Increasing Knowledge of Sexual Abuse

Abstract

Objective: Child sexual abuse is a significant health problem with potential long-term consequences for victims. Therefore, prevention and education programs are critical. This preliminary study evaluates changes in children’s knowledge of sexual abuse using a school-based train-the-trainer curriculum. Emphasis was placed on developing a curriculum that considered the unique cultural context in Hawai‘i. Method: School staff who had been trained on how to implement the My Body, My Boundaries curriculum, which targets the third to fifth grade, were invited to participate in the study. Three schools agreed; students in third grade classrooms in two schools received the curriculum and students in the third school served as the comparison. Result: Children in intervention schools significantly increased their knowledge of appropriate and inappropriate touch and what to do if they experience sexual abuse. Conclusion: Findings suggest the utility of a train-the-trainer model in social work practice to address sensitive topics such as child sexual abuse.

Keywords

child sexual abuse school based prevention train-the-trainer model

Introduction

Child sexual abuse can have devastating long-term effects on the physical health, social, and psychological well-being of its victims (Dube et al., 2005; Lalor & McElvaney, 2010; Paolucci, 2001). Because of the insidious and hidden nature of this crime, one strategy that has been developed to protect children from its effects is to increase children’s knowledge of sexual abuse prevention concepts and skills through school-based curricula. The past two decades have produced multiple studies evaluating these school-based curricula and their potential to increase knowledge and prevent child sexual abuse. The various merits and challenges of this work are discussed below.

However, what has not received enough research attention is the importance of ensuring that prevention and education curricula are culturally appropriate for the context in which they are implemented. Most of the existing programs have been implemented with primarily Caucasian samples, which may not transfer to other more culturally diverse contexts (Kenny et al., 2008; Topping & Barron, 2009). The current pilot study addresses this limitation by conducting an evaluation to examine changes in children’s knowledge of sexual abuse prevention concepts using a culturally tailored school-based curriculum that was implemented in diverse communities across Hawai‘i. In addition, the merits of using a train-the-trainer model for implementation of the curriculum are explored.

Literature Review

Although there has been some debate over the last 25 years about the most effective approach to the prevention of child sexual abuse, the need for prevention and education efforts is rarely questioned given the myriad consequences associated with victimization. Numerous studies have shown that experiences of sexual abuse as a child have correlations to multiple negative health, social, and psychological outcomes. For example, in a national survey of adolescents aged 12–17, exposure to interpersonal violence (e.g., physical assault, sexual assault) was strongly associated with a host of comorbidly occurring disorders including posttraumatic stress disorder, major depressive disorder, and substance abuse (Kilpatrick et al., 2003). In addition, a large study by Dube et al. (2005), using a community sample, demonstrated that childhood sexual abuse was a strong risk factor for alcohol problems, suicide attempts, marrying an alcoholic, and adult marital and family problems. Other reviews also discuss long-term negative consequences of exposure to sexual abuse, including low self-esteem, anxiety, lower academic performance, vulnerability to later sexual revictimization, and engagement in high-risk sexual behavior (Lalor & McElvaney, 2010; Paolucci, 2001). Victimization as a child has been linked to further exposure to various traumas (not simply sexual revictimization), thus setting up a potential trajectory for additional traumatic experiences and associated mental health consequences over the lifespan (Banyard, Williams, & Siegel, 2001).

Given these consequences and the fact that social workers often serve victims of sexual abuse and their families, it is important to have information on current prevention and education efforts (Tutty, 2000). Efforts, thus far have been directed at: (1) using the justice system to control and deter offenders (e.g., offender registration and lengthening sentences); (2) using mental health treatment of offenders to reduce the likelihood of reoffending; (3) using community prevention efforts to create awareness among adults (e.g., public service announcements); and (4) using school-based prevention and education to teach children to identify and resist abuse (Finkelhor, 2009). While there is still some debate about its effectiveness, much of the research to date has focused on developing school-based child sexual abuse prevention programs that rely largely on increasing awareness of sexual abuse among children (e.g., bad touch) and teaching skills to resist abuse. The rationale for this is that school-based prevention programs reach a large number of children and are therefore a practical and cost effective way to disseminate prevention skills and concepts.

Although there are many positive aspects to school-based and knowledge-focused prevention efforts, the controversy over these programs centers on questions of their actual effectiveness in preventing child sexual abuse and on concerns over the possible negative effects of these programs. Reviews of the literature in this area have concluded that school-based prevention and education programs can be effective in teaching children the target concepts such as good touch/bad touch (Finkelhor, 2009; Kenny et al., 2008; Topping & Barron, 2009). One meta-analysis found large effect sizes (d = .71) for significant knowledge gains on posttest measures administered to children who participated in prevention programs, as opposed to those who had not. These effect sizes remained strong (d = .62) in studies that conducted follow-up evaluations several months after the intervention (Rispens, Aleman, & Goudena, 1997), indicating an ability of children to retain these knowledge gains.

While these reviews clearly demonstrate the ability of children to learn prevention concepts, there are significant challenges showing whether knowledge acquisition translates into sexual abuse prevention. Some have argued that prevention programs cannot possibly prepare children for the wide range of situations in which sexual abuse can occur (Bolen, 2003). Whether the knowledge imparted during school-based prevention programs increases a child’s ability to avoid or stop sexual abuse is difficult to measure. A few studies have relied on retrospective designs with adults and youth to help answer this question. Specifically, in two studies using retrospective surveys, result showed that those who reported participating in school-based prevention programs also reported lower rates of child sexual abuse (Gibson & Leitenberg, 2000), and were more likely to report both the use of self-protection strategies and higher rates of disclosure if they were victimized than those who did not receive prevention education (Finkelhor, Asdigian, & Dziuba-Leatherman, 1995). However, given the retrospective nature of these studies it is difficult to determine the causal ordering of these experiences.

Similar limitations have been discussed in the literature as fewer than half of the programs reviewed by Topping and Barron (2009) had control group designs and an even smaller proportion were randomized control trials. Within this set of studies there are two examples of programs that have undergone randomized control trials: Project Trust (Oldfield, Hays, & Megel, 1996) and Who Do You Tell (Tutty, 1997, 2000). Both of these evaluations found that children were able to learn sexual abuse prevention concepts and the Project Trust study found that there were more first time disclosures of abuse in the group that received the program versus the control group (Oldfield et al., 1996).

Even with this evidence on increase in knowledge acquisition and lower rates of child sexual abuse for those who participated in prevention programs, critics have raised concerns over the usefulness of these programs given hypothesized potential negative effects such as increased anxiety, fear of positive or benign touch, and effects on later sexual development (Kenny et al., 2008). Fortunately, several of the reviews in this area found that fears related to the negative side effects of prevention programs were either unfounded or minor (Finkelhor, 2007; Kenny et al., 2008; Topping & Barron, 2009). For example, Tutty (1997) and Finkelhor and Dziuba-Leatherman (1995) both found some evidence of increased anxiety in a small number of children after a sexual abuse prevention program, but Finkelhor and Dziuba-Leatherman noted that these same children reported high satisfaction with the program. In a survey of adult college students, Gibson and Leitenberg (2000) found that there was no difference in sexual satisfaction between those who participated in prevention programs and those who did not.

Further, Topping and Barron (2009) reported that over a third of the studies they reviewed actually found evidence of emotional gains for the participant group, including greater sense of efficacy in using self-protective skills, increased self-esteem, and less social anxiety. Similarly, in a 2008 review of school-based prevention programs, Kenny et al. (2008) observed that where reactions to the program were measured, typically program satisfaction was very high (e.g., Boyle & Lutzker, 2005). Some researchers have also found increases in parent–child communication about sexual abuse after a prevention program (Finkelhor & Dziuba-Leatherman, 1995).

In addition to these emotional gains, some consideration should be given to other positive effects of these programs. Child sexual abuse is often a hidden crime with many incidents undisclosed and unreported, making it difficult to determine true prevalence rates. One potential positive outcome of school-based prevention programs is an increase in students who disclose prior or current abuse, thus stopping ongoing abuse and helping children access support and services sooner than they might otherwise. Some studies have indeed found higher rates of disclosures of abuse after a prevention program (Currier & Wurtele, 1996; Oldfield et al., 1996). Increasing a child’s ability to disclose abuse is a very important and often overlooked aspect of prevention programs. Additionally, Finkelhor (2007) indicated that prevention programs have been associated with a decreased likelihood that children will blame themselves after the abuse.

While there does seem to be some evidence that increasing knowledge is a worthy goal for child sexual abuse prevention programs, and that offering such programs does not result in negative unintended emotional consequences, a large gap in the literature is the attention that has been paid to the cultural values of the population intended to receive these prevention messages. In fact, in their 2009 review, Topping and Barron (2009) noted that few studies gave attention to location and ethnicity in their evaluations of programs, and where these were reported, the studies tended to come largely from urban and Caucasian populations. For example, when examining the sample demographics for several of the studies described above (those using retrospective surveys and the two studies that used randomized control trials, the overwhelming majority of these samples were Caucasian (e.g., 91% for Project Trust and 88% for Who Do You Tell). Topping and Barron suggest that cultural factors may have some effect on the recipients’ understanding of prevention concepts and emphasize that more research is needed in this area. Others have also argued that prevention programs need to be designed and evaluated in a cultural context (Kenny et al., 2008; Taal & Edelaar, 1997).

Consistent with the call to consider cultural context, the current study provides one example of why this aspect of prevention is so important. Hawai‘i is one of the most diverse states in the nation¹ with a large proportion of residents identifying as being of Asian descent. While this group is in itself extremely diverse in terms of country of origin and generation in America (Futa, Hsu, & Hansen, 2001), some researchers have found trends in the characteristics of child sexual abuse in Asian American populations. In a large study conducted at The Child and Adolescent Sexual Abuse Resource center in San Francisco, Rao, Diclemente, and Ponton (1992), found that compared to Caucasian, African American, and Hispanic families, children and adolescents of Asian/Pacific Islander descent were underrepresented at their clinic (6.6% vs. a 35% Asian/Pacific Islander population in the area school district; note that this study did not examine Asian and Pacific Islanders separately). The same study found that children and adolescents of Asian/Pacific Islander descent were less likely to be believed by primary caretakers, who were also less likely to be involved in treatment. Disbelief on the part of parents, coupled with a strong sense of filial piety and a preference to resolve problems within the family, could lead to a lower rate of disclosures among this population (Kenny & McEachern, 2000). Therefore, with the majority of prevention programs aimed at Caucasian and urban populations it was necessary to develop a set of new curricula that was culturally appropriate for Hawai‘i’s populations.

The need to develop culturally appropriate prevention materials is compounded by a more general need for continued commitment to child sexual abuse prevention as the academic attention given to the implementation and evaluation of school-based prevention programs has waned in recent years (Finkelhor, 2009). While it has been difficult to assess whether these programs actually prevent abuse, they have been shown to have a number of important outcomes including increasing disclosures, reducing self-blame, and raising the awareness of teachers and parents. Finkelhor (2007) stressed that, “these programs could be justified solely on the basis of these goals even if actual prevention was relatively uncommon” (p. 642). Therefore, in order to maintain these programs in Hawai‘i and other schools nationwide, it is important that prevention materials be easily integrated into existing lesson plans and consistent with the current style of standardized education. Given the lack of specialized prevention education staff in schools and communities other options for program delivery may also be necessary.

One such option is the use of a train-the-trainer model. The train-the-trainer model has been successfully tailored to diverse intervention efforts ranging from large scale public health preparedness (Orfaly et al., 2005) to social work programs for children with human immunodeficiency virus (DePoy, Burke, & Sherwen, 1992) and clinical training programs (Olmstead, Carroll, Canning-Ball, & Martino, 2011). It has also been used successfully in school-based interventions (Carruth et al., 2010). In the train-the-trainer models, experts in a particular field train others in the community, school, or other setting to implement or disseminate a prevention effort. In the case of the current study with elementary school-aged children, experts from the Sex Abuse Treatment Center (SATC; a statewide social service agency comprised of social workers with expertise in sexual violence prevention and treatment) trained school teachers, counselors, and social workers to implement a series of sexual abuse prevention curricula for students in grades K-12. This method has the advantage of minimizing the time and expense required of outside staff to implement the program as well as harnessing the relationships that already exist between teachers and students (Orfaly et al., 2005).

It is important to note that although many of the school-based prevention programs discussed in the reviews above used teachers to deliver prevention messages, these efforts would not necessarily be classified as train the trainer, given that most teachers had not participated in any training before presenting the material to their students. Rather, the benefit of a train-the-trainer model is that prior to implementation educators are trained intensively on how to deliver the material and then they are supported throughout implementation, thereby increasing their comfort level and chances for a successful and rewarding experience (which also can affect how the messages are received by students and the impact of the curriculum).

The Present Study

With the host of negative consequences associated with child sexual abuse it is critical that prevention and education efforts continue. In addition, it is important that these programs be appropriate to the cultural context in which they are implemented. With these two imperatives, the goal of the current study is to evaluate the use of a train-the-trainer model to increase knowledge about child sexual abuse among third graders attending rural public schools on the island of Oahu, Hawai‘i. The curriculum, My Body, My Boundaries (MBMB), is focused on prevention (increasing students understanding of the difference between appropriate and inappropriate touch so that they can get away before they are abused) and response (arming children with the knowledge of how and where to get help if they are abused).

Specifically, it was hypothesized that students in the treatment schools would score higher at posttest on knowledge questions related to appropriate and inappropriate touch than students in the comparison school. Also, an important message from the curriculum being implemented is that students should keep telling if the first person they tell does not believe them about sexual abuse. Therefore, a second hypothesis was that students in the treatment schools would score higher on the number of correct responses than students in the comparison school when asked what they should do in a situation where the first person they tell does not believe them. It is important to note that this preliminary study did not address whether changes in knowledge translates to reductions in the prevalence of child sexual abuse. However, if the curriculum is found to increase children’s knowledge, future research can begin to address the translational question of changes in protective behaviors and, ultimately, prevalence of child sexual abuse.

Method

The Curriculum

The MBMB curriculum for third to fifth grade students is part of a comprehensive set of sexual violence prevention curricula developed by the SATC for students in grades K-12. The key goals of the K-12 curricula are to protect children and teens from sexual abuse and to teach them the importance of respecting personal boundaries. Specifically, the MBMB curriculum includes four lesson plans, with the following topics to help children: identify the three types of sexual abuse (unwanted talking, showing, and touching of private parts), recognize and respond to unsafe behaviors (e.g., how to say a form of “no”; how to get away); learn how to identify and tell others if they are victimized; understand what personal boundaries are and the importance of respecting them; and learn how to stay safe from Internet predators. As recommended by Tutty (2000), the curriculum consists of a variety of kinesthetic exercises, role plays, and discussion questions that are geared for the different grade levels, with the material presented in developmentally appropriate ways (i.e., simplistic methods and messages for younger audiences and more sophisticated role plays and writing assignments for older audiences).

Each of the four lesson plans incorporates the Hawai‘i Department of Education’s (DOE) standards for health education. For example, lesson plans detail the grade-level benchmarks to be achieved and include a variety of performance assessments to determine whether benchmarks have been met. In addition to these assessments, pretest and posttest questions were developed for this study to examine changes in students’ knowledge about child sexual abuse, including safety rules and their understanding of how to access help if they are victimized.

Given the ethnicity and racial diversity of Hawai‘i, particular attention was given to ensuring that the curriculum was culturally appropriate to the diverse student population. The SATC drew on its 25-year history of teaching in Hawai‘i’s culturally mixed classrooms in developing the curriculum, in addition to consulting with Hawai‘i DOE teachers and curriculum specialists and testing and incorporating their written and verbal feedback. Lesson plans were also developed and fine-tuned based on feedback from a cultural cross section of students in classrooms statewide. For example, in the curriculum, there are options for role plays that are written entirely with Hawaiian names and concepts, such as utilizing the connection to nature and the ocean with characters in the form of a dolphin and turtle. In addition, commonly used terms in Hawaiian and Pidgin (a local name referring to Hawai’i Creole English) were incorporated to explain terms such as gut feelings (na‘au). Those implementing the curriculum were also advised on how to educate students using specific phrasing of safety rules and safe responses and how these phrases change in meaning if spoken in Pidgin.

Finally, the curriculum was developed as a train-the-trainer curriculum. With a shortage of prevention education staff, it was necessary to use a different method to ensure that prevention messages would still be disseminated. In addition, the SATC believes in the value of building a school’s capacity to prevent sexual abuse (such as with trained staff, classroom lessons from an easily implemented curriculum, curriculum-related classroom posters, handouts for parents, etc.). The SATC saw the benefit of teachers and counselors, who know their students best, having the tools to effectively educate children as well as be available should a child disclose at that time, or sometime in the future. Therefore, the curriculum has step-by-step instructions for teachers and counselors to implement each lesson plan, provides the actual words to use to explain sensitive concepts to students, and has tips and answers to common questions that may arise in the classroom. There is specific information on how to respond to disclosures from students and how to report sexual violence. Informative handouts and a sample letter describing the curriculum are also included and can be given to parents and school counseling offices prior to implementing the curriculum.

Before finalizing the curriculum it was pilot tested over a 2-year period. During this time, SATC taught the curriculum in classrooms, trained hundreds of teachers to teach the curriculum, and then solicited their feedback on the age and cultural appropriateness of the content, value of the lessons and topics taught, and technology used. SATC also solicited feedback from hundreds of students after they had been taught the curriculum. Students were given questionnaires asking their opinion of the MBMB curriculum, including what they liked, what they did not like, and what they did not understand. As the curriculum was refined, trained teachers continued to provide feedback on updates until there was widespread agreement that the curriculum was ready to be evaluated using more rigorous methods (i.e., pretest/posttest with a comparison group).

Training School Staff

To acquire the SATC’s MBMB curriculum, educators (e.g., teachers, counselors, social workers, human service professionals working with youth, etc.) must attend a multi-session training (ranging from 6 to 18 hr depending on the needs of the staff; however, there is a requirement of at least 6 contact hours) put on by prevention education staff from the SATC. DOE instructional services representatives support and attend these trainings, as do program managers from relevant community-based agencies (it is important to note that in addition to the curriculum being implemented in the schools, many social work and community-based agencies in Hawai‘i have requested the training so that they can implement it with their clientele). Training includes an overview of relevant information about child sexual abuse, the potential for prevention, local statistics and services, and opportunities to role play lessons and skill-building exercises for teaching sensitive and challenging health topics. Trainees also learn how to effectively receive a disclosure, report abuse, and support a victim. In addition to this training, attendees are offered technical assistance throughout implementation. The goal for those attending the training is to develop the skills, confidence, and comfort level to effectively implement the curriculum.

Educators who attend the training course are evaluated throughout the training. Trainees are given preknowledge and postknowledge tests after the content of each lesson is covered. They are also asked to teach a lesson out of the curriculum to their peers in the training course. This activity is evaluated by both the peers and the instructors. Trainees are then required to teach the curriculum to students where they work (e.g., in their own classroom if they are a teacher or with children who are in their care if they work at a community-based agency). As part of their teaching, they are required to submit a portfolio with lesson plans, student work, and their reflections after teaching each lesson. All of this information is evaluated by instructors of the course. Trainees must pass the course to be approved to teach the curriculum; those who pass also receive the equivalent of college credit, which has the potential to improve their pay scale.

Often at the elementary level, the curriculum is taught by licensed teachers, counselors, or social workers in the school. In middle and high school, the curriculum is usually taught in health education classes as well as special education classes, leadership or at-risk health groups, or incorporated into other content areas (e.g., English and science) by educators who have completed the SATC’s trainings and expressed interest in teaching it to their classes. As part of the current study, fidelity monitoring was conducted to examine the extent to which implementation by school staff was consistent with the curriculum content as it was presented by the SATC.

Fidelity monitoring consisted of one member of the University of Hawai’i research team attending three of the four lessons to assess whether core content was covered. The checklist for this assessment was developed by the research team in collaboration with the SATC. Over the course of several meetings, core principles, activities, and role plays were selected for each lesson. In some cases, teachers had the flexibility to choose between two or three activities, whereas in other cases, teachers were required to cover specific content without deviation. These choices and requirements appeared on a monitoring checklist (and were also discussed with teachers), which was used by the research assistant to determine the level of fidelity to the curriculum. The research assistant was trained on the checklist and instructed to take detailed notes during each lesson that could also be used if there were any questions on whether the content was covered adequately. Because of the classroom structure (small classes where multiple outside observers could have an impact on children’s attention) it was not possible to have more than one coder; therefore, reliability of the observations was not possible.

Research Design

We utilized a quasi-experimental design in which schools were not randomly assigned to a condition. Rather, teachers and other school staff who had been trained on the MBMB curriculum within the 6 months prior to the study (i.e., 16 schools) were invited to take part in the efficacy study and to serve as the intervention school. Responding to our invitation, two counselors from demographically similar elementary schools on Oahu agreed to participate as intervention schools. Once these schools were selected, a comparison school was identified based on the same student demographics as the intervention schools. For the initial evaluation, students in the third grade were selected as the recipients of the curriculum.

Participants

We recruited 80 students to participate in the study, with 53 students in the intervention schools and 27 students in the comparison school. The intervention schools were combined as there were no demographic or pretest group differences. The gender breakdown was similar between intervention and comparison schools (e.g., approximately 50% girls). The majority of the third grade students (91%) were either 8 or 9 years old. Given the complexity of race and ethnicity in Hawai‘i, students were not asked to complete their race and/or ethnicity on the pretest or posttest.² Rather, this information is presented at the school level only (see Table 1 for sample and school demographics).

Table 1.

Demographics of Study Schools.

Demographic Characteristic	Intervention School, n = 53 (%)	Comparison School, n = 27 (%)
Race/ethnicity^a
Asian/Pacific Islander	75	70
White, not Hispanic	20	26
Hispanic	5	3
Black, not Hispanic	0	1
Female	49	52
Age
7 years old	10	4
8 years old	86	81
9 years old	2	15
10 years old	2	0

Note. ^aBased on school-level demographics; remaining data in this table are based on the current study’s specific sample.

Measures

The elementary school measure was based on the standardized Children’s Knowledge of Abuse Questionnaire (CKAQ-R III; this was a shortened version of the original CKAQ), which tests the knowledge levels related to abuse prevention concepts in elementary school-aged children in Grades 1–6. The measure has established psychometric properties, but was standardized with a largely Caucasian population. With this population it had an internal consistency of α = .87, and 1 month test–retest reliability of .88 (Tutty, 1995, 1997). Validity of the original CKAQ was assessed using the Personal Safety Questionnaire (PSQ; a widely used measure to test knowledge of child sexual abuse prevention concepts; Saslawsky & Wurtele, 1986). The resulting correlation between the PSQ and the CKAQ was .92, providing evidence that the CKAQ was useful in measuring these established concepts. Construct validity was assessed by examining whether the instrument was sensitive to change after an intervention. In research with 400 elementary school children who were tested 3 times, before participating in a prevention program, 2 weeks after, and a 5-month follow-up (Tutty, 1992), results showed that those in the intervention group scored significantly better and maintained their knowledge at the follow-up, providing support for the construct validity of the measure.

Once the CKAQ-R-III was selected for use in the current study, there was a need to adapt the questions to fit with both the content of the curriculum as well as the cultural context in Hawai‘i. This process included several meetings with SATC’s prevention educators until the wording of final questions was agreed upon. The CKAQ-R-III included 33 questions; of these, 6 were eliminated because of their lack of relevance to the curriculum (e.g., You can always tell who’s a stranger—they look mean. and If a mean kid at school orders you to do something, you had better do it.) and their redundancy with other items. The curriculum does not refer to strangers so to ask these types of questions would have been inconsistent with the topics and terms taught in the MBMB curriculum. In addition, wording of some items were rephrased to be culturally appropriate to the context in Hawai‘i. For example, one question from the CKAQ-R-III asked children: “If your babysitter tells you to take off all of your clothes but it’s not time to get undressed for bed, you have to do it.” The word babysitter was replaced with older cousin because many children in Hawai‘i are cared for by extended family members, (e.g., cousins, aunties, uncles) not babysitters. The resulting 27-item scale had adequate reliability, with a Cronbach’s α of .68. The scale was analyzed as a total scale as well as subscales related to appropriate touch and inappropriate touch (Tutty, 1995).

Appropriate touch questions were included because, according to Tutty (1997), when children are exposed to messages related to child sexual abuse and inappropriate touching they sometimes overgeneralize to believe that it is not appropriate for anyone to touch them (e.g., hugs from teachers or letting a doctor examine them). Therefore, appropriate touch items included questions like “If you fell off your bike and hurt your private parts it would be OK for a doctor or nurse to check your private parts.” Of the 27 items, 8 were questions related to appropriate touch. The remaining 19 questions were about inappropriate touching, either directly or indirectly. An example of an inappropriate touch question is “Sometimes it’s OK to say no to a grownup.”

One additional question was included to evaluate the MBMB curriculum content related to the importance of telling someone if the child experiences unwanted touching. The MBMB curriculum emphasizes the importance of continuing to tell until the child is believed. This concept is particularly important for children who have been raised in cultures where filial piety and respect for elders is important, as allegations of abuse may be less likely to be believed by adults at home (Kenny & McEachern, 2000). The additional question was qualitative, with children being asked to write in their answer of what they would do if the first person they tell about unwanted touching does not believe them.

Procedures

Study procedures were approved by the University of Hawai‘i Committee on Human Studies and the Hawai‘i DOE, as it is necessary to obtain DOE approval for all research that is conducted in the public school system. Before students could participate in the evaluation, parental consent needed to be obtained. We received a good response from parents in the intervention schools, with 53 of the 63 students returning signed parent consent forms (response rate of 84%). Our response rate was not as high for the comparison school. Of the 65 third-grade students, less than half (n = 27) returned signed consent forms from their parents (response rate of 42%). This was the response rate was after two rounds of reminders to parents. After talking with the teacher it appeared as if the lack of response had more to do with the timing of when the consent forms were sent out (on a Friday before a long weekend thus increasing the risk that the form would be forgotten or misplaced) than on any specific parental reservation at having their child participate. Rather than opting to send out another reminder, a decision was made to move forward with the study given the approaching end of the semester. Students who did not return parental consent forms were taken out of the classroom and given other tasks to do while the survey administrations were taking place.

Before distributing the pretests, students were given an agreement form to sign describing the purpose of the project and their rights as participants using developmentally appropriate wording. Once pretests were completed and collected, the counselors at the intervention schools taught the MBMB curriculum, which occurred over a 3-week period. Following the last day of the MBMB instruction, posttests were given to students at the intervention and comparison schools. Participating students were given a $5.00 gift card as a thank-you each time they filled out a pretest or posttest. The intervention school counselors and comparison school teacher were each given a $75.00 gift card to spend on school supplies.

After posttests were completed, students at the comparison school received a debriefing session in which a prevention educator from the SATC discussed with them the appropriate answers to the survey items. Rather than going through the survey items one by one, the prevention educator asked students to participate in an interactive session concerning key points of the curriculum such as appropriate and inappropriate touch, personal boundaries, and what to do if someone you tell about unwanted touching does not believe you.

Data Analysis

Data were entered and checked for accuracy. Items were summed to create a total score as well as 2 subscale scores for appropriate and inappropriate touch. Analyses were conducted controlling for pretest scores. Gender was also entered as a covariate. Then, three ANCOVAs (analysis of covariance) were conducted, one for the total measure, one for the appropriate touch subscale, and one for the inappropriate touch subscale. As per Tutty (1997), changes in scores for the appropriate touch subscale was used to identify the possibility of negative effects, whereas changes in scores for the inappropriate touch subscale was used to identify improvement.

Finally, answers to the qualitative question on what to do if someone does not believe you were entered verbatim. Categories were then created to reflect no answer/incorrect answer or the correct answer of “keep telling” or “tell another person.” These responses were coded as “0” or “1,” and then chi-square analyses were conducted to examine school differences in the percent of correct responses at pretest and posttest.

Results

Total Scale

Table 2 shows the results of the ANCOVA for the total scale. With pretest scores controlled for, there was a significant difference between intervention and comparison schools. Children who received the prevention curriculum scored significantly higher at posttest than children in the comparison school. Examining the mean scores from pretest to posttest results showed that the intervention schools’ scores increased significantly, while scores for the comparison school remained virtually unchanged (see Table 3).

Table 2.

Analysis of Covariance for Total Scale, Appropriate Touch Subscale, and Inappropriate Touch Subscale.

Source	df	Mean Square	F	Partial η²
Total scale
Pretest knowledge (covariate)	1	848.01	82.06***	.52
School (Intervention vs. Comparison)	1	96.10	9.30**	.11
Gender	1	.00	.00	.00
Error	76	10.33
Appropriate touch subscale
Pretest knowledge (covariate)	1	55.76	23.24***	.23
School (Intervention vs. Comparison)	1	11.84	4.94*	.06
Gender	1	1.43	.60	.01
Error	76	2.40
Inappropriate touch subscale
Pretest knowledge (covariate)	1	568.85	93.52***	.55
School (intervention vs. comparison)	1	45.89	7.55**	.09
Gender	1	2.54	.42	.01
Error	76	6.08

Note. *p < .05. **p < .01. ***p < .001.

Table 3.

Pretest and Posttest Mean Scores and Standard Deviations by Condition.

Measure	Pretest		Posttest
Measure	M	SD	M	SD
Total scale
Intervention	18.06	3.63	20.94*	3.87
Comparison	18.15	4.16	18.70	5.74
Appropriate touch subscale
Intervention	6.26	1.38	6.75**	1.22
Comparison	5.74	1.61	5.63	2.48
Inappropriate touch subscale
Intervention	11.79	3.34	14.19^†	3.42
Comparison	12.41	3.26	13.07	4.03

Note. *p < .05. **p < .01. ^† p < .10. Denotes significant difference at posttest between intervention and comparison schools.

Knowledge of Appropriate Touch

Next, it was important to determine if there were differences in children’s understanding of appropriate versus inappropriate touch. After controlling for pretest scores, results showed a significant difference between intervention and comparison schools at posttest. Scores for the intervention schools increased, while the comparison school remained essentially the same (see Tables 2 and 3). These findings indicate that at posttest children in the intervention group were able to distinguish between appropriate and inappropriate touch, whereas children in the comparison group remained unclear about when it is appropriate for adults to touch them, thus suggesting that there were no negative effects from the intervention (i.e., children receiving the intervention believing that it is inappropriate for anyone to touch them under any circumstances).

Knowledge of Inappropriate Touch

Results showed that there was a significant difference at posttest on the inappropriate touch subscale (see Table 2). Similar to findings for the total scale and appropriate touch subscale, posttest scores for the intervention schools increased, compared to virtually no change in scores from the comparison school’s students (see Table 3), suggesting that the curriculum was efficacious in increasing student knowledge of what is considered inappropriate touching.

What to do About Unwanted Touching?

Students were asked to describe what they would do if someone they told about unwanted touching did not believe them. Results showed that there was not a statistically significant difference at pretest between the intervention and comparison school. Many of the students wrote that they were “not sure” or they “did not know” what to do in this case. However, at posttest, students in the intervention schools overwhelmingly responded with the correct answer, which is to keep telling until someone believes them, χ² (N = 80) = 18.12, p < .001 (see Figure 1).

Figure 1.

Keep telling.

Fidelity Monitoring

To ensure that the curriculum was being taught as it was intended by the SATC, and that it met Hawai‘i’s health education performance standards, fidelity monitoring of three of the four lessons was conducted. To be implemented as intended, at least 85% of the core concepts identified by the SATC must be covered in each lesson. Results showed that in Lesson 1, 94% of the concepts were covered; in Lesson 2, 94% were covered, and in Lesson 3, 86% of the core concepts were covered. These results suggest that school staff, when appropriately trained and supported, are able to teach sensitive health topics to elementary school children. In fact, feedback from the counselors who taught the MBMB curriculum suggested that they felt comfortable teaching the topic given the training they received and the detailed approach to curriculum topics in each of the lessons. The only downside to the curriculum, in their opinion, was that they could not take the time to cover all of the topics (as the fidelity monitoring showed). Rather, both counselors reported being forced to cut some of the activities/topics given competing demands in the classroom.

Discussion and Applications to Social Work

Results from this study are promising in that students who received SATC’s MBMB curriculum scored significantly higher at posttest on their knowledge of appropriate and inappropriate touching than students in the comparison school. Significant findings are certainly important; in addition it is helpful to understand the strength of the association between teaching the curriculum and increases in student knowledge. With a partial η² = .10, this would be considered a medium to large effect (Cohen, 1988). One caveat is that in small samples such as with this study, η² tends to overestimate the variance explained in the population. Therefore, while this study provides preliminary evidence of the positive effect of the curriculum on children’s knowledge, additional research is needed to confirm this relationship as well as the strength of the relationship.

In addition to increasing general knowledge of child sexual abuse, one core area of the curriculum is teaching students what to do if they experience unwanted touching. The message is simple: “Keep telling until someone believes you.” Results showed that children in both groups did not quite know what to do at pretest. At pretest, many children put “?” or “don’t know” or some other ambiguous answer (e.g., I would prove it); however, the majority of children (75%) in the intervention group answered correctly at posttest, compared to only 26% of children in the comparison group. Children in the intervention schools listed the answer verbatim to what was in the curriculum, indicating the curriculum’s ability to teach children, in theory, how to respond if they are abused. Longitudinal studies are necessary to evaluate whether children will actually put their answers into action if unwanted touching happens to them.

As with much of the previous literature, there were no gender differences in knowledge at posttest, thus suggesting that the curriculum’s effect on boys’ and girls’ knowledge of child sexual abuse topics was comparable. However, it is worth noting that two prior studies did find that girls learned more of the materials and retained it over time compared to boys (Finkelhor & Dziuba-Leatherman, 1995; Hazzard, Webb, Kleemeier, Angert, & Pohl, 1991). Future research is necessary to understand gender more thoroughly, especially as it relates to sustaining program gains and engaging in self-protective behaviors.

In addition to evaluating program outcomes, the question of program fidelity is also one that is important to examine, especially as this was a newly implemented curriculum. In the review by Topping and Barron (2009), they report that none of the 22 studies reviewed included data on implementation fidelity. This lack of data makes it difficult to fully interpret evaluation findings as it is unclear what material was presented to the children. Therefore, the strength of the current study is that fidelity monitoring was conducted and results showed that implementation was consistent with SATC’s curriculum guidelines. This finding adds to the literature in two ways. First, evaluation results are interpretable in that program content and methods of delivery are known, which increases our understanding of the process in which children gained knowledge of child sexual abuse topics. Second, there is now evidence that counselors and other school staff can successfully and competently deliver information on sensitive health topics, thereby increasing our ability to reach greater numbers of children with prevention messages that can affect their health trajectories.

Utilizing a train-the-trainer model also has the added benefit of increasing teacher competence in addressing child abuse. According to Kenny (2004), teachers self-reported a lack of awareness of child abuse as well how to report it. The MBMB curriculum addresses these issues clearly. In addition, SATC role plays in their training what to do if a child discloses and walks trainees through a step-by-step process. The K-12 curricula have also been approved by the Hawai‘i DOE, which adds another layer of support for educators who choose to address this topic. With regard to social work practice, this model can be especially helpful to social workers who work in schools as once they are trained they can then train others in the school. They can also work from the inside to promote this topic among teachers and other school staff, and be a source of expertise for the school when an incident is reported by a student. Of course, in some cases social workers may already provide this service, but for others the opportunity to obtain focused and practical training on child sexual abuse prevention can be invaluable to their work in schools or other community-based agencies.

Although it appears that the MBMB curriculum is associated with increases in children’s knowledge of sexual abuse prevention concepts and that school staff also benefit from being trained to deliver such content, a question remains on the ability of such efforts to be sustained and whether the added benefit to schools actually outweighs the costs in terms of teachers’ time to implement the curriculum and the time taken away from teaching academically oriented materials to students This is a more complicated question than simply showing feasibility, but rather requires evidence of specific value beyond simply having outside prevention educators come in to deliver the content to children each year. A cost–benefit analysis is outside the scope of this study but it is a question that merits some attention.

It may be that there is an upfront cost to delivering the MBMB curriculum in terms of training teachers and providing technical assistance during the first few times that it is taught. However, after this initial investment, the benefits (not only monetary benefits but also social benefits) may begin to outweigh the costs. For example, one benefit is that in-house expertise can be cultivated rather than schools and community-based agencies having to continue to rely on and pay for outsiders to provide this service. And, a typical scenario is that once this content is presented (regardless of who presents it) there are some students who self-disclose. Research shows that teachers often feel unprepared with how to deal with disclosures (Kenny, 2004). And, although it may seem that abuse prevention falls outside the scope of teacher workload, social and academic issues often collide as students may have no one else to turn to. This is not to discount an important cost: Teachers and other school staff are already extremely busy trying to make sure that students meet their school’s academic requirements. But, the importance of teachers feeling competent in all aspects of their job cannot be overlooked. Thus, teachers who are trained to teach on this topic (which requires more understanding and expertise than simply being trained on the topic) may be more able to address disclosures effectively. Certainly, there are other benefits as well as costs to implementing such a curriculum and a full cost benefit analysis is needed before any conclusions are drawn on how best to deliver this content, and by whom it should be delivered.

Another benefit of this study is that, to date little research has explored the interplay between prevention concepts and culture. Tutty (2000) reminds us that the prevention concepts often used in sexual abuse education curricula are not just facts, but beliefs. These prevention beliefs (say no to an adult who is making you uncomfortable) may clash with cultural beliefs (respect adults). Many Asian cultures stress respect for elders, keeping family matters private, and place a taboo on discussing sexual matters (Futa et al., 2001), all of which have consequences for whether or not prevention strategies are efficacious in this population. This study provides some preliminary evidence that a culturally sensitive curriculum can deliver important prevention knowledge to children who come from Hawai’i’s unique cultural climate. More research is needed to determine how parents of the children who participated in this study would receive similar prevention messages and whether children from Asian/Pacific Island populations would be able to actually “keep telling” in the face of contradictory cultural norms.

As with any study, in addition to strengths there are limitations that must be discussed. First, the sample size was limited, especially for the comparison group. While 84% of the parents of students in the intervention group agreed to participate in the study, only 42% of the parents in the comparison group allowed their children to be surveyed. Although there did not appear to be any systematic reason why children in the comparison school did not return parental consent forms, differences between those who participated and those who did not may have impacted the results of the study.

Second, it is not possible to determine whether our sample demographics actually matched the school level demographics in terms of race/ethnicity of the students. Because of the complexity of race, ethnicity, and culture in Hawai‘i, and with research showing that individuals tend to identify as “local” rather than of a particular racial/ethnic/cultural group (O’Donnell & Williams, 2012), we opted not to ask students for this information. The complexity was an especially salient issue given that our sample was comprised of 8- and 9-year olds. However, without this information we cannot provide a definitive demographic breakdown of our sample; rather we can only provide school level data.

A third limitation is related to the validity of our findings based on the research design employed. We used a quasi-experimental design which does not allow us to rule out certain threats to validity (Shadish, Cook, & Campbell, 2002). While some of these threats may not have been an issue (such as maturation and testing) given the short duration between pre- and posttests and our inclusion of a comparison group, others may have had an effect on our results. For example, as discussed above, differential response rates between intervention and comparison schools may have influenced the results. By not asking for demographic information from students it was also not possible to determine the heterogeneity within groups. This is a threat to statistical conclusion validity (i.e., our ability to draw valid inferences about the size of the covariation in knowledge between intervention and comparison groups) (Shadish et al., 2002).

Another threat to validity relates to the measure we chose to use and its reliability. Internal consistency for the measure in our sample was only adequate at .68. In addition, for some of the questions a high percentage of children answered correctly at the pretest (e.g., If your friend’s dad asks to touch your private parts it’s OK to let him), thereby making it difficult for change to occur at posttest. These questions will need to be re-examined in future studies to ensure that they are developmentally appropriate for the age of study participants (Topping & Barron, 2009).

Furthermore, whether the measure is valid with our population is as important as its reliability. Using an established measure as the basis of our measure gives us some confidence in our findings. However, given the vastly different populations included in the current study it was necessary to adapt the measure, though where possible, questions were left unaltered. This measure was originally normed on Caucasian children and although we attempted to adapt the measure to be culturally appropriate for Hawai‘i’s children, it is clear that additional pilot testing of the measure is needed to establish whether the questions are meaningful to children within the Hawaiian cultural context.

A final limitation is that no follow-up data were collected to assess whether knowledge gains were sustained by children in the intervention schools. One issue with school-based studies is whether children will retain information over time and also whether they will actually use this information to protect themselves from sexual abuse. Both of these questions remain unanswered and in need of additional research.

But, even with these limitations there is reason for cautious optimism. According to Topping and Barron (2009), the following are components of effective school-based abuse prevention programs: (1) have evaluation of effectiveness built in; (2) incorporate modeling, discussion, and skills rehearsal; (3) be at least four to five sessions long; (4) have the capacity to be delivered by a range of personnel; and (6) have parental involvement. The MBMB curriculum includes all but one component. Evaluation has been built in from the start, though it will be important for future studies to include larger samples and follow-up data collection. The MBMB curriculum also incorporates a range of methods to help engage children in the material (Tutty, 2000). The curriculum is four sessions long and can be delivered by a variety of personnel (after being trained by the SATC).

The one component that is missing is parental involvement, though SATC makes every effort to include parents using a variety of methods. SATC introduces the curriculum at parent nights held at schools prior to curriculum implementation. Parents are informed in this session and in a written letter about the material that will be presented in their child’s classroom, and they are invited to contact SATC or their child’s teacher with any questions. SATC has also developed free brochures and handouts, elaborate website programs including songs parents can sing with their children and parent tips for talking with their children. However, the difficulty has been in getting parents to avail themselves of these discussions/materials. Similar parental engagement difficulties have been expressed in prior research as well (Topping & Barron, 2009). Therefore, although parental involvement is minimal, attempts continue to be made to cultivate and maintain this involvement. Future work should explore the feasibility of increasing parental involvement, with a focus on what type of involvement is most beneficial to children.

In conclusion, findings from this study support the efficacy of the MBMB curriculum in increasing children’s knowledge of child sexual abuse prevention topics. In particular, it appears that a train-the-trainer model has utility for teaching children about inappropriate touching and what to do if it happens to them. Professionals in a school setting (e.g., teachers, social workers, counselors) play an important part in children’s lives, and this study supports their ability to not only impact children academically but also in ways that have the potential to change their health trajectories. More broadly, the train-the-trainer model is a tool that can be leveraged by those in helping professions (not simply in school settings) as they seek to achieve broader level change.

Finally, given that the majority of child sexual abuse prevention materials are geared toward Caucasian populations, the need for prevention materials that consider other cultural contexts is clear. In particular, Asian and Pacific Islander populations have been overlooked in the literature. Although additional research is necessary, the MBMB curriculum begins to fill this important gap and, as such, can serve as a promising practice for social workers who work with culturally diverse populations as a means of preventing experiences of child sexual abuse that may have lasting effects into adulthood.

Footnotes

Acknowledgments

The authors wish to acknowledge the commitment of Hawai‘i’s educators to the prevention of child sexual abuse. Special thanks to the schools who participated in this efficacy study and to Ann Horiuchi of the Hawai‘i Department of Education for her help and support throughout the development, implementation, and evaluation of the My Body, My Boundaries curriculum.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by funding from the State of Hawai‘i Department of Health, Sexual Violence Prevention Program, Maternal and Child Health Branch. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the funding agency.

Notes

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