Child Sexual Abuse Prevention Education for Primary School Children (Child Sexual A)

Introduction Child maltreatment is a major public health problem with significant medical, legal, and social implications that can result in serious injuries, permanent disabilities, and even death. It may occur in the form of physical, emotional, or sexual abuse, or as multiple forms of maltreatment occurring simultaneously, leading to devastating consequences for children's physical, psychological, and social well-being. The World Health Organization (WHO) defines child maltreatment as all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, exploitation, or other acts that result in actual or potential harm to a child's health, survival, development, or dignity within a relationship of responsibility, trust, or power. Children may be exposed to four main forms of maltreatment: physical abuse, emotional (psychological) abuse, sexual abuse, and neglect. Although emotional abuse and emotional neglect are recognized as among the most prevalent forms of child maltreatment, child sexual abuse is considered one of the most severe forms because of its profound and long-lasting adverse effects on children's physical and mental health. Child sexual abuse is a complex form of maltreatment that involves a child in sexual activities that he or she does not fully comprehend, is developmentally unable to consent to, or cannot legally consent to, and that are intended to provide sexual gratification or benefit to an adult or another individual who is older or in a position of power. Such acts are characterized by the absence of genuine consent and constitute abusive and unwanted experiences for the child. Child sexual abuse may involve physical contact, including touching and penetrative acts, as well as non-contact behaviors such as sexually explicit conversations, exhibitionism, and voyeurism. Accurately determining the incidence and prevalence of child sexual abuse is challenging. This is largely attributed to underreporting, children's reluctance to disclose abusive experiences, and barriers to reporting cases to legal authorities. In the WHO European Region, it is estimated that before the age of 18, approximately 18 million children experience sexual abuse, 44 million experience physical abuse, and 55 million experience emotional abuse. In Türkiye, according to the 2025 statistics of the Turkish Statistical Institute (TurkStat), 279,620 children were referred to security units as victims, of whom 240,872 were recorded as victims of crime. Among these child victims, 10.8% were victims of sexual offenses.

One of the most effective strategies for combating child sexual abuse is the development and implementation of preventive intervention programs. Accordingly, several school-based child sexual abuse prevention programs, including Body Safety Training, Talking About Touching, Feeling Yes, Feeling No, and Who Do You Tell?, have been implemented in both developed and developing countries. Although school-based child sexual abuse prevention programs were initially implemented primarily in Western countries, they have increasingly been developed and adopted in many other countries, including Ecuador, South Korea, China, Taiwan, and South Africa. In the context of child sexual abuse, the victim's age and the relationship between the victim and the perpetrator are considered important factors in understanding the characteristics of abuse. Although previous studies have reported that children of all age groups under the age of 18 are at risk of child sexual abuse, primary school age (6-12 years) has been identified as the period during which children are at the greatest risk of experiencing sexual abuse for the first time. However, our literature review found no study conducted in Türkiye that evaluated a multi-session, structured child sexual abuse prevention education program specifically designed for second-grade primary school students using a randomized controlled design. Furthermore, there is no comprehensive educational curriculum in Türkiye that systematically aims to improve awareness of child sexual abuse and self-protective skills among school-aged children. Therefore, this study aimed to evaluate the effect of the Child Sexual Abuse Prevention Education Program implemented among second-grade primary school students on children's knowledge levels and protective skills related to the prevention of child sexual abuse.

Hypothesis H1: The Child Sexual Abuse Prevention Education Program improves second-grade primary school students' knowledge of child sexual abuse.

Population and Sample The study population consisted of second-grade primary school students enrolled in two primary schools located in the relevant district center (N=500). The schools included in the study were located in the same region of the district center, served children with similar sociodemographic characteristics, had the highest student populations in the district, and were positioned at a sufficient distance from each other to prevent interaction between the Experimental group and Control group. The study was conducted with second-grade primary school students because children in this age group begin to develop body awareness, are able to identify themselves as girls or boys, have acquired basic reading and writing skills, and have reached a cognitive developmental level that enables them to benefit from education aimed at preventing child sexual abuse.

The sample size was calculated using G*Power version 3.1 software. The calculation was based on the Inappropriate Touching subscale, using the mean scores reported by Tahan et al. (2024) (16.45 ± 4.03 for Group 1 and 13.15 ± 3.04 for Group 2). For an independent samples t-test with a two-tailed design, an effect size of 0.92, α = 0.05, 90% statistical power, and an allocation ratio of 1:1, the minimum required sample size was calculated as 52 participants, with 26 participants in each group. Considering possible attrition, 15% was added to the sample size, and the study was completed with 59 participants: 32 in the Experimental group and 27 in the Control group.

Each of the two primary schools included in the study had seven second-grade classes, with approximately 25-30 students per class. As the target sample size was expected to be achieved, one second-grade class from each school was included in the study. A two-stage cluster randomization procedure was employed. In the first stage, the two schools were randomly assigned to either the Experimental group or the Control group by drawing lots. In the second stage, one second-grade class from each school was randomly selected by drawing lots for inclusion in the study. Cluster randomization is a study design in which groups or clusters, rather than individual participants, are randomly selected or assigned and is particularly recommended for evaluating educational interventions. Following randomization, the baseline characteristics of the Experimental and Control groups were compared to assess group comparability before the intervention was initiated. At baseline, the Experimental group consisted of 34 students. One student withdrew from school after completing the pretest, and one student was excluded from the study because they did not complete either the pretest or the posttest. Consequently, the pretest was completed by 33 students, and the posttest by 32 students in the Experimental group. The Control group initially consisted of 28 students. One student withdrew from school before the pretest and was therefore not included in the study. Consequently, both the pretest and posttest were completed by 27 students in the Control group. The participant flow throughout the study is presented in the CONSORT flow diagram.

Data Collection Instruments Data were collected using the Descriptive Information Form and the Children's Knowledge of Abuse Questionnaire.

Descriptive Information Form: The Descriptive Information Form was developed by the researchers based on the relevant literature and finalized following expert review by three specialists. The form consists of 10 items assessing the child's age, sex, family type, mother's age, educational level, and employment status, father's age, educational level, and employment status, and the family's perceived income level.

Children's Knowledge of Abuse Questionnaire: The Children's Knowledge of Abuse Questionnaire, developed by Tutty (1995), is an instrument designed to assess children's knowledge of child sexual abuse prevention concepts. The questionnaire consists of 33 items for children aged 6-12 years. It begins with general questions related to peer relationships, non-sexual touching, and attitudes toward strangers, which are familiar to children and facilitate their ability to respond comfortably to subsequent questions. Items addressing child sexual abuse and potentially confusing or uncomfortable touching by familiar individuals are presented toward the end of the questionnaire. The questionnaire uses a three-point response format (True, False, and Don't know). A score of 1 is assigned to each correct response, whereas incorrect and Don't know responses are scored 0. The total score is calculated by summing the item scores. Items 1, 3, 11, 12, 15, 19, 22, 25, 27, 31, and 32 are reverse-scored. Items 2, 4, 5, 6, 7, 8, 9, 10, 13, 14, 16, 17, 18, 20, 21, 23, 24, 26, 28, 29, 30, and 33 are scored as correct responses. The total score ranges from 0 to 33, with higher total and subscale scores indicating greater knowledge of child sexual abuse prevention concepts. The questionnaire consists of two subscales: Proper Touching (9 items) and Inappropriate Touching (24 items). In the Turkish adaptation study, the internal consistency coefficient (Cronbach's alpha) was reported as 0.69. In the present study, the Children's Knowledge of Abuse Questionnaire demonstrated good internal consistency, with a Cronbach's alpha coefficient of 0.80 for the total scale. At the subscale level, the Cronbach's alpha coefficients were 0.70 for Proper Touching and 0.80 for Inappropriate Touching.

Data Collection Pretest and posttest data were collected face-to-face by the researchers at the participating schools after obtaining written informed consent from the parents or legal guardians and verbal assent from the children. A single-blind design was implemented by ensuring that the children and their parents were unaware of group allocation throughout the study.

Pretest Data Collection: Written informed consent was first obtained from the parents or legal guardians during meetings held at the participating schools. Following parental consent, the Descriptive Information Form was completed by the parents. Subsequently, the Children's Knowledge of Abuse Questionnaire was administered to the children in both the Experimental and Control groups. The pretest assessments were conducted face-to-face by two researchers in the presence of the school counselor. Each item of the questionnaire was read aloud individually to the children, and they were asked to provide their responses. Data collection required approximately 20 minutes for each child. The process of obtaining parental informed consent and conducting the pretest assessments took place between September 15 and October 5, 2025.

Posttest Data Collection: During the posttest phase, the Children's Knowledge of Abuse Questionnaire was administered to the children in both the Experimental and Control groups. The posttest assessments were conducted face-to-face by two researchers in the presence of the school counselor. Each item of the questionnaire was read aloud individually to the children, and they were asked to provide their responses. Data collection required approximately 20 minutes for each child. The posttest assessments were conducted between January 26 and February 13, 2026, at least three weeks after completion of the intervention and following the semester break, to minimize the potential influence of immediate recall on the study outcomes.

Nursing Intervention Following completion of the pretest assessments, the Child Sexual Abuse Prevention Education Program was implemented as a nursing intervention by the researchers for the children in the Experimental group. The program consisted of nine sessions delivered once a week, with each session lasting approximately 25-30 minutes. The educational sessions were conducted as group-based classroom activities at scheduled times determined in collaboration with the school administration and classroom teachers. All sessions were delivered by the researchers under the supervision of the classroom teacher. The Child Sexual Abuse Prevention Education Program was implemented using a child-centered and interactive approach. During the educational sessions, a variety of teaching methods were used, including storytelling, educational games, role modeling, role-playing, scenario-based activities, question-and-answer sessions, group discussions, visual materials, and coloring activities. To enhance the children's knowledge and skills, each session incorporated activities that promoted experiential learning. At the end of each session, the content covered was reinforced and evaluated through question-and-answer sessions and reinforcement activities. The titles and content of the educational sessions are presented in Table 1.

The session titles and educational content of the Child Sexual Abuse Prevention Education Program were developed based on the relevant literature and were finalized following expert review by five academics with expertise in Psychiatric Nursing, Mental Health and Psychiatric Nursing, Pediatric Nursing, and Public Health Nursing. The nursing intervention was implemented between October 6 and December 14, 2025, in accordance with the planned study protocol.

Control Group No intervention was provided to the Control group during the study period. After completion of the study, a condensed version of the Child Sexual Abuse Prevention Education Program was delivered to the children in the Control group for ethical reasons.

Data analysis Data were analyzed using IBM SPSS Statistics version 22.0. The normality of the data distribution was assessed using skewness and kurtosis coefficients. Descriptive statistics were presented as frequencies, percentages, means, and standard deviations. Baseline sociodemographic characteristics of the Experimental and Control groups were compared using the chi-square test for categorical variables and the independent samples t-test for continuous variables. A two-way mixed analysis of variance (Mixed ANOVA) was performed to examine the effects of group, time, and the group × time interaction on the total and subscale scores of the Children's Knowledge of Abuse Questionnaire. Effect sizes were evaluated using partial eta squared (ηp²), with values of 0.01, 0.06, and 0.14 interpreted as small, medium, and large effect sizes, respectively. Internal consistency of the questionnaire was assessed using Cronbach's alpha coefficient. Statistical significance was set at p < .05.

Limitations This study has several limitations. First, because the study was conducted among second-grade children attending only two primary schools in a single district, the findings are generalizable only to children with similar characteristics. Second, the data were based on the children's self-reports. Third, the effectiveness of the Child Sexual Abuse Prevention Education Program was evaluated only through pretest and posttest assessments; therefore, the long-term retention of the acquired knowledge and skills could not be determined. Despite these limitations, the randomized controlled design and the structured educational intervention provide robust evidence regarding the effectiveness of school-based child sexual abuse prevention education.

Ethical Considerations Prior to the commencement of the study, ethical approval was obtained from the Tokat Gaziosmanpaşa University Social and Human Sciences Research Ethics Committee (Date: March 5, 2025; Decision No. 04.23), and official permission was obtained from the Ministry of National Education. Permission to use the Children's Knowledge of Abuse Questionnaire was obtained from the original developer via e-mail. After receiving a detailed explanation of the study purpose and procedures, written informed consent was obtained from the parents or legal guardians, and verbal assent was obtained from the children. Throughout the study, the ethical principles of informed consent, respect for autonomy, confidentiality, and the principles of the Declaration of Helsinki were strictly observed.