family monthly income, parent’s age, job, and education level.

Personal safety questionnaire

The twelve-question “Personal Safety Questionnaire (PSQ)” evaluated children’s knowledge about sexual abuse prevention. The responses included “Yes,” “No,” and “I don’t know.” The answer “yes” was given 1 point, and the answers “no” and “I do not know” were 0 points. The scores ranged from 0 to 12, where a higher score indicated children’s better CSA knowledge (Wurtele & Owens, 1997). The psychometric properties of the Persian version of this scale have been confirmed. The Cronbach’s alpha coefficient of the PSQ-P was .74, and test-retest reliability with a 2-week interval showed appropriate stability of the instrument with Pearson’s coefficient r = .88, p < .001(Gholamfarkhani et al., 2018).

What if situation test

The What If Situation Test (WIST) questionnaire examined children’s sexual self-protective skills, including six scenarios that describe hypothetical CSA situations. Three scenarios (questions 1, 2, and 3) described “appropriate and safe” requests. Three scenarios (questions 4, 5, and 6) represented “inappropriate and dangerous” requests, and for each of these questions, four skills of “Say” (saying no), “Do” (Leaving the place), “Tell” (Telling the parents or trusted people), and “Report” (Explaining important details) assessed by a separate single question. The total score of the questionnaire was between 0 and 30, which included the score of “appropriate requests” (range 0–3), “inappropriate requests” (range 0–3), “Say” skills (0–6), “Do” skills (0–6), “Tell” skills (0–6), and “report” skills (0–6). Consequently, each of the three dangerous scenarios had two scores; one for detecting dangerous situations (0 = wrong detection or 1 = right detection) and the other for appropriate child's skill and reaction to unsafe conditions (Wurtele et al., 1998). For each question, a semi-structured interview was conducted with the children to complement the questionnaire. Psychometric properties of the Persian version of the WIST scale were confirmed for use in the Iranian target. Cronbach’s alpha ranged from .71 to .96 for the subscales of WIST-P. The reliability of the total skill was appropriate with Cronbach’s alpha = .91 and correlation coefficient .89 (Gholamfarkhani et al., 2018).

Self-Disclosure Checklist

A researcher-made checklist was used to detect any history of sexual abuse in children, consisting of three questions: (1) has anyone made unauthorized and inappropriate requests from you?; (2) if yes, please explain it; (3) Does this unauthorized and inappropriate request continue? Ten children and specialists evaluated the face and content validity of these three questions.

Fear Assessment Thermometer Scale

The twelve-question Fear Assessment Thermometer Scale (FATS) assessed the probable fear among children receiving CSAPP (as a side-effect). This scale assesses children’s fear of objects, humans, and situations. Each question was scored from 1 to 7, with 1 indicating “lack of fear” and 7 “extreme fear.” The total questionnaire score varied between 12 and 84, where higher scores demonstrated higher levels of child fear. The significant difference in child fear before and after the intervention indicated an unfavorable side-effect (Wurtele & Miller-Perrin, 1987).

Given the children’s age and lack of literacy, the parents filled out the “Fear assessment scale” and demographic information. “PSQ,” “WIST,” and “self-disclosure” questions were completed by the research team members (ZM in the pretest and FF in the post-test) through face-to-face interviews with the children.

Statistical Analysis

The sample size was determined based on Wurtele and colleagues’ study (Wurtele et al., 1986). Thirty-eight individuals were included in each group, considering an error coefficient of .05, a statistical power of 80%, and a dropout rate of 10%. T-test (independent and paired) and chi-square statistical tests were employed to compare the findings between the two groups, and backward and inter-regression models were used to control interfering variables. Data analysis was conducted using SPSS version 22.

Results

Out of 76 children in the study, 70 fully participated in the intervention included in the analysis. One individual was excluded from the intervention group due to being absent for more than one session. In the control group, five children were excluded due to disease, relocation, and parents’ reluctance to continue with the intervention.

Demographic

About 54.5% of the children in the control group and 45.9% in the intervention group were girls. Most children were 6 years old, single-child, and with appropriate economic conditions. Most mothers had a university education and were homemakers, with an average age of 35 years. Most fathers also had a university education and were employees, with an average age of 38.7 years. The intervention and control groups did not significantly differ in demographic characteristics (Table 2).

Table 2.

Baseline Demographic Variables.

Categories	Control Group (N = 33); N (%)	Intervention Group (N = 37); N (%)	p-Value
Kindergarten’s Location in Tehran
North	7 (21.2)	5 (13.5)	.888
South	9 (27.3)	9 (24.3)
East	5 (15.2)	6 (16.2)
West	5 (15.2)	8 (21.6)
Center	7 (21.2)	9 (24.3)
Children’s Age
5	11 (33.3)	13 (35.1)	.874
6	22 (66.7)	24 (64.9)	.874
Children’s Gender
Female	18 (54.5)	17 (45.9)	.473
Male	15 (45.5)	20 (54.1)	.473
Mother’s Education
Illiterate	1 (3.0)	1 (2.7)	.455
Under diploma	1 (3.0)	6 (16.2)
Diploma	9 (27.3)	2 (5.4)
Under and postgraduate	22 (66.7)	28 (75.7)
Father’s Education
Illiterate	0 (0.0)	1 (2.7)	.478
Under diploma	5 (15.2)	6 (16.2)
Diploma	3 (9.1)	7 (18.9)
Under and postgraduate	25 (75.8)	23 (62.2)
Number of Family Children
1	23 (69.7)	18 (48.6)	.189
2	10 (30.3)	16 (43.2)
3	0 (0.0)	1 (2.7)
4	0 (0.0)	1 (2.7)
5	0 (0.0)	1 (2.7)
Mother’s Job
Housekeeper	18 (54.5)	18 (48.6)	.250
Employee	9 (27.3)	16 (43.2)
Part-time	6 (18.2)	3 (8.1)
Father’s Job
Non-governmental	8 (24.2)	18 (48.6)	.09
Employee	17 (51.5)	14 (37.8)
Part-time	8 (24.2)	5 (13.5)
Family Economic Status
Inappropriate	4 (12.1)	11 (29.7)	.073
Appropriate	29 (87.9)	26 (70.3)	.073
	Mean (SD)	Mean (SD)
Mother’s Age	34.3 (3.8)	36 (4.6)	.104
Father’s Age	38.2 (3.4)	39.3 (4.2)	.116

Baseline Outcomes

Knowledge

Before conducting the study, there was no significant difference between the two groups in the main variables. The children obtained 70% of the total knowledge score. The findings of baseline linear regression revealed that gender and fathers’ education level influenced the children’s CSA knowledge (p = .03). On average, girls and children whose fathers had higher educational degrees showed 7.5% higher levels of knowledge than others.

Self-protective skills

Children obtained 45% of the total protective skill score at the baseline. The children also achieved up to 66% score on diagnosing “appropriate requests” and 88% on “inappropriate requests.” The highest and lowest scores of the four skills belonged to the “Say” and “Report” skills, respectively. No meaningful relation was found in the regression model between protective skills and other variables.

Self-disclosure

Investigations for child self-disclosure revealed that one child in each group had prior experience of sexual abuse.

Fear

The mean fear score in the intervention group was significantly more than the control group (p = .04) (Table 3).

Table 3.

Comparison of Knowledge, Protective Skills, Fear, and Disclosure of Children in Intervention and Control Groups in Pre- and Post-Test.

Dependent Variable	Intervention N = 37; Mean (SD)	Control N = 33; Mean (SD)	Independent Sample Test
Dependent Variable	Intervention N = 37; Mean (SD)	Control N = 33; Mean (SD)	p-Value
Knowledge^a (Score Range 0–12)			.0001***
Pretest	8.0 (1.6)	8.7 (1.7)
Post-test	10.4 (1.9) p = .0001	8.9 (1.3) p = .263
Protective Skills, WIST Total^b (Score Range 0–30)			.0001***
Pretest	13.4 (5.5)	13.5 (5.6)
Post-test	26.5 (7.0) p = .0001	15.8 (6.6) p = .935
WIST Appropriate Requests (Score Range 0–3)			.0001***
Pretest	2.2 (0.9)	1.8 (1.0)
Post-test	2.8 (0.3) p = .0001	2.1 (0.9) p = .54
WIST Inappropriate Requests (Score Range 0–3)			.577
Pretest	2.5 (0.8)	2.8 (0.6)
Post-test	2.8 (0.4) p = .577	2.8 (0.4) p = .187
Fear^c (Score Range 12–84)			.06
Pretest	20.27 (6.6)	17.3 (5.4)
Post-test	20.24 (6.1) p = .986	17.6 (5.1) p = .739
	N (%)	N (%)	χ²
Disclosure			1000
Pretest	1 (2.7)	1 (3.03)
Post-test	2 (5.4)	1 (3.03)

Note. PSQ = personal safety questionnaire; WIST = What if situation test; FATS = fear assessment thermometer scale.

Assessed by PSQ.

Assessed by WIST.

Assessed by FATS.

***

p < .000.

Follow-Up Outcomes

Knowledge

The mean knowledge score in the intervention group increased significantly (p < .001) and from 8 in the baseline reached 10.4 (vs. 0.2 increase in the control group score). Linear regression in the intervention group indicated that no factor significantly influenced knowledge.

Self-protective skills

The mean protective skills score in the intervention group increased from 13.4 to 26.5, indicating a significant improvement (p < .001) compared to a 2.3 score increase in the control group. Diagnosing “appropriate requests” in the intervention and control groups increased .6 and .3 scores, respectively, showing a significant difference (p < .001). Although the intervention group improved in diagnosing inappropriate requests, the difference was insignificant (Table 3). However, after detecting the inappropriate situation, the intervention group showed better reactions and performed significantly better in the four skills of “Say” (p < .01), “Do” (p < .001), “Tell” (p < .001), and “Report” (p < .001), than the control group. The upgrade points in each of the four skills were as follows: Say (3.6–5.3), Do (1.8–5.3), Tell (2.3–5.4), and Report (0.6–4.7). The most remarkable change and improvement occurred in the “Report” skill (which had the lowest baseline score) (Table 4). Regarding protective skills, gender was the only factor influencing the total score (p = .006), and girls’ skill was 13.3% more than the boys’. Improvements in diagnosing “appropriate requests” were associated with increased age of mother (p = .04), “Say” skill with mothers’ higher educational level (p = .03), “Do” skill with child’s older age (p = .03), “Tell” skill with female gender (p = .03), and “Report” skill with female gender (p = .009), and mother’s older age (p = .04).

Table 4.

Comparison of Different Aspects of Prevention Skills of Children in Intervention and Control Groups in Pre- and Post-Test.

Dependent variable	Intervention N = 37; Mean (SD)	Control N = 33; Mean (SD)	Intervention N = 37; Mean (SD)	Independent sample test
Dependent variable	Intervention N = 37; Mean (SD)	Control N = 33; Mean (SD)	Intervention N = 37; Mean (SD)	p-Value
Say Skill (Score Range 0–8)				.008**
Pretest	3.62 (2.07)	3.90 (1.8)	3.62 (2.07)
Post-test	5.35 (1.60)	4.12 (2.16)	5.35 (1.60)
Do Skill (Score Range 0–8)				.000***
Pretest	1.86 (1.88)	1.96 (1.7)	1.86 (1.88)
Post-test	5.35 (1.70)	2.81 (2.14)	5.35 (1.70)
Tell Skill (Score Range 0–8)				.000***
Pretest	2.37 (2.28)	1.84 (2.34)	2.37 (2.28)
Post-test	5.40 (1.62)	2.60 (2.62)	5.40 (1.62)
Report Skill (Score Range 0–8)				.0001***
Pretest	0.64 (1.0)	1.0 (1.63)	0.64 (1.0)
Post-test	4.7 (2.3)	1.3 (2.12)	4.7 (2.3)

p < .01. ***p < .001.

Self-disclosure

A new self-disclosure case was found after the intervention. Although this difference was not statistically significant, clinically it was very important. The total rate of sexual abuse among 70 children was 4.2% (n = 3).

Fear

There was no significant difference between the two groups regarding the mean child fear after the training. Also, the intervention did not show any side effects (Table 3).

Discussion

The findings of this study indicated the considerable effects of CSA prevention training on children's knowledge, skills, and self-disclosure, without causing any significant fear or anxiety among them. Moreover, given the lack of data in Iran and the many Middle East countries, the baseline data also could be very important since it demonstrates the CSA situation in society.

Before the intervention, the lowest knowledge score belonged to question five (Are strangers the only individuals who try to touch children's private parts of the body?). Given the prevalence of CSA by acquaintances, it is crucial to emphasize this point, particularly in societies where people have many family ties. In another study conducted in Malaysia with a nearly similar culture to Iran, this finding has repeated, and although most children were aware of a stranger’s potential danger, few could understand the probable threat of known abusers (Weatherley et al., 2012). On the other hand, given the lack of CSAPPs in Iranian schools and national media, this satisfactory level of CSA knowledge is surprising. The only interpretation could be the positive role of parents in training children. Our regression findings approved this assumption that a high level of parents’ education directly correlates with children’s knowledge. The UNESCO report in 2020 shows that approximately 60% of Iranian adults have an education above a diploma. In the present study, despite sampling from various socio-economical populations, 71% of the mothers and 69% of the fathers had a university degree. Despite being a pleasing situation, a higher level of knowledge among girls points to the necessity of paying more attention to the training of boys since this finding was mentioned in two other review studies by Topping (Topping & Barron, 2009).

In the follow-up, the knowledge score was increased by 13.6% in the intervention and 1.5% in the control group. Questions one and eight were the lowest raised scores, “Are you the boss of your body?” and “Is it OK for a child to touch a bigger person’s private parts?” It is possible that in traditional countries, individual rights were less legitimated. It seems that discussions relating to “body ownership” and “private parts of the body” should be more emphasized in CSAPP. In line with our findings, many other studies (Hébert et al., 2001; Walsh et al., 2015) and reviews (Russell et al., 2020) showed the efficacy of the CSAPPs. In contrast, in Chen’s study, interventions could not improve children’s knowledge which could be due to the children’s high baseline knowledge and ceiling effect (Chen et al., 2012).

Before the intervention, protective skills in children were insufficient (only 45% of the total score), despite a satisfactory baseline knowledge level. This finding demonstrates that knowledge per se cannot help distinguish appropriate requests from inappropriate ones.

In follow-up, the intervention group obtained 88% of the total protective skills score and 93% of the appropriate and inappropriate requests score through training. Concerning the inappropriate requests, the change was insignificant between the two groups. This finding can be related to the high level of “diagnosing dangerous situations” skills among the two groups at the beginning of the study. In other words, parents or media provide relatively appropriate training for dangerous scenarios, and children can detect hazardous situations. Meanwhile, safe situations are less discussed, and children face more detection challenges.

Before the intervention, the “say” skill was satisfactory in facing dangerous situations. However, children did not react well to “Do” and “Tell” skills. In other words, even after diagnosing a dangerous condition, children could not “leave the place” and “tell parents or trusted people.”

In follow-up and after the CSAPP, all four skills improved. Obviously, prevention of CSA is not possible without achieving all four skills. Similarly, many other studies confirm the effect of the CSAPP on children’s performance (Chen et al., 2012; Hébert et al., 2001; Weatherley et al., 2012).

Disclosure can terminate the ongoing CSA and reduce re-victimization. Disclosure of two sexual abuses in the baseline demonstrates that most young children can diagnose inappropriate situations without formal training. Disclosing another CSA case after the intervention indicates the efficiency of the training. Overall, with three cases of sexual abuse, the frequency of CSA in this study is 4.2%, which, given the scarcity of data in Iran, is highly significant. Increased self-disclosure cases among children participating in training programs have been shown in various studies (Topping & Barron, 2009; Walsh et al., 2015). The intervention did not increase children’s fear in this study. Most studies reporting unfavorable effects were short-term and mild (Topping & Barron, 2009).

In this survey, conducting a randomized controlled trial was impossible due to the educational nature of the study. Despite this limitation, a study in the context with no previous data about CSA, sampling in a heterogeneous area, blind data gathering and analyzing, and acceptable sample size despite the research team's difficulty completing the questionnaires are among the strengths of the present study.

Conclusion

The current study provided valuable information about Iranian children’s sexual self-care conditions. At the baseline, children’s level of CSA knowledge was acceptable. This optimal level of knowledge, despite the lack of official CSAPPs, shows the significant role of parents in children’s sexual self-care. We think that an acceptable parent’s educational level had an essential role in children’s knowledge and skills, confirmed in our regression analysis. Further studies comparing the effectiveness of this training provided by parents and teachers may shed more light on this issue. At the baseline, the least knowledge score related to “understanding the danger of known people.” It is highlighting the importance of a clear and detailed explanation of the “danger of known people” for children, especially in traditional societies where people have extensive connections with family and friends. Although higher levels of knowledge among girls were favorable, it highlights the necessity of paying more attention to boys’ education.

Despite an acceptable level of knowledge at the baseline, protective skills remained insufficient. This is reemphasizing that CSA prevention will practically fail, and the risk of children being abused will continue to remain in the absence of appropriate reactions to dangerous situations being taken, such as escaping or detailed reporting. Although the children detected hazardous situations at the beginning of the study, it was difficult for them to distinguish between safe and dangerous conditions. This finding indicates that the education content should not solely focus on dangerous scenarios.

Like other studies, post-intervention findings showed considerable improvement in the children’s knowledge and skills. Even after receiving CSAPP, children’s understanding of “body ownership” and “private parts of the body” did not sufficiently improve. This finding highlights the need for greater emphasis on individual rights, especially in collectivist cultures, where more roles emphasize the importance of society. Various scenarios and appropriate training methods are needed to promote defensive skills, particularly for “leaving the place” and “report” skills. The correlation between better protective skills and female gender and mothers’ higher educational level indicated the critical role of parents’ education in preventing CSA.

A report of two cases of sexual abuse at the baseline shows that most young children can distinguish the unfavorable conditions. However, reporting sexual abuse by one child solely after receiving the training reconfirms the importance of CSAPP. The 4.2% frequency of sexual abuse in our sample was another notable result of this study.

Clinical Implications

Although our findings can be helpful in many societies, they may be more critical in Collectivist cultures where relationships with other people play a central role in each person's identity. Many Asian or South American countries have particular respect for adults. In this context, it is far-fetched for children to imagine any mistake being made by adults. On the other hand, people tend to be more cautious about sharing their problems. These factors lead to fewer reports of sexual abuse and an increased likelihood of continued abuse. As a result, CSAPP in the traditional context should emphasize individual rights, such as body ownership and assertiveness skills. Paying attention to social characteristics and creating cultural adaptations is a prerequisite for the success of prevention programs (Russell et al., 2020)

Footnotes

Acknowledgements

We would thank all of the children that helped us in this survey.

Author Contribution

Designation of the study, ZM, MD, MR, and FF: acquisition of data, ZM; analysis and interpretation of data, ZM, MR, and FF; drafting the article, ZM, and FF; final approval of the completed paper, ZM, MD, MR, and FF.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: The Tehran University of Medical Sciences supported this work by Grant number 98-01-28-41375.

ORCID iD

Farnaz Farnam

Author Biographies

Zohre Maleki, MSc, was an MSc midwifery student at the Tehran University of Medical Sciences. This project was part of her master’s thesis as a student in the Department of Reproductive Health, University of Tehran.

Maryam Damghanian, PhD in Reproductive Health, associated professor in Reproductive Health department at Tehran University of Medical Sciences. Since 2019, her research has focused on sexual and reproductive rights and female identity.

Maryam Rad, DDS, MSC, PhD in Epidemiology and statistics. She is an expert in the research and work as faculty member on Dental Diseases Research Center at Kerman University of Medical Sciences. She is an expert on study designing and her works focus on health promotion. In our last eight surveys, she has worked on sexuality subjects.

Farnaz Farnam, PhD in Reproductive Health, associate professor in Reproductive Health department at Tehran University of Medical Sciences. She has worked in the field of sexuality for more than 20 years. Her research interests include violence prevention (intimate and Transgender violence, child sexual abuse); sexual education for different groups (students, couples, Transgender youth, cancer sufferers. . .) and ages (children, teenagers, and menopause women); and sexual disorders and problems (dyspareunia, female desire disorder, pornography).

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